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Endoscopic Bilateral Nipple-sparing Mastectomy via a Single Axillary Incision with Immediate Pre-pectoral Implant-based Breast Reconstruction
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Bridging the Gap between Intent and Implementation: A Mixed-Methods Systematic Review of Barriers and Enablers of
Marta Maes-Carballo1, Laura Sampol-Ramírez2, Natalia de-la-Puente-Mota2
1Department of General Surgery, Hospital Público de Verín, Ourense, Spain.
Background:
Postmastectomy breast reconstruction (PMBR) is a preference-sensitive decision that requires alignment between clinical evidence and patient values. Shared decision making (SDM) supports patient-centered care, yet its systematic implementation in PMBR remains inconsistent. This mixed-methods systematic review synthesizes barriers and facilitators to SDM adoption and identifies strategies to improve decision quality, patient experience, and equity.
Methods:
A systematic review was preregistered (OSF: https://osf.io/mu9hv) and conducted in accordance with PRISMA 2020 guidelines. Six databases (PubMed, Embase, Scopus, Web of Science, Cochrane Library, Trip Database) were searched from inception to November 2025. Eligible studies included qualitative, quantitative, or mixed-methods research examining barriers and/or facilitators to SDM implementation in PMBR across micro (individual), meso (organizational), and macro (system) levels. Data were synthesized using a convergent integrated approach and mapped to the Consolidated Framework for Implementation Research.
Results:
Thirty-one studies (n = 15-485 participants) from North America, Europe, and Asia were included. SDM interventions-particularly decision aids, digital tools, preconsultation education, and culturally tailored strategies-improved patient knowledge (+6%-32%), decisional clarity, and satisfaction. Decisional conflict decreased by 13 to 25 points, and consultation time was reduced by up to 41%. Facilitators were identified across micro (eg, clinician engagement), meso (eg, multidisciplinary collaboration and organizational support), and macro (eg, supportive implementation strategies), whereas barriers included limited SDM literacy, workflow limitations and insufficient documentation, and structural inequities, respectively. Despite demonstrated effectiveness, sustained implementation was limited.
Conclusions:
SDM enhances informed and value-concordant decisions in PMBR. Effective implementation requires multilevel strategies, including clinician training, workflow integration, culturally adapted interventions, and organizational support. Future research should prioritize scalable and equitable models to ensure consistent integration of SDM into routine practice.