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LETTERS

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reast Reconstructionfter Mastectomy

ichael J Halls, BSc, MD, FRCS(C), FACS

an Diego, CAn reaction to the Collective Review, by Lee and col-eagues,1 I would caution any clinical decisions or referralias based on the reported findings.As a reconstructive plastic surgeon, practicing for the last

wenty-five years, I have seen an incredible evolution inreast reconstructive techniques and implants. Lumpingogether studies as far back as 1987 does not do justice tohe current state of the art. Our recent literature is repleteith more recent studies of patients’ positive feelings con-

erning their reconstructions.2

Although discussed briefly by Lee and colleagues,1 the pa-ient bias is the single most important aspect of these kinds oftudies. Those who select reconstruction already have placedhemselves in an unmatchable cohort as they have broughtersonal expectations and experiences into that choice. Pa-ients who decide against reconstruction obviously have a dif-erent mindset on what is acceptable to their own self-imagend sexual identity. These patients are often older as well.

Patients should best be educated about, and offered all fea-ible methods of breast cancer management including optionsor both immediate and delayed reconstruction. The decisions to how to proceed will always remain an intensely personalecision for the patient herself rather than a physician’s choice.

On a personal note, the number of women who haveived with a mastectomy deformity and then opted foreconstruction, in my practice, have never wished to returno that deformity.

EFERENCES

. Lee C, Sunu C, Pignone M. Patient-reported outcomes of breastreconstruction after mastectomy: a systematic review. J Am CollSurg 2009;209:123–133.

. Hu E, Pusic A, Waljee J, et al. Patient-reported aesthetic satisfaction with breast reconstruction during the long-term survivor-ship period. Plast Reconstr surg 2009;124:1–8.

eply

lara Lee, MD, Christine Sunu, BA,ichael Pignone

hapel, NC t

7902009 by the American College of Surgeons

ublished by Elsevier Inc.

e would like to thank Dr Halls for his letter. We agree thathe decision about breast reconstruction is “an intensely per-onal decision.” In fact, the decision about breast reconstruc-ion is a perfect example of a “preference sensitive” decision,or which the right choice depends primarily upon the pa-ient’s personal preferences. Such decisions call for shared de-ision making between the patient and her providers.

We also agree that bias arising from patient differencesundamentally limits the literature on outcomes of breasteconstruction. Without prospective measurement of pa-ient characteristics prior to surgery, accurate evaluation ofostoperative outcomes is a challenge. We question, how-ver, the notion of “an unmatchable cohort,” which couldonceivably apply to just about any treatment decision.igorous methods exist for minimizing bias in clinical

tudies of treatment efficacy and could certainly apply tohe study of reconstruction outcomes.

Regarding the date of studies included in our review, weote that 20 of 33 studies were published in the past 10ears and were no more likely than older studies to find aositive outcome of reconstruction. Recent studies ofreast reconstruction, such as the one that Dr Halls cites,o provide insight into outcomes of reconstruction, butot in relation to outcomes of mastectomy.We believe that an opportunity exists to raise the bar on

tudies of breast reconstruction after mastectomy. Surgeonsught to collaborate to conduct prospective cohort studies ofreast reconstruction that include measurement of pre-reatment characteristics and patient preferences. Such studiesdeally would use validated patient–reported outcome mea-ures and prioritize the patient’s perspective over that ofroviders.

ostoperative Morbidity withiversion after Low Anterior Resection

n the Era of Neoadjuvant Therapy:Single Institution Experience

iuseppe Pappalardo, MD, FACS,omenico Spoletini, MD

ome, Italyhe use of a protective stoma in anterior resection and in

oloanal anastomoses for rectal cancer was, till now, con-

roversial.1,2 Neoadjuvant therapy is considered a risk factor

ISSN 1072-7515/09/$36.00doi:10.1016/j.jamcollsurg.2009.08.016