Influence of age on patient decision regret following breast reconstruction: A multicenter collaborative study in Japan

Influence of age on patient decision regret following breast reconstruction: A multicenter collaborative study in Japan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Influence of age on patient decision regret following breast reconstruction: A multicenter collaborative study in Japan Yoshihiro Sowa, Hirohito Seki, Hiroyasu Abe, Takako Komiya, Maho Kato, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5767750/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 May, 2025 Read the published version in Breast Cancer → Version 1 posted 5 You are reading this latest preprint version Abstract BACKGROUND In recent years, the age range of patients undergoing breast reconstruction has expanded. Establishment of the influence of the age of a patient with breast cancer on the level of regret after breast reconstruction could assist in decision-making across age groups at the time of choice of options for breast cancer surgery. OBJECTIVES The objective of the study is to investigate the current age distribution of patients undergoing treatment for breast cancer in Japan through a multicenter collaborative study, and to examine the impact of age on post-surgical decision regret, analyzed by type of surgical procedure. METHODS A multicenter observational retrospective study was conducted in 576 patients who were diagnosed with breast cancer pathologically and underwent mastectomy (Bt), breast-conserving surgery (Bc) or breast reconstruction (Br). Demographic and outcome data were collected and the level of regret concerning the surgical decision was surveyed using the Decision Regret Scale (DRS) across the different patient groups. RESULTS The average age of the Bt group was significantly higher than those in the Bc and Br groups. The level of regret was slightly but significantly higher in the Br group compared to the other groups. Regression analysis of the relationship between age and DRS scores indicated that reconstruction is associated with an increase of about 5 points in the DRS score. This analysis also revealed that the DRS score slightly increases with advancing age, regardless of the surgical method. CONCLUSIONS In reconstruction cases, addition of new surgical procedures may lead to more complications, which might have slightly increased regret; however, the increase was not significant. Although minor, it is also important to note the tendency for the level of regret to increase with age. age breast reconstruction breast-conserving surgery mastectomy decision regret decision-making Figures Figure 1 Figure 2 Introduction Appearance and quality of life (QOL) after breast cancer treatment are important because the prognosis for many breast cancer cases is relatively good. In Japan, breast implant reconstruction became covered by insurance in 2013, increasing patient awareness and choices for breast reconstruction [ 1 – 3 ]. Additionally, advances in genetic diagnostics have identified the presence of hereditary breast and ovarian cancer syndrome (HBOC), leading to insurance coverage for risk-reducing mastectomy in BRCA mutation carriers starting in April 2020 [ 4 – 6 ]. With these changes, it is likely that breast reconstruction procedures will continue to increase. The number of patients with breast cancer in the adolescent & young adult (AYA) generation has risen [ 7 – 10 ], but the proportion of older adults with breast cancer has also increased in Japan's aging society, leading to more opportunities for breast reconstruction in elderly patients [ 11 – 13 ]. However, concerns about increased complications and a perceived lower interest in body image among older patients mean that some reconstructive surgeons still consider elderly patients to be relatively contraindicated for breast reconstruction. In breast cancer surgery, options such as mastectomy (Bt) aim for both curative outcomes and maintenance of aesthetics to preserve QOL through breast-conserving surgery (Bc) and breast reconstruction (Br). Despite the expected expansion of the applicable age range, there are few multicenter studies of the age distribution and surgical techniques chosen for breast reconstruction in Japan. Furthermore, surgical outcomes may not always be satisfactory, and there has been insufficient assessment of whether younger or older patients experience regret following breast reconstruction. The objective of this study is to investigate the age distribution of patients with breast cancer in Japan through a multicenter collaborative study and to examine the impact of age on post-surgical decision regret and by type of surgery. Clarification of the influence of age on satisfaction after breast reconstruction could aid with decision-making in choice of cancer surgery and may improve the overall quality of breast cancer treatment. Methods Study Design and Setting A multicenter observational retrospective study was conducted in surgical facilities in Japan certified by the Japanese Society of Breast Oncoplastic Surgery (JOPBS). University hospitals, including Jichi Medical University, and general municipal hospitals that perform more than 50 breast cancer surgeries and more than 20 breast reconstructions per year—representing an average case volume for Japan—were included in the study. In contrast, high-volume centers with more than 50 breast cancer surgeries per year or institutions with fewer than 20 cases annually were not included as participating study sites. The subjects were 576 female patients aged 20 and older who were diagnosed with breast cancer pathologically and underwent mastectomy (Bt: 194 cases), breast-conserving surgery (Bc: 185 cases), or breast reconstruction (Br: 198 cases) between August 1, 2013, and July 31, 2021, and had follow-up of at least 18 months. The following exclusion criteria were established: 1) bilateral breast cancer, 2) secondary breast reconstruction, 3) breast cancer at stage 4 or higher, 4) diagnosis of breast cancer recurrence or distant metastasis, 5) an inserted expander, 6) history of surgery on the contralateral breast, such as mastopexy or augmentation, 7) treatment for other malignant diseases, 8) pregnancy or breastfeeding, 9) difficulty responding to questionnaires in Japanese, 10) patients deemed unsuitable by the physician, and 11) patients who refused to participate in the study. Demographic and Outcomes Data Demographic and outcome data were collected. Basic information included a subject identification code, date of birth, age, body mass index (BMI), and smoking history. Clinical data related to breast cancer treatment encompassed clinical stage, lesion site, date of surgery, presence of axillary dissection, and whether chemotherapy or radiotherapy was administered. Severe postoperative complications were also recorded, and were defined as those requiring hospital management or surgical intervention, such as flap necrosis or implant replacement [ 14 , 15 ]. Decision Regret Scale (DRS) The DRS was selected as the outcome measure (Fig. 1 ) [ 16 , 17 ]. The DRS consists of five items that are answered on a Likert scale from 1 = strongly agree to 5 = strongly disagree. Scores range from 0 to 100, with higher scores indicating a greater level of regret regarding the decision to undergo breast reconstruction. A more detailed explanation, including the method for calculating DRS, is explained in detail on the following website ( https://decisionaid.ohri.ca/docs/develop/User_Manuals/UM_Regret_Scale.pdf ). In a short introductory statement, respondents should be asked to reflect on a specific past decision, and then asked to indicate the extent to which they agree or disagree with the statements in the regret scale by indicating a number from 1 (Strongly Agree) to 5 (Strongly Disagree) that best indicates their level of agreement. The Decision Regret Scale questionnaire is shown in Fig. 1 . Psychometric evaluations of this scale have shown high internal consistency (Cronbach's α = 0.86), and the utility of the DRS has been well-validated in patients with breast cancer and those undergoing breast reconstruction [ 18 – 20 ]. Statistical Analysis Continuous variables are expressed as means, standard deviations, medians, and minimum and maximum values. Categorical variables are shown as frequencies and proportions. Age is summarized in age groups of five-year increments. All descriptive statistics were calculated by reconstruction methods. The proportions of patients over 60 and under 40 years old were compared among reconstruction method groups by chi-squared test and pairwise comparisons are conducted by chi-squared test. The means DRS score was compared among reconstruction methods by one-way analysis of variance (ANOVA). If the ANOVA test was significant, pairwise comparison by two sample t-test was conducted. DRS score was summarized for each surgical procedure and age groups. Multivariate linear regression was used to investigate the main effects of surgical methods and age (as continual variable), and the interaction effect between the two. All reported P-values are two-sided and P < 0.05 was considered significant. Statistical analyses were performed using JMP Pro ver. 18 (SAS Institute, Inc., Cary, NC, USA). Results Age Distribution in Each Group The age distribution in each group and demographic and outcome data are shown in Tables 1 and 2 . The mean age was 53.6 ± 11.5 years for all patients, 58.1 ± 11.9 years in the Bt group, 54.8 ± 11.5 years in the Bc group, and 48.1 ± 8.6 years in the Br group. In the Bt group, the age peak was between 60 and 70 years, whereas the peaks in the Bc and Br groups were between 40 and 50 years. The proportions of patients over 60 were 45.9% in Bt group, 33.2% in Bc group, and 11.6% in Br group, which were significantly different (P < 0.000). In pairwise comparisons, the proportions were significantly difference between all two pairs of the groups (Bt vs Bc: P = 0.0115; Bt vs Br: P < 0.000; Bc vs Br: P < 0.000). The proportions of patients under 40 were 6.2% in Bt group, 5.4% in Bc group, and 15.2% in Br group, which were significantly different (P = 0.001). In pairwise comparisons, the proportions were significantly difference between Bt and Br group (P = 0.004) and Bc and Br group (P < 0.002), but not significant between Bt and Bc group (P = 0.755). Table 1 Age distribution of all patients and in each group. Parameter All patients Bt group Bc group Br group (N = 576) (N = 194) (N = 185) (N = 198) Age Mean ± SD 53.6 ± 11.5 58.1 ± 11.9 54.8 ± 11.4 48.1 ± 8.6 Median (range) 51 ( 24, 86 ) 58 ( 35, 86 ) 53 ( 31, 83 ) 48 ( 24, 74 ) < 40 52 ( 9.0% ) 12 ( 6.2% ) 10 ( 5.4% ) 30 ( 15.2% ) 40–45 81 ( 14.1% ) 13 ( 6.7% ) 24 ( 13.0% ) 44 ( 22.2% ) 45–50 114 ( 19.8% ) 30 ( 15.5% ) 38 ( 20.7% ) 46 ( 23.2% ) 50–55 91 ( 15.8% ) 28 ( 14.4% ) 27 ( 14.7% ) 36 ( 18.2% ) 55–60 65 ( 11.3% ) 22 ( 11.3% ) 24 ( 13.0% ) 19 ( 9.6% ) 60–65 66 ( 11.5% ) 30 ( 15.5% ) 21 ( 11.4% ) 15 ( 7.6% ) 65–70 46 ( 8.0% ) 25 ( 12.9% ) 15 ( 8.2% ) 6 ( 3.0% ) 70–75 33 ( 5.7% ) 17 ( 8.8% ) 14 ( 7.6% ) 2 ( 1.0% ) 75–80 18 ( 3.1% ) 10 ( 5.2% ) 8 ( 4.3% ) 0 ( 0.0% ) 80 < 10 ( 1.7% ) 7 ( 3.6% ) 3 ( 1.6% ) 0 ( 0.0% ) DRS score Mean ± SD 14.3 ± 15.9 13.8 ± 14.8 12.4 ± 14.5 16.4 ± 17.8 Median (range) 10 ( 0, 100 ) 10 ( 0, 60 ) 10 ( 0, 80 ) 15 ( 0, 100 ) SD ; standard deviation, DRS; decision regret scale. Table 2 Demographic and outcome data. Parameter Bt group (N = 194) Bc group (N = 185) Br group (N = 198) Age Value 58.1 54.8 48.1 SD 11.9 11.4 8.6 BMI Value 22.4 25.4 22.4 SD 3.9 14.1 6.6 Number % Number % Number % Smoking Yes 10 5.2 7 3.8 31 15.7 No 182 93.8 170 91.9 158 79.8 Unknown 2 1 8 4.3 9 4.5 Axillary approach SNB 46 23.7 8 4.3 28 14.1 Ax 1 0.52 5 2.7 0 0 No 144 74.2 172 93 167 84.3 Unknown 3 1.5 0 0 3 1.5 Stage 0 83 42.8 8 4.3 72 36.4 1 70 36.1 128 69.2 64 32.3 2 3 1.5 46 24.9 53 26.8 3 18 9.3 2 1.1 4 2 Unknown 1 0.52 1 0.5 5 2.5 Chemotherapy Yes 79 40.7 36 19.5 54 27.3 No 115 59.3 149 80.5 144 72.7 Radiotherapy Yes 28 14.4 163 88.1 22 11.1 No 166 85.6 22 11.9 176 88.9 Postoperative Complications (> grade 3) Yes 3 1.5 0 0 14 7.1 No 191 98.5 185 100 184 92.9 Timing of Reconstruction Immediate 43 21.7 Secondary 155 78.3 Breast Reconstruction Method SBI 129 65.2 LD 43 21.7 DIEP 26 13.1 BMI ; body mass index, SD ; standard deviation, SNB ; sentinel node biopsy, Ax ; axillary dissection, SBI ; silicone breast implant, LD ; latissimus dorsi fap, DIEP ; deep inferior epigastric artery perforator fap. Decision Regret Scores by Surgical Method (Table.3) The DRS scores by three surgical methods are shown in Table 3 . The mean DRS score was 14.3 ± 15.9 in all patients, 13.8 ± 14.8 in the Bt group, 12.4 ± 14.5 in the Bc group, and 16.4 ± 17.8 in the Br group. A one-way ANOVA revealed that there was a statistically significant difference in DRS score between at least two groups (P = 0.042). Pairwise comparisons found that DRS score was significantly different between Bc and Br group (P = 0.014), but not significantly different between Bt and Bc group (P = 0.410) and between Bt and Br group (P = 0.096). Table 3 Decision Regret Scores by Surgical Methods (N = 567*). Bt group Bc group Br group p-value** (N = 192) (N = 179) (N = 196) Mean ± SD 13.8 ± 14.8 12.4 ± 14.5 16.4 ± 17.8 0.042 Median (range) 10 ( 0, 60 ) 10 ( 0, 80 ) 15 ( 0, 100 ) Pairwise p-values*** Bt group - 0.410 0.096 Bc group - 0.014 * 10 patients have missing values of DRS. ** ANOVA test. *** Pairwise t-test. Regression Model for Predicting DRS Scores Considering Surgical Method and Age (Table.4) Table 4 shows the results of multivariate linear regression of DRS score on the surgical method and age. It revealed that there were significant main effects of group (P = 0.009) and age (P = 0.001) but there was not significant interaction effect between group and age. Figure 2 shows the equation of the estimated model. This model indicates that the difference of DRS between the Br and Bt group was 4.76 and between Br and Bc group was 4.88, and that the DRS score increases 0.216 with advancing age, regardless of the surgical method. Supplemental Table S1 show the mean and SD of DRS score by surgical methods and Age group. Table 4 Multivariate Analysis of Age and Surgical Method Group for DRS (N = 566*). Factors Coefficient 95%CI p-value**** Intercept 13.915 ( 12.511, 15.319 ) - Age** 0.216 ( 0.090, 0.343 ) 0.0008 Group*** Bt group -1.544 ( -3.507, 0.419 ) 0.0093 Bc group -1.667 ( -3.604, 0.271 ) Intersection between Age and Group Bt group 0.089 ( -0.078, 0.256 ) 0.5411 Bc group -0.002 ( -0.175, 0.171 ) - * One patient of patients with no missing value of DRS have missing of age . ** "Age" variable is centered on its mean value (= 53.466). *** We use dummy variable coding by [-1, 0, 1], e.g. "Bt" is defined as -1, 0, and 1 for Br group, Bc group, and Bt group, respectively. **** F-test whether variable(s) related to the factor are (is) needed or not. Discussion In recent years, the quality of decision-making by breast cancer patients opting for breast reconstruction and which reconstruction method best suits them has gained attention [ 21 – 23 ]. Historically, the peak age for breast reconstruction has been 40–50 years old, but there has been an expected broadening in the age range, leading to more discussion of the appropriateness of breast reconstruction in older adults [ 10 – 12 ]. The findings of this study on the age distribution of breast cancer surgeries, including mastectomy alone, breast-conserving surgery, and breast reconstruction, indicated that about half of the patients who chose mastectomy (Bt group) were aged 60 or older, while only slightly more than one in ten who chose reconstruction (Br group) were over 60. In breast-preserving cases (Bc group), Approximately 1/3 of the patients were 60 or older, which was a significantly higher proportion than that in the Br group. This suggests that breast-preserving surgeries, which do not require autologous tissue flaps, are more common in elderly patients (above 60 years old). Conversely, in patients under 40, the proportion of those opting for reconstruction was significantly higher, indicating that younger patients are more likely to choose breast reconstruction.The decision to pursue breast reconstruction should be made by weighing the risks against the benefits. In this context, there have been sporadic reports examining the safety of breast reconstruction in elderly patients, and these have indicated that the incidence of postoperative complications and rehospitalization is higher among older patients [ 24 – 28 ]. Use of tissue expanders in breast reconstruction surgery may lead to an increased risk of postoperative wound infections, delayed wound healing, and complications requiring removal of the expander [ 24 , 25 , 29 ]. However, overall, many reports indicate that the incidence of complications and delayed wound healing following reconstruction surgery is not necessarily higher compared to other age groups [24.30–34]. Evaluating the benefits of breast reconstruction is particularly important, and there has been a recent increase in studies assessing postoperative patient satisfaction and QOL using the patient-reported Breast-Q [ 35 – 37 ]. Many of these studies have found that patient satisfaction is relatively well maintained. However, satisfaction and regret can coexist, and dissatisfaction with surgical outcomes does not necessarily equate to the level of regret about undergoing surgery. In this context, the DRS most directly reflects whether the patient felt that it was beneficial to have the reconstruction and provides significant feedback for surgical decision-making. The DRS is a five-item questionnaire designed to measure regret and distress following healthcare decisions. Scores are quantified on a 0-100 scale, with higher scores indicating stronger regret. Development of an official Japanese version in 2016 has enhanced the reliability of interpreting DRS results in Japan [ 38 ]. A distinctive feature of this study is the direct assessment of the degree of postoperative regret among patients who underwent breast reconstruction (Br), mastectomy (Bt), and breast-conserving surgery (Bc) using the DRS. The average DRS scores were slightly higher in the Br group compared to the Bt and Bc groups, and regression analysis indicated that the DRS score increased with age. However, the increase, for example, at age 60 compared to age 40 (a 20-year difference) was just 0.216 x 20 = 4.32 points. This suggests that even among older adults, the increase in regret level is very modest, hardly amounting to a difference of one item among the five questions on the scale. Therefore, while regret levels do increase significantly with age, the rate of increase is minimal. Thus, although more cautious surgical criteria are desirable for older patients, age alone should not be a deterrent to opting for breast reconstruction. Since this study did not assess postoperative aesthetic outcomes, it is difficult to discuss the correlation between regret and aesthetics, and any interpretation remains speculative. However, given the general understanding that breast ptosis tends to increase with age, making aesthetic improvement more challenging, it is possible that differences in satisfaction with postoperative aesthetics contribute, at least in part, to the observed variations in regret. Factors influencing patient regret following surgery extend beyond improvements in aesthetics and QOL. Empirical evidence suggests that regret significantly decreases when patients are satisfied with the preoperative information provided by plastic surgeons [ 39 , 40 ]. Additionally, regardless of sociodemographic characteristics, patients with greater self-efficacy and confidence in obtaining appropriate medical information from healthcare providers report higher satisfaction with the information received [ 41 ]. Considering these and other significant factors, a more rigorous analysis would likely require excluding these variables to more accurately assess their impact on surgical outcomes. This study has several limitations. First, it is a retrospective, longitudinal survey of patients for more than 18 months post-surgery, and the timing of the questions asked was not standardized across cases. Consequently, the influence of the time elapsed since surgery on the level of regret could not be considered. Second, elderly patients were defined as those aged 60 and over; however, due to advances in healthcare and improved nutritional status, progression of age-related physical changes has become more gradual, making it increasingly difficult to draw a clear distinction between elderly and non-elderly cases. The definition of elderly is not standardized, with many countries defining an elderly patient as aged 65 and over. The age distribution of the patients included in this study was consistent with nationwide data published by the Japanese Ministry of Health, Labour and Welfare. For instance, the breast reconstruction rate in patients aged 80 years or older was below 2%. However, given the relatively small sample size, we cannot exclude the possibility that selection bias influenced the study results, and it remains uncertain whether this cohort accurately represents the general distribution of breast cancer patients in Japan. Conclusion The findings of this study indicate that the degree of regret associated with breast cancer reconstruction increases very gradually with age, suggesting that the justification for recommending reconstructive surgery to older patients may be insufficient. However, the magnitude of this increase may not be clinically significant. From here on, wider use of versatile and valid assessment methods, such as patient-centered assessment with the BREAST-Q, DRS, and Decision Conflict Scale, is needed for evaluation of this issue in breast reconstruction for elderly patients. Declarations Data availability Data for this study are available upon request. Funding statement Costs related to statistical analysis and manuscript publication were funded by the Department of Plastic and Reconstructive Surgery, Kyoto Prefectural University of Medicine. Declaration of competing interest No conflicts of interest. Ethics Statement The involvement of human participants in the study was reviewed and approved by the KPUM Institutional Review Board and the study was conducted in accordance with the ethical standards of institutional and national research committees (Kyoto Prefectural University of Medicine IRBMED Number ERB-C-2390-1). Participants provided written informed consent. Acknowledgements We thank Mrs. Wakako Osaka, Faculty of Nursing and Medical Care, Keio University, for editorial advice. References Japanese Breast Cancer Society Report [Internet]. https://protect2.fireeye.com/v1/url?k=31323334-501d2dca-3136e0dd-454455534531-4ab5843a6bc1ec71&q=1&e=eb4f04aa-7dde-4cb3-855e-e73372eab2c9&u=https%3A%2F%2Fmemberpage.jbcs.gr.jp%2FC52%2Fmenu_details%2F28 (accessed 10/06/2024). National Cancer Center Cancer Control Information Center. Cancer statistics in Japan; table download. cancer information service. Available: http://ganjoho.jp/reg_stat/statistics/dl/index.html [Accessed 29 Mar 2020].Google Scholar Sasada S, Kumamaru H, Hayashi N, Kinukawa N, Toi M, Jinno H, et al. Impact of immediate breast reconstruction on perioperative therapy: insights from a Japanese Nationwide Registry. Breast Cancer. 2024;31:909-916. Nomura H, Abe A, Fusegi A, Yoshimitsu T, Misaka S, Murakami A, et al. Impact of the coverage of risk-reducing salpingo-oophorectomy by the national insurance system for women with BRCA pathogenic variants in Japan. Sci Rep. 2023;13:1018. Nagura N, Hayashi N, Takei J, Yoshida A, Ochi T, Iwahira Y, et al. Breast reconstruction after risk-reducing mastectomy in BRCA mutation carriers. Breast Cancer. 2020;27:70-76. Morgan R, Brown A, Hamman KJ, Sampson J, Naik A, Massimino K. Risk management decisions in women with BRCA1 and BRCA2 mutations. Am J Surg. 2018;215:899-903. Manrique OJ, Charafeddine A, Abu-Ghname A, Banuelos J, Jacobson SR, MartinezJorge J,et al. Two-Staged Implant-Based Breast Reconstruction: A Long-Term Outcome Study in a Young Population. Medicina (Kaunas). 2019;55:481. Chen H, Zhang P, Zhang M, Wang M, Bai F, Wu K. Growing Trends of Contralateral Prophylactic Mastectomy and Reconstruction in Young Breast Cancer. J Surg Res. 2019;239:224-232. Fanakidou I, Zyga S, Alikari V, Tsironi M, Stathoulis J, Theofilou P. Mental health, loneliness, and illness perception outcomes in quality of life among young breast cancer patients after mastectomy: the role of breast reconstruction. Qual Life Res. 2018;27:539-543. Li XR, Zhang YJ, Wang JD, Cheng LQ, Liu L, Li J, et al. Application of immediate breast reconstruction with silicon prosthetic implantation following bilateral mammary gland excision in treatment of young patients with early breast cancer. J Thorac Dis. 2013;5:278-82. Yamakado R, Ishitobi M, Kondo N, Yamauchi C, Sasada S, Nogi H, et al. Collaborative Study Group of Scientific Research of the Japanese Breast Cancer Society. Physicians' perception about the impact of breast reconstruction on patient prognosis: a survey in Japan. Breast Cancer. 2023;30:302-308. Heikkinen J, Bonde C, Oranges CM, Toia F, di Summa PG, Giordano S. Efficacy of breast reconstruction in elderly women (>60 years) using deep inferior epigastric perforator flaps: A comparative study. J Plast Reconstr Aesthet Surg. 2023;84:266-272. Sada A, Day CN, Hoskin TL, Degnim AC, Habermann EB, Hieken TJ. Mastectomy and immediate breast reconstruction in the elderly: Trends and outcomes. Surgery. 2019;166:709-714. Momeni A, Kanchwala S, Sbitany H. Oncoplastic procedures in preparation for nipple-sparing mastectomy and autologous breast reconstruction: controlling the breast envelope. Plast Reconstr Surg.2020;145:914–920. Momeni A, Heier M, Torio-Padron N, Penna V, Bannasch H, Stark BG. Correlation between complication rate and patient satisfaction in abdominoplasty. Ann Plast Surg. 2009;62:5-6. Brehaut JC, O'Connor AM, Wood TJ, Hack TF, Siminoff L, Gordon E, et al. Validation of a decision regret scale. Med Decis Making. 2003;23:281-92. AMOC.Usermanual-decision regret scale. Accessed August 2, 2021 at:https://decisionaid.ohri.ca/docs/develop/User_manuals/UM_Regret_ Scale.pdf Sheehan J, Sherman KA, Lam T, Boyages J. Association of information satisfaction, psychological distress and monitoring coping style with post-decision regret following breast reconstruction. Psychooncology 2007;16:342–351. Goel V, Sawka CA, Thiel EC, Gort EH, O’Connor AM. Randomized trial of a patient decision aid for choice of surgical treatment for breast cancer. Med Decis Making 2001;21:1–6. Sheehan J, Sherman K, Lam T, Boyages J. Regret associated with the decision for breast reconstruction: The association of negative body image, distress and surgery characteristics with decision regret. Psychol Health 2008;23:207–219. Oprea N, Ardito V, Ciani O. Implementing shared decision-making interventions in breast cancer clinical practice: a scoping review. BMC Med Inform Decis Mak. 2023;23:164. Sowa Y, Inafuku N, Tsuge I, Yamanaka H, Katsube M, Sakamoto M, et al. Development and implementation of a decision aid for post-mastectomy breast reconstruction for Japanese women with breast cancer: a field-testing study. Breast Cancer. 2023;30:570-576. Politi MC, Lee CN, Philpott-Streiff SE, Foraker RE, Olsen MA, Merrill C, et al. A Randomized Controlled Trial Evaluating the BREASTChoice Tool for Personalized Decision Support About Breast Reconstruction After Mastectomy. Ann Surg. 2020;271:230-237. Oh DD, Flitcroft K, Brennan ME, et al. Patterns and outcomes of breast reconstruction in older women a systematic review of the literature. Eur J Surg Oncol. 2016;42:604-15. Gibreel WO, Day CN, Hoskin TL, et al. Mastectomy and immediate breast reconstruction for cancer in the elderly a National Cancer Data Base study. J Am Coll Surg. 2017;224: 895-905. In H, Jiang W, Lipsitz SR, et al. Variation in the utilization of reconstruction following mastectomy in elderly women. Ann Surg Oncol. 20: 1872-9, 2013 Butz DR, Lapin B, Yao K, et al. Advanced age is a predictor of 30-day complications after autologous but not implant-based postmastectomy breast reconstruction. Plast Reconstr Surg. 135: 253 e-61 e, 2015 Jeevan R, Cromwell DA, Browne JP, Trivella M, Pereira J, Caddy CM, et al. Regional variation in use of immediate breast reconstruction after mastectomy for breast cancer in England. Eur J Surg Oncol. 2010;36(8):750-5. Hanwright PJ, Davila AA, Mioton LM, Fine NA, Bilimoria KY, Kim JY. A predictive model of risk and outcomes in tissue expander reconstruction: a multivariate analysis of 9786 patients. J Plast Surg Hand Surg. 2013;47:513-8. Santosa KB, Qi J, Kim HM, Hamill JB, Pusic AL, Wilkins EG. Effect of Patient Age on Outcomes in Breast Reconstruction: Results from a Multicenter Prospective Study. J Am Coll Surg. 2016;223:745-754. Seidenstuecker K, Munder B, Mahajan AL, Richrath P, Behrendt P, Andree C. Morbidity of microsurgical breast reconstruction in patients with comorbid conditions. Plast Reconstr Surg. 2011;127:1086-1092. Xue DQ, Qian C, Yang L, Wang XF. Risk factors for surgical site infections after breast surgery: a systematic review and meta-analysis. Eur J Surg Oncol. 2012;38:375-81. Massenburg BB, Sanati-Mehrizy P, Ingargiola MJ, et al. Flap failure and wound complications in autologous breast reconstruction a national perspective. Aesthetic Plast Surg. 39: 902-9, 2015 Klasson S, Nyman J, Svensson H, Velander P. Smoking increases donor site complications in breast reconstruction with DIEP flap. J Plast Surg Hand Surg. 2016;50:331-335. Danko D, Ash ME, Brown OH, Losken A, Thompson PW. Implant-Based Breast Reconstruction in the Elderly: Complications and Patient-Reported Outcomes in Women Older Than 70 Years. Ann Plast Surg. 2023;91:55-61. Kim M, Ali B, Zhang K, Vingan P, Boe L, Ly CL, et al. Age Impacts Clinical and Patient Reported Outcomes following Post Mastectomy Breast Reconstruction. Plast Reconstr Surg. 2024; Epub ahead of print. Santosa KB, Qi J, Kim HM, Hamill JB, Pusic AL, Wilkins EG. Effect of Patient Age on Outcomes in Breast Reconstruction: Results from a Multicenter Prospective Study. J Am Coll Surg. 2016;223:745-754. Tanno K, Bito S, Isobe Y, Takagi Y. Validation of a Japanese Version of the Decision Regret Scale. J Nurs Meas. 2016;24: E44-54. Haworth, J. E., Moniz, D., & Lane, I. F. Patient satisfaction and the role of preoperative information in elective surgery. British Journal of Surgery. 