Cognitive Bias and Therapy Choice in Breast Reconstruction Surgery Decision-Making

Project dates: 2020 - 2022

The aim of this study is to explore how framing and behavioral bias affect elective restorative surgery decision-making, such as breast reconstruction following cancer treatment.

Why is this important?

Making the decision whether to have a breast reconstruction is a complex process influenced by numerous factors, including age, education, ethnicity, socioeconomic status, access to plastic surgeons, risks and benefits associated with various surgical options, costs, distance to the hospital, and personal preferences and values (Hall & Holman, 2003; Bell, Robinson, Fradkin, Schwarz & Davis, 2012; Azzopardi, Walsh, Chong & Taylor, 2014; Flitcroft, Brennan & Spillane, 2017; Storm-Dickerson, Das, Gabriel, Gitlin, Farias & Macarios, 2018). However, research has only recently begun to explore cognitive and behavioral bias in surgical breast cancer decision-making. Breast reconstruction is a considerable personal decision for women, and there is little doubt that patients and health care professionals alike use both reflective and automatic thinking processes when informing and recommending surgical choices for patients (Magid, McIlvennan, & Jones, 2016). Although information asymmetries and financial incentives have been studied in the literature, there is a void of research exploring how behavioral biases affect this necessary communication (Dulleck & Kerschbamer, 2006; Dulleck, Kerschbamer & Sutter, 2011; Iizuka, 2007; Balafoutas, Beck, Kerschbamer & Sutter, 2013; Smith, Whyte, Chan et al., 2019).

Understanding how medical experts and their patients process and transfer information is of critical importance for efficient health care provision. Behavioral economics has explored similar credence markets where economic incentives, information asymmetry, and cