Comparison of Patient Satisfaction on a Day-case Mastectomy Pathway for Breast Cancer Versus a Traditional Inpatient Delivery Model, Using a Validated Questionnaire

Discussion

This study is one of the very few to examine patients' experience of day-case mastectomy. It provides evidence that patients having a mastectomy are equally satisfied when having the procedure as a day-case compared to as an inpatient. This is in contrast to a UK study in 2015 (9) where patients expressed a preference to having the procedure as an inpatient (n=41 respondents). However, that study asked patients who had been managed as inpatients whether they “found their night in hospital helpful”. That approach cannot answer the question as to whether a cohort managed carefully and selected with appropriate pre-operative work-up can be managed on a day-case basis without a loss in satisfaction. Our study directly assessed patient satisfaction with their allocated pathway.

It is clear that there is a significant psychosocial aspect for patients in receiving a diagnosis of any cancer but those with breast cancer, in particular (9-11) seem to suffer more. The UK study above (9) found that 50% of those undergoing mastectomy with sentinel node biopsy and 70% of those undergoing mastectomy with axillary node clearance found the night in hospital useful because of the reassurance it conferred. Whilst this is understandable from the patient point of view, it does not necessarily follow that we cannot manage patients on a day-case pathway if the pre-operative counselling is rigorous and supportive.

Satisfaction scores. The Utrecht questionnaire attempts to assess whether there is a statistically significant difference between two groups rather than assess the quantum of satisfaction in one or the other. In our study, the similarities in the scores suggest that whether managed on a day-case or inpatient pathway, patients are satisfied with their treatment pathway. This implies that both groups were adequately prepared pre-operatively with regards to their expectations of each pathway.

Complications. Overall, there were fewer complications in the day-case group. This study has not highlighted any reason as to why that might be the case, but it does suggest that day-case mastectomy can be offered to patients within an acceptable safety profile. The most common complication was haematoma formation. The main reason for readmission was for evacuation of a haematoma. The rates of wound infection in our sample of 2.5% (day-case) and 2.1% (inpatient) are acceptable when compared the benchmark of 4.34%. We had no deaths within 30 days in either group.

Whilst there is no doubt that seroma formation is a significant problem, there is discussion in the published literature as to whether this should still be considered as a complication rather than a consequence of the operation. Rates as high as 85% have been reported after mastectomy and focus now lies with surgical techniques to try and reduce them (8). Our rates are well below this (5.1% day-case and 7.6% inpatient), but the raw figures underplay the impact these complications have on the patient and hide the cost to the NHS. Aspiration was undertaken in the clinic, in some cases up to seven times. In one case an aspiration caused a haematoma requiring a return to the theatre and another caused a sterile seroma to become infected.

Limitations. The authors accept that there are a number of limitations in this study. The first is the sample size. Although we have 86 patients in this study, only 26 in the day-case group completed the questionnaire, so robust statistical analysis is limited. The authors accept that there is a risk of type 2 error in this study. In addition, common with any retrospective questionnaire, recall bias cannot be excluded. We tried to minimise bias by only including patients who had the procedure within the prior 18 months of receiving the telephone call.

This series of patients came from a pooled process so it does not represent a single-surgeon series. It is possible that there are differences between surgeons that could affect outcomes. Finally, the inpatient group were older than the day-case group. Accurate comparison needs a matched group and it may well be that some of that elderly population cannot be managed on the day-case pathway, particularly those operated on late in the day.

The previous UK study appears to highlight that psychological barriers remain the major issue in persuading the more elderly that they can be managed safely as a day-case. We also have to accept that the day-case pathway will simply be unsuitable for a number of patients due to co-morbidities or more commonly due to the social situation and lack of a support network at home.

Although some patients would not manage on a day-case pathway, the general trend to find new options for delivering treatment in hospital are happening alongside very significant advances in the understanding of the genetics of breast cancer (12). In the future, it is clear that a targeted, day-case pathway with a highly individualised treatment plan, based on an individual's genetic profile will become the standard of care.

Patient experience in their own words. Once answers were collected for the questionnaire, the authors had the opportunity to discuss with the patients any other matters that they felt that the questions did not capture. Comments presented in this way are not rigorous for analysis, but they are certainly useful in understanding some of the common problems hospitals will face when setting up this service. The authors felt it was useful to highlight these comments to help other Centres understand some of the issues that would need to be addressed in order to provide a safe, functional day-case service to their local populations.

It was notable that there was a significant variation in the standard of care given on the wards over the study period. As an example, patient A expressed herself as “absolutely delighted with the care”. However, just two weeks later at the same hospital, patient B stated that she had waited 5 hours for a transfer and was “completely ignored” on the transfer from recovery.

Making patients feel welcome onto a new ward was also frequently not done by the clinical staff which had the effect of making patients feel vulnerable and isolated. Examples are patient C “I was treated like a machine” and patient D “no one introduced themselves”. This lack of basic communication was a significant driver for the #hellomynameis campaign in the United Kingdom which highlighted frequent failings of staff to perform well in basic tasks of communication. There is a significant body of published literature highlighting the psychosocial aspect of mastectomy and how it can affect outcomes. Getting this essential part right in the day-case pathway will be crucial to the success or otherwise, of offering day-case mastectomy as a routine procedure.

Another theme related to patient concerns is about the management of drains at home. However, patients would then report in retrospect that it was the anticipation which worried them rather than the reality. Patient E is a good example “my drain was a nuisance but not a problem”.

A common theme in the inpatient group was that most wanted to stay in for reassurance because the operation was considered as major life event. Patient F “I wanted to stay in. It's a scary procedure and is just like a major operation”. This is echoed by patient G “I was very nervous. I'd never had an operation before”. This was highlighted in the UK study (9). Managing and addressing patients' concerns in the pre-operative setting will be crucial to delivery of a successful day-case service.

In our institution, we felt that these concerns had been rigorously addressed prior to their operations. Every patient had at least one meeting with both the surgeon and their nominated breast care nurse. This was followed-up with “open access” to the Breast Care Nurse both before and after their operations. All were given written information on the operation that they were to undergo and information regarding the management of drains at home. Yet, despite this, some patients clearly felt that they would not be able to manage on their own at home. This highlights the crucial importance of patient selection when setting up this service so that there is an immediately positive result from providing day-case mastectomy to enable the service to flourish.