2014;101:1004-1011. Honigman RJ, Phillips KA, Castle DJ. A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004;113:1229-37. Smith SG, Pandit A, Rush SR, Wolf MS, Simon CJ. The Role of Patient Activation in Preferences for Shared Decision Making: Results From a National Survey of U.S. Adults. J Health Commun. 2016;21:67-75. Supplementary Files SuppTable.1.docx Table S1: DRS scores by surgical methods and age groups Cite Share Download PDF Status: Published Journal Publication published 04 May, 2025 Read the published version in Breast Cancer → Version 1 posted Reviewers agreed at journal 27 Mar, 2025 Reviewers invited by journal 26 Mar, 2025 Editor assigned by journal 26 Mar, 2025 First submitted to journal 25 Mar, 2025 Editorial decision: Minor Revision 04 Feb, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5767750","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":434514326,"identity":"2f00917e-badf-41ce-9277-816054dc2f2a","order_by":0,"name":"Yoshihiro Sowa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYBADOQkwdQAuwEZQi7EEAzOJWhJnoGnBDeTbeww/89TcSZ/Z3n/wAcOZO4kNYgcYP/xg4MvDpcXgzBljaZ5jz3Jn8xxmNmC48SyxQTqBWbKHga0YpxaJ3A3SOWyHc+dJJLNJMHw4nLj/dgKDNNAviQ24HDYjd/PvnH+H0+VgWkC2/ManheFG7jbp3LbDCdJgLTfAWtjw2mJw5vw36799hw1n9hw2Nkg488y4QTqxzbLHALdf5Nvbkm/O+HZYXuJ448MHH47dkW2QTj5840fFMZwhhgoSwBHDCHSSwbEE4rQgxWUN0VpGwSgYBaNg2AMAEnZZ4d9xDVAAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-7112-1630","institution":"Kyoto University Graduate School of Medicine Faculty of Medicine: Kyoto Daigaku Daigakuin Igaku Kenkyuka Igakubu","correspondingAuthor":true,"prefix":"","firstName":"Yoshihiro","middleName":"","lastName":"Sowa","suffix":""},{"id":434514327,"identity":"a3ea99e5-5478-4cc5-a0d1-91e2ae22d43d","order_by":1,"name":"Hirohito Seki","email":"","orcid":"","institution":"Kyorin University Faculty of Medicine: Kyorin Daigaku Igakubu Daigakuin Igaku Kenkyuka","correspondingAuthor":false,"prefix":"","firstName":"Hirohito","middleName":"","lastName":"Seki","suffix":""},{"id":434514328,"identity":"334fa95b-6082-4ccf-b224-db742b8cf1c3","order_by":2,"name":"Hiroyasu Abe","email":"","orcid":"","institution":"Wakayama Medical University - Kimiidera Campus: Wakayama Kenritsu Ika Daigaku","correspondingAuthor":false,"prefix":"","firstName":"Hiroyasu","middleName":"","lastName":"Abe","suffix":""},{"id":434514329,"identity":"15f51833-5dfa-4fa5-be73-15bf082f5115","order_by":3,"name":"Takako Komiya","email":"","orcid":"","institution":"Tokyo Medical University: Tokyo Ika Daigaku","correspondingAuthor":false,"prefix":"","firstName":"Takako","middleName":"","lastName":"Komiya","suffix":""},{"id":434514330,"identity":"e890511d-1451-4d99-b02f-4eeba2b1daea","order_by":4,"name":"Maho Kato","email":"","orcid":"","institution":"Aichi Medical University: Aichi Ika Daigaku","correspondingAuthor":false,"prefix":"","firstName":"Maho","middleName":"","lastName":"Kato","suffix":""},{"id":434514331,"identity":"0d4818dd-8d16-453a-980b-469a5ef1b1ca","order_by":5,"name":"Junji Takano","email":"","orcid":"","institution":"Saitama City Medical Center: Shakai Iryo Hojin Saitama Shimin Iryo Center","correspondingAuthor":false,"prefix":"","firstName":"Junji","middleName":"","lastName":"Takano","suffix":""},{"id":434514332,"identity":"022f1025-7a19-4ac7-bbbf-a567d7f471b9","order_by":6,"name":"Kotaro Yoshimura","email":"","orcid":"","institution":"Jichi Medical University: Jichi Ika Daigaku","correspondingAuthor":false,"prefix":"","firstName":"Kotaro","middleName":"","lastName":"Yoshimura","suffix":""},{"id":434514333,"identity":"b05a1563-0913-4ff7-8fde-469d993d6301","order_by":7,"name":"Miho Saiga","email":"","orcid":"","institution":"Okayama University: Okayama Daigaku","correspondingAuthor":false,"prefix":"","firstName":"Miho","middleName":"","lastName":"Saiga","suffix":""}],"badges":[],"createdAt":"2025-01-05 12:31:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5767750/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5767750/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s12282-025-01709-3","type":"published","date":"2025-05-04T15:57:40+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79907540,"identity":"b8dda04b-f607-4385-b287-907ce44d1bc9","added_by":"auto","created_at":"2025-04-04 11:12:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":74417,"visible":true,"origin":"","legend":"\u003cp\u003eThe Decision Regret Scale questionnaire\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5767750/v1/211eb9bd363010d30c6a48e4.png"},{"id":79907541,"identity":"732e01b9-036b-4e52-bcaa-086b63eda882","added_by":"auto","created_at":"2025-04-04 11:12:02","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003eThe regression model for predicting DRS scores\u003c/p\u003e","description":"","filename":"placeholderimage.png","url":"https://assets-eu.researchsquare.com/files/rs-5767750/v1/308892e9ccc48c5b5dde668e.png"},{"id":81988474,"identity":"1b933d0c-fa2b-4c52-992b-5032e20a0b15","added_by":"auto","created_at":"2025-05-05 16:08:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":767493,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5767750/v1/57970853-d17b-44d1-9c01-09defb7796d5.pdf"},{"id":79907546,"identity":"5a8fddb8-b2a7-4b84-9ff2-b2281655d839","added_by":"auto","created_at":"2025-04-04 11:12:02","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24519,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTable S1:\u003c/strong\u003e DRS scores by surgical methods and age groups\u003c/p\u003e","description":"","filename":"SuppTable.1.docx","url":"https://assets-eu.researchsquare.com/files/rs-5767750/v1/63c5b25252ebe153de13c16f.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003eInfluence of age on patient decision regret following breast reconstruction: A multicenter collaborative study in Japan\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAppearance and quality of life (QOL) after breast cancer treatment are important because the prognosis for many breast cancer cases is relatively good. In Japan, breast implant reconstruction became covered by insurance in 2013, increasing patient awareness and choices for breast reconstruction [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Additionally, advances in genetic diagnostics have identified the presence of hereditary breast and ovarian cancer syndrome (HBOC), leading to insurance coverage for risk-reducing mastectomy in BRCA mutation carriers starting in April 2020 [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. With these changes, it is likely that breast reconstruction procedures will continue to increase.\u003c/p\u003e \u003cp\u003eThe number of patients with breast cancer in the adolescent \u0026amp; young adult (AYA) generation has risen [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], but the proportion of older adults with breast cancer has also increased in Japan's aging society, leading to more opportunities for breast reconstruction in elderly patients [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, concerns about increased complications and a perceived lower interest in body image among older patients mean that some reconstructive surgeons still consider elderly patients to be relatively contraindicated for breast reconstruction.\u003c/p\u003e \u003cp\u003eIn breast cancer surgery, options such as mastectomy (Bt) aim for both curative outcomes and maintenance of aesthetics to preserve QOL through breast-conserving surgery (Bc) and breast reconstruction (Br). Despite the expected expansion of the applicable age range, there are few multicenter studies of the age distribution and surgical techniques chosen for breast reconstruction in Japan. Furthermore, surgical outcomes may not always be satisfactory, and there has been insufficient assessment of whether younger or older patients experience regret following breast reconstruction.\u003c/p\u003e \u003cp\u003eThe objective of this study is to investigate the age distribution of patients with breast cancer in Japan through a multicenter collaborative study and to examine the impact of age on post-surgical decision regret and by type of surgery. Clarification of the influence of age on satisfaction after breast reconstruction could aid with decision-making in choice of cancer surgery and may improve the overall quality of breast cancer treatment.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy Design and Setting\u003c/p\u003e \u003cp\u003eA multicenter observational retrospective study was conducted in surgical facilities in Japan certified by the Japanese Society of Breast Oncoplastic Surgery (JOPBS). University hospitals, including Jichi Medical University, and general municipal hospitals that perform more than 50 breast cancer surgeries and more than 20 breast reconstructions per year\u0026mdash;representing an average case volume for Japan\u0026mdash;were included in the study. In contrast, high-volume centers with more than 50 breast cancer surgeries per year or institutions with fewer than 20 cases annually were not included as participating study sites. The subjects were 576 female patients aged 20 and older who were diagnosed with breast cancer pathologically and underwent mastectomy (Bt: 194 cases), breast-conserving surgery (Bc: 185 cases), or breast reconstruction (Br: 198 cases) between August 1, 2013, and July 31, 2021, and had follow-up of at least 18 months. The following exclusion criteria were established: 1) bilateral breast cancer, 2) secondary breast reconstruction, 3) breast cancer at stage 4 or higher, 4) diagnosis of breast cancer recurrence or distant metastasis, 5) an inserted expander, 6) history of surgery on the contralateral breast, such as mastopexy or augmentation, 7) treatment for other malignant diseases, 8) pregnancy or breastfeeding, 9) difficulty responding to questionnaires in Japanese, 10) patients deemed unsuitable by the physician, and 11) patients who refused to participate in the study.\u003c/p\u003e \u003cp\u003eDemographic and Outcomes Data\u003c/p\u003e \u003cp\u003eDemographic and outcome data were collected. Basic information included a subject identification code, date of birth, age, body mass index (BMI), and smoking history. Clinical data related to breast cancer treatment encompassed clinical stage, lesion site, date of surgery, presence of axillary dissection, and whether chemotherapy or radiotherapy was administered. Severe postoperative complications were also recorded, and were defined as those requiring hospital management or surgical intervention, such as flap necrosis or implant replacement [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDecision Regret Scale (DRS)\u003c/p\u003e \u003cp\u003eThe DRS was selected as the outcome measure (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The DRS consists of five items that are answered on a Likert scale from 1\u0026thinsp;=\u0026thinsp;strongly agree to 5\u0026thinsp;=\u0026thinsp;strongly disagree. Scores range from 0 to 100, with higher scores indicating a greater level of regret regarding the decision to undergo breast reconstruction.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA more detailed explanation, including the method for calculating DRS, is explained in detail on the following website (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://decisionaid.ohri.ca/docs/develop/User_Manuals/UM_Regret_Scale.pdf\u003c/span\u003e\u003cspan address=\"https://decisionaid.ohri.ca/docs/develop/User_Manuals/UM_Regret_Scale.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). In a short introductory statement, respondents should be asked to reflect on a specific past decision, and then asked to indicate the extent to which they agree or disagree with the statements in the regret scale by indicating a number from 1 (Strongly Agree) to 5 (Strongly Disagree) that best indicates their level of agreement. The Decision Regret Scale questionnaire is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Psychometric evaluations of this scale have shown high internal consistency (Cronbach's α\u0026thinsp;=\u0026thinsp;0.86), and the utility of the DRS has been well-validated in patients with breast cancer and those undergoing breast reconstruction [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eContinuous variables are expressed as means, standard deviations, medians, and minimum and maximum values. Categorical variables are shown as frequencies and proportions. Age is summarized in age groups of five-year increments. All descriptive statistics were calculated by reconstruction methods. The proportions of patients over 60 and under 40 years old were compared among reconstruction method groups by chi-squared test and pairwise comparisons are conducted by chi-squared test. The means DRS score was compared among reconstruction methods by one-way analysis of variance (ANOVA). If the ANOVA test was significant, pairwise comparison by two sample t-test was conducted. DRS score was summarized for each surgical procedure and age groups. Multivariate linear regression was used to investigate the main effects of surgical methods and age (as continual variable), and the interaction effect between the two. All reported P-values are two-sided and P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant. Statistical analyses were performed using JMP Pro ver. 18 (SAS Institute, Inc., Cary, NC, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAge Distribution in Each Group\u003c/p\u003e \u003cp\u003eThe age distribution in each group and demographic and outcome data are shown in Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The mean age was 53.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5 years for all patients, 58.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11.9 years in the Bt group, 54.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5 years in the Bc group, and 48.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6 years in the Br group. In the Bt group, the age peak was between 60 and 70 years, whereas the peaks in the Bc and Br groups were between 40 and 50 years. The proportions of patients over 60 were 45.9% in Bt group, 33.2% in Bc group, and 11.6% in Br group, which were significantly different (P\u0026thinsp;\u0026lt;\u0026thinsp;0.000). In pairwise comparisons, the proportions were significantly difference between all two pairs of the groups (Bt vs Bc: P\u0026thinsp;=\u0026thinsp;0.0115; Bt vs Br: P\u0026thinsp;\u0026lt;\u0026thinsp;0.000; Bc vs Br: P\u0026thinsp;\u0026lt;\u0026thinsp;0.000). The proportions of patients under 40 were 6.2% in Bt group, 5.4% in Bc group, and 15.2% in Br group, which were significantly different (P\u0026thinsp;=\u0026thinsp;0.001). In pairwise comparisons, the proportions were significantly difference between Bt and Br group (P\u0026thinsp;=\u0026thinsp;0.004) and Bc and Br group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.002), but not significant between Bt and Bc group (P\u0026thinsp;=\u0026thinsp;0.755).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAge distribution of all patients and in each group.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBt group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBc group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBr group\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;576)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;194)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;185)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;198)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 ( 24, 86 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 ( 35, 86 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53 ( 31, 83 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48 ( 24, 74 )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 ( 9.0% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 ( 6.2% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 ( 5.4% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30 ( 15.2% )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81 ( 14.1% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 ( 6.7% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 ( 13.0% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e44 ( 22.2% )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114 ( 19.8% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 ( 15.5% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38 ( 20.7% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e46 ( 23.2% )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u0026ndash;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 ( 15.8% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 ( 14.4% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 ( 14.7% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36 ( 18.2% )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 ( 11.3% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 ( 11.3% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 ( 13.0% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19 ( 9.6% )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u0026ndash;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66 ( 11.5% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 ( 15.5% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 ( 11.4% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15 ( 7.6% )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 ( 8.0% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 ( 12.9% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 ( 8.2% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 ( 3.0% )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u0026ndash;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 ( 5.7% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 ( 8.8% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 ( 7.6% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 ( 1.0% )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75\u0026ndash;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 ( 3.1% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 ( 5.2% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 ( 4.3% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 ( 0.0% )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 \u0026lt;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 ( 1.7% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 ( 3.6% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 ( 1.6% )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 ( 0.0% )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDRS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.8\u0026thinsp;\u0026plusmn;\u0026thinsp;14.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;17.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 ( 0, 100 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 ( 0, 60 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 ( 0, 80 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15 ( 0, 100 )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003e\u003cem\u003eSD\u003c/em\u003e; standard deviation, DRS; decision regret scale.\u0026nbsp;\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and outcome data.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eBt group (N\u0026thinsp;=\u0026thinsp;194)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eBc group (N\u0026thinsp;=\u0026thinsp;185)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eBr group (N\u0026thinsp;=\u0026thinsp;198)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e58.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e54.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e48.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e22.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e25.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e22.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e91.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e79.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAxillary approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSNB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e84.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eStage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e36.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e69.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e32.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e26.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e27.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e80.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e72.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRadiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e88.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePostoperative Complications (\u0026gt;\u0026thinsp;grade 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e98.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e92.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTiming of Reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImmediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"4\" nameend=\"c4\" namest=\"c3\" rowspan=\"5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"4\" nameend=\"c6\" namest=\"c5\" rowspan=\"5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e21.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e78.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eBreast Reconstruction Method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSBI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e65.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e21.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDIEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \n\u003cp\u003e\u003cem\u003eBMI\u003c/em\u003e; body mass index,\u0026nbsp;\u003cem\u003eSD\u003c/em\u003e; standard deviation,\u0026nbsp;\u003cem\u003eSNB\u003c/em\u003e;\u0026nbsp;sentinel node biopsy, \u003cem\u003eAx\u003c/em\u003e; axillary dissection, \u003cem\u003eSBI\u003c/em\u003e; silicone breast implant, \u003cem\u003eLD\u003c/em\u003e; latissimus dorsi fap, \u003cem\u003eDIEP\u003c/em\u003e; deep inferior epigastric artery perforator fap.\u003c/p\u003e\n\u003cp\u003eDecision Regret Scores by Surgical Method (Table.3)\u003c/p\u003e \u003cp\u003eThe DRS scores by three surgical methods are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The mean DRS score was 14.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.9 in all patients, 13.8\u0026thinsp;\u0026plusmn;\u0026thinsp;14.8 in the Bt group, 12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5 in the Bc group, and 16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;17.8 in the Br group. A one-way ANOVA revealed that there was a statistically significant difference in DRS score between at least two groups (P\u0026thinsp;=\u0026thinsp;0.042). Pairwise comparisons found that DRS score was significantly different between Bc and Br group (P\u0026thinsp;=\u0026thinsp;0.014), but not significantly different between Bt and Bc group (P\u0026thinsp;=\u0026thinsp;0.410) and between Bt and Br group (P\u0026thinsp;=\u0026thinsp;0.096).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDecision Regret Scores by Surgical Methods (N\u0026thinsp;=\u0026thinsp;567*).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBt group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBc group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBr group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value**\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;192)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;179)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;196)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.8\u0026thinsp;\u0026plusmn;\u0026thinsp;14.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;17.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 ( 0, 60 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 ( 0, 80 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 ( 0, 100 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePairwise p-values***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBt group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.410\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.096\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBc group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e* 10 patients have missing values of DRS.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e** ANOVA test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*** Pairwise t-test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegression Model for Predicting DRS Scores Considering Surgical Method and Age (Table.4)\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the results of multivariate linear regression of DRS score on the surgical method and age. It revealed that there were significant main effects of group (P\u0026thinsp;=\u0026thinsp;0.009) and age (P\u0026thinsp;=\u0026thinsp;0.001) but there was not significant interaction effect between group and age. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the equation of the estimated model. This model indicates that the difference of DRS between the Br and Bt group was 4.76 and between Br and Bc group was 4.88, and that the DRS score increases 0.216 with advancing age, regardless of the surgical method. Supplemental Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e show the mean and SD of DRS score by surgical methods and Age group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate Analysis of Age and Surgical Method Group for DRS (N\u0026thinsp;=\u0026thinsp;566*).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCoefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value****\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.915\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e( 12.511, 15.319 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e( 0.090, 0.343 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBt group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.544\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e( -3.507, 0.419 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0093\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBc group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.667\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e( -3.604, 0.271 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntersection between Age and Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBt group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e( -0.078, 0.256 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.5411\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBc group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e( -0.175, 0.171 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e* One patient of patients with no missing value of DRS have missing of age .\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e** \"Age\" variable is centered on its mean value (=\u0026thinsp;53.466).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*** We use dummy variable coding by [-1, 0, 1], e.g. \"Bt\" is defined as -1, 0, and 1 for Br group, Bc group, and Bt group, respectively.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e**** F-test whether variable(s) related to the factor are (is) needed or not.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn recent years, the quality of decision-making by breast cancer patients opting for breast reconstruction and which reconstruction method best suits them has gained attention [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Historically, the peak age for breast reconstruction has been 40\u0026ndash;50 years old, but there has been an expected broadening in the age range, leading to more discussion of the appropriateness of breast reconstruction in older adults [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe findings of this study on the age distribution of breast cancer surgeries, including mastectomy alone, breast-conserving surgery, and breast reconstruction, indicated that about half of the patients who chose mastectomy (Bt group) were aged 60 or older, while only slightly more than one in ten who chose reconstruction (Br group) were over 60. In breast-preserving cases (Bc group), Approximately 1/3 of the patients were 60 or older, which was a significantly higher proportion than that in the Br group. This suggests that breast-preserving surgeries, which do not require autologous tissue flaps, are more common in elderly patients (above 60 years old). Conversely, in patients under 40, the proportion of those opting for reconstruction was significantly higher, indicating that younger patients are more likely to choose breast reconstruction.The decision to pursue breast reconstruction should be made by weighing the risks against the benefits. In this context, there have been sporadic reports examining the safety of breast reconstruction in elderly patients, and these have indicated that the incidence of postoperative complications and rehospitalization is higher among older patients [\u003cspan additionalcitationids=\"CR25 CR26 CR27\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Use of tissue expanders in breast reconstruction surgery may lead to an increased risk of postoperative wound infections, delayed wound healing, and complications requiring removal of the expander [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, overall, many reports indicate that the incidence of complications and delayed wound healing following reconstruction surgery is not necessarily higher compared to other age groups [24.30\u0026ndash;34].\u003c/p\u003e \u003cp\u003eEvaluating the benefits of breast reconstruction is particularly important, and there has been a recent increase in studies assessing postoperative patient satisfaction and QOL using the patient-reported Breast-Q [\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Many of these studies have found that patient satisfaction is relatively well maintained. However, satisfaction and regret can coexist, and dissatisfaction with surgical outcomes does not necessarily equate to the level of regret about undergoing surgery. In this context, the DRS most directly reflects whether the patient felt that it was beneficial to have the reconstruction and provides significant feedback for surgical decision-making.\u003c/p\u003e \u003cp\u003eThe DRS is a five-item questionnaire designed to measure regret and distress following healthcare decisions. Scores are quantified on a 0-100 scale, with higher scores indicating stronger regret. Development of an official Japanese version in 2016 has enhanced the reliability of interpreting DRS results in Japan [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. A distinctive feature of this study is the direct assessment of the degree of postoperative regret among patients who underwent breast reconstruction (Br), mastectomy (Bt), and breast-conserving surgery (Bc) using the DRS. The average DRS scores were slightly higher in the Br group compared to the Bt and Bc groups, and regression analysis indicated that the DRS score increased with age. However, the increase, for example, at age 60 compared to age 40 (a 20-year difference) was just 0.216 x 20\u0026thinsp;=\u0026thinsp;4.32 points. This suggests that even among older adults, the increase in regret level is very modest, hardly amounting to a difference of one item among the five questions on the scale. Therefore, while regret levels do increase significantly with age, the rate of increase is minimal. Thus, although more cautious surgical criteria are desirable for older patients, age alone should not be a deterrent to opting for breast reconstruction.\u003c/p\u003e \u003cp\u003eSince this study did not assess postoperative aesthetic outcomes, it is difficult to discuss the correlation between regret and aesthetics, and any interpretation remains speculative. However, given the general understanding that breast ptosis tends to increase with age, making aesthetic improvement more challenging, it is possible that differences in satisfaction with postoperative aesthetics contribute, at least in part, to the observed variations in regret. Factors influencing patient regret following surgery extend beyond improvements in aesthetics and QOL. Empirical evidence suggests that regret significantly decreases when patients are satisfied with the preoperative information provided by plastic surgeons [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Additionally, regardless of sociodemographic characteristics, patients with greater self-efficacy and confidence in obtaining appropriate medical information from healthcare providers report higher satisfaction with the information received [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Considering these and other significant factors, a more rigorous analysis would likely require excluding these variables to more accurately assess their impact on surgical outcomes.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, it is a retrospective, longitudinal survey of patients for more than 18 months post-surgery, and the timing of the questions asked was not standardized across cases. Consequently, the influence of the time elapsed since surgery on the level of regret could not be considered. Second, elderly patients were defined as those aged 60 and over; however, due to advances in healthcare and improved nutritional status, progression of age-related physical changes has become more gradual, making it increasingly difficult to draw a clear distinction between elderly and non-elderly cases. The definition of elderly is not standardized, with many countries defining an elderly patient as aged 65 and over. The age distribution of the patients included in this study was consistent with nationwide data published by the Japanese Ministry of Health, Labour and Welfare. For instance, the breast reconstruction rate in patients aged 80 years or older was below 2%. However, given the relatively small sample size, we cannot exclude the possibility that selection bias influenced the study results, and it remains uncertain whether this cohort accurately represents the general distribution of breast cancer patients in Japan.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study indicate that the degree of regret associated with breast cancer reconstruction increases very gradually with age, suggesting that the justification for recommending reconstructive surgery to older patients may be insufficient. However, the magnitude of this increase may not be clinically significant. From here on, wider use of versatile and valid assessment methods, such as patient-centered assessment with the BREAST-Q, DRS, and Decision Conflict Scale, is needed for evaluation of this issue in breast reconstruction for elderly patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData for this study are available upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCosts related to statistical analysis and manuscript publication were funded by the Department of Plastic and Reconstructive Surgery, Kyoto Prefectural University of Medicine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe involvement of human participants in the study was reviewed and approved by the KPUM Institutional Review Board and the study was conducted in accordance with the ethical standards of institutional and national research committees (Kyoto Prefectural University of Medicine IRBMED Number ERB-C-2390-1). Participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Mrs. Wakako Osaka, Faculty of Nursing and Medical Care, Keio University, for editorial advice.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eJapanese Breast Cancer Society Report [Internet]. https://protect2.fireeye.com/v1/url?k=31323334-501d2dca-3136e0dd-454455534531-4ab5843a6bc1ec71\u0026amp;q=1\u0026amp;e=eb4f04aa-7dde-4cb3-855e-e73372eab2c9\u0026amp;u=https%3A%2F%2Fmemberpage.jbcs.gr.jp%2FC52%2Fmenu_details%2F28 (accessed 10/06/2024).\u003c/li\u003e\n \u003cli\u003eNational Cancer Center Cancer Control Information Center. Cancer statistics in Japan; table download. cancer information service. Available: http://ganjoho.jp/reg_stat/statistics/dl/index.html [Accessed 29 Mar 2020].Google Scholar\u003c/li\u003e\n \u003cli\u003eSasada S, Kumamaru H, Hayashi N, Kinukawa N, Toi M, Jinno H, et al. Impact of immediate breast reconstruction on perioperative therapy: insights from a Japanese Nationwide Registry. Breast Cancer. 2024;31:909-916.\u003c/li\u003e\n \u003cli\u003eNomura H, Abe A, Fusegi A, Yoshimitsu T, Misaka S, Murakami A, et al. Impact of the coverage of risk-reducing salpingo-oophorectomy by the national insurance system for women with BRCA pathogenic variants in Japan. Sci Rep. 2023;13:1018.\u003c/li\u003e\n \u003cli\u003eNagura N, Hayashi N, Takei J, Yoshida A, Ochi T, Iwahira Y, et al. Breast reconstruction after risk-reducing mastectomy in BRCA mutation carriers. Breast Cancer. 2020;27:70-76.\u003c/li\u003e\n \u003cli\u003eMorgan R, Brown A, Hamman KJ, Sampson J, Naik A, Massimino K. Risk management decisions in women with BRCA1 and BRCA2 mutations. Am J Surg. 2018;215:899-903.\u003c/li\u003e\n \u003cli\u003eManrique OJ, Charafeddine A, Abu-Ghname A, Banuelos J, Jacobson SR, MartinezJorge J,et al. Two-Staged Implant-Based Breast Reconstruction: A Long-Term Outcome Study in a Young Population. Medicina (Kaunas). 2019;55:481.\u003c/li\u003e\n \u003cli\u003eChen H, Zhang P, Zhang M, Wang M, Bai F, Wu K. Growing Trends of Contralateral Prophylactic Mastectomy and Reconstruction in Young Breast Cancer. J Surg Res. 2019;239:224-232.\u003c/li\u003e\n \u003cli\u003eFanakidou I, Zyga S, Alikari V, Tsironi M, Stathoulis J, Theofilou P. Mental health, loneliness, and illness perception outcomes in quality of life among young breast cancer patients after mastectomy: the role of breast reconstruction. Qual Life Res. 2018;27:539-543.\u003c/li\u003e\n \u003cli\u003eLi XR, Zhang YJ, Wang JD, Cheng LQ, Liu L, Li J, et al. Application of immediate breast reconstruction with silicon prosthetic implantation following bilateral mammary gland excision in treatment of young patients with early breast cancer. J Thorac Dis. 2013;5:278-82.\u003c/li\u003e\n \u003cli\u003eYamakado R, Ishitobi M, Kondo N, Yamauchi C, Sasada S, Nogi H, et al. Collaborative Study Group of Scientific Research of the Japanese Breast Cancer Society. Physicians\u0026apos; perception about the impact of breast reconstruction on patient prognosis: a survey in Japan. Breast Cancer. 2023;30:302-308.\u003c/li\u003e\n \u003cli\u003eHeikkinen J, Bonde C, Oranges CM, Toia F, di Summa PG, Giordano S. Efficacy of breast reconstruction in elderly women (\u0026gt;60 years) using deep inferior epigastric perforator flaps: A comparative study. J Plast Reconstr Aesthet Surg. 2023;84:266-272.\u003c/li\u003e\n \u003cli\u003eSada A, Day CN, Hoskin TL, Degnim AC, Habermann EB, Hieken TJ. Mastectomy and immediate breast reconstruction in the elderly: Trends and outcomes. Surgery. 2019;166:709-714.\u003c/li\u003e\n \u003cli\u003eMomeni A, Kanchwala S, Sbitany H. Oncoplastic procedures in preparation for nipple-sparing mastectomy and autologous breast reconstruction: controlling the breast envelope. Plast Reconstr Surg.2020;145:914\u0026ndash;920.\u003c/li\u003e\n \u003cli\u003eMomeni A, Heier M, Torio-Padron N, Penna V, Bannasch H, Stark BG. Correlation between complication rate and patient satisfaction in abdominoplasty. Ann Plast Surg. 2009;62:5-6.\u003c/li\u003e\n \u003cli\u003eBrehaut JC, O\u0026apos;Connor AM, Wood TJ, Hack TF, Siminoff L, Gordon E, et al. Validation of a decision regret scale. Med Decis Making. 2003;23:281-92.\u003c/li\u003e\n \u003cli\u003eAMOC.Usermanual-decision regret scale. Accessed August 2, 2021 at:https://decisionaid.ohri.ca/docs/develop/User_manuals/UM_Regret_ Scale.pdf\u003c/li\u003e\n \u003cli\u003eSheehan J, Sherman KA, Lam T, Boyages J. Association of information satisfaction, psychological distress and monitoring coping style with post-decision regret following breast reconstruction. Psychooncology 2007;16:342\u0026ndash;351.\u003c/li\u003e\n \u003cli\u003eGoel V, Sawka CA, Thiel EC, Gort EH, O\u0026rsquo;Connor AM. Randomized trial of a patient decision aid for choice of surgical treatment for breast cancer. Med Decis Making 2001;21:1\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eSheehan J, Sherman K, Lam T, Boyages J. Regret associated with the decision for breast reconstruction: The association of negative body image, distress and surgery characteristics with decision regret. Psychol Health 2008;23:207\u0026ndash;219.\u003c/li\u003e\n \u003cli\u003eOprea N, Ardito V, Ciani O. Implementing shared decision-making interventions in breast cancer clinical practice: a scoping review. BMC Med Inform Decis Mak. 2023;23:164.\u003c/li\u003e\n \u003cli\u003eSowa Y, Inafuku N, Tsuge I, Yamanaka H, Katsube M, Sakamoto M, et al. Development and implementation of a decision aid for post-mastectomy breast reconstruction for Japanese women with breast cancer: a field-testing study. Breast Cancer. 2023;30:570-576.\u003c/li\u003e\n \u003cli\u003ePoliti MC, Lee CN, Philpott-Streiff SE, Foraker RE, Olsen MA, Merrill C, et al. A Randomized Controlled Trial Evaluating the BREASTChoice Tool for Personalized Decision Support About Breast Reconstruction After Mastectomy. Ann Surg. 2020;271:230-237.\u003c/li\u003e\n \u003cli\u003eOh DD, Flitcroft K, Brennan ME, et al. Patterns and outcomes of breast reconstruction in older women a systematic review of the literature. Eur J Surg Oncol. 2016;42:604-15.\u003c/li\u003e\n \u003cli\u003eGibreel WO, Day CN, Hoskin TL, et al. Mastectomy and immediate breast reconstruction for cancer in the elderly a National Cancer Data Base study. J Am Coll Surg. 2017;224: 895-905.\u003c/li\u003e\n \u003cli\u003eIn H, Jiang W, Lipsitz SR, et al. Variation in the utilization of reconstruction following mastectomy in elderly women. Ann Surg Oncol. 20: 1872-9, 2013\u003c/li\u003e\n \u003cli\u003eButz DR, Lapin B, Yao K, et al. Advanced age is a predictor of 30-day complications after autologous but not implant-based postmastectomy breast reconstruction. Plast Reconstr Surg. 135: 253 e-61 e, 2015\u003c/li\u003e\n \u003cli\u003eJeevan R, Cromwell DA, Browne JP, Trivella M, Pereira J, Caddy CM, et al. Regional variation in use of immediate breast reconstruction after mastectomy for breast cancer in England. Eur J Surg Oncol. 2010;36(8):750-5.\u003c/li\u003e\n \u003cli\u003eHanwright PJ, Davila AA, Mioton LM, Fine NA, Bilimoria KY, Kim JY. A predictive model of risk and outcomes in tissue expander reconstruction: a multivariate analysis of 9786 patients. J Plast Surg Hand Surg. 2013;47:513-8.\u003c/li\u003e\n \u003cli\u003eSantosa KB, Qi J, Kim HM, Hamill JB, Pusic AL, Wilkins EG. Effect of Patient Age on Outcomes in Breast Reconstruction: Results from a Multicenter Prospective Study. J Am Coll Surg. 2016;223:745-754.\u003c/li\u003e\n \u003cli\u003eSeidenstuecker K, Munder B, Mahajan AL, Richrath P, Behrendt P, Andree C. Morbidity of microsurgical breast reconstruction in patients with comorbid conditions. Plast Reconstr Surg. 2011;127:1086-1092.\u003c/li\u003e\n \u003cli\u003eXue DQ, Qian C, Yang L, Wang XF. Risk factors for surgical site infections after breast surgery: a systematic review and meta-analysis. Eur J Surg Oncol. 2012;38:375-81.\u003c/li\u003e\n \u003cli\u003eMassenburg BB, Sanati-Mehrizy P, Ingargiola MJ, et al. Flap failure and wound complications in autologous breast reconstruction a national perspective. Aesthetic Plast Surg. 39: 902-9, 2015\u003c/li\u003e\n \u003cli\u003eKlasson S, Nyman J, Svensson H, Velander P. Smoking increases donor site complications in breast reconstruction with DIEP flap. J Plast Surg Hand Surg. 2016;50:331-335.\u003c/li\u003e\n \u003cli\u003eDanko D, Ash ME, Brown OH, Losken A, Thompson PW. Implant-Based Breast Reconstruction in the Elderly: Complications and Patient-Reported Outcomes in Women Older Than 70 Years. Ann Plast Surg. 2023;91:55-61.\u003c/li\u003e\n \u003cli\u003eKim M, Ali B, Zhang K, Vingan P, Boe L, Ly CL, et al. Age Impacts Clinical and Patient Reported Outcomes following Post Mastectomy Breast Reconstruction. Plast Reconstr Surg. 2024; Epub ahead of print.\u003c/li\u003e\n \u003cli\u003eSantosa KB, Qi J, Kim HM, Hamill JB, Pusic AL, Wilkins EG. Effect of Patient Age on Outcomes in Breast Reconstruction: Results from a Multicenter Prospective Study. J Am Coll Surg. 2016;223:745-754.\u003c/li\u003e\n \u003cli\u003eTanno K, Bito S, Isobe Y, Takagi Y. Validation of a Japanese Version of the Decision Regret Scale. J Nurs Meas. 2016;24: E44-54.\u003c/li\u003e\n \u003cli\u003eHaworth, J. E., Moniz, D., \u0026amp; Lane, I. F. Patient satisfaction and the role of preoperative information in elective surgery. British Journal of Surgery. 2014;101:1004-1011.\u003c/li\u003e\n \u003cli\u003eHonigman RJ, Phillips KA, Castle DJ. A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004;113:1229-37.\u003c/li\u003e\n \u003cli\u003eSmith SG, Pandit A, Rush SR, Wolf MS, Simon CJ. The Role of Patient Activation in Preferences for Shared Decision Making: Results From a National Survey of U.S. Adults. J Health Commun. 2016;21:67-75.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"breast-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brca","sideBox":"Learn more about [Breast Cancer](http://link.springer.com/journal/12282)","snPcode":"12282","submissionUrl":"https://www.editorialmanager.com/brca/default2.aspx","title":"Breast Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"age, breast reconstruction, breast-conserving surgery, mastectomy, decision regret, decision-making","lastPublishedDoi":"10.21203/rs.3.rs-5767750/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5767750/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e \u003cp\u003eIn recent years, the age range of patients undergoing breast reconstruction has expanded. Establishment of the influence of the age of a patient with breast cancer on the level of regret after breast reconstruction could assist in decision-making across age groups at the time of choice of options for breast cancer surgery.\u003c/p\u003e\u003ch2\u003eOBJECTIVES\u003c/h2\u003e \u003cp\u003eThe objective of the study is to investigate the current age distribution of patients undergoing treatment for breast cancer in Japan through a multicenter collaborative study, and to examine the impact of age on post-surgical decision regret, analyzed by type of surgical procedure.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e \u003cp\u003eA multicenter observational retrospective study was conducted in 576 patients who were diagnosed with breast cancer pathologically and underwent mastectomy (Bt), breast-conserving surgery (Bc) or breast reconstruction (Br). Demographic and outcome data were collected and the level of regret concerning the surgical decision was surveyed using the Decision Regret Scale (DRS) across the different patient groups.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eThe average age of the Bt group was significantly higher than those in the Bc and Br groups. The level of regret was slightly but significantly higher in the Br group compared to the other groups. Regression analysis of the relationship between age and DRS scores indicated that reconstruction is associated with an increase of about 5 points in the DRS score. This analysis also revealed that the DRS score slightly increases with advancing age, regardless of the surgical method.\u003c/p\u003e\u003ch2\u003eCONCLUSIONS\u003c/h2\u003e \u003cp\u003eIn reconstruction cases, addition of new surgical procedures may lead to more complications, which might have slightly increased regret; however, the increase was not significant. Although minor, it is also important to note the tendency for the level of regret to increase with age.\u003c/p\u003e","manuscriptTitle":"Influence of age on patient decision regret following breast reconstruction: A multicenter collaborative study in Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-04 11:11:58","doi":"10.21203/rs.3.rs-5767750/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-03-27T12:47:40+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-26T22:34:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-26T12:38:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"Breast Cancer","date":"2025-03-26T02:50:18+00:00","index":"","fulltext":""},{"type":"decision","content":"Minor Revision","date":"2025-02-05T03:53:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"breast-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brca","sideBox":"Learn more about [Breast Cancer](http://link.springer.com/journal/12282)","snPcode":"12282","submissionUrl":"https://www.editorialmanager.com/brca/default2.aspx","title":"Breast Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4ac7226d-c239-4aac-b3fc-2be9122e51b9","owner":[],"postedDate":"April 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-05T16:08:04+00:00","versionOfRecord":{"articleIdentity":"rs-5767750","link":"https://doi.org/10.1007/s12282-025-01709-3","journal":{"identity":"breast-cancer","isVorOnly":false,"title":"Breast Cancer"},"publishedOn":"2025-05-04 15:57:40","publishedOnDateReadable":"May 4th, 2025"},"versionCreatedAt":"2025-04-04 11:11:58","video":"","vorDoi":"10.1007/s12282-025-01709-3","vorDoiUrl":"https://doi.org/10.1007/s12282-025-01709-3","workflowStages":[]},"version":"v1","identity":"rs-5767750","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5767750","identity":"rs-5767750","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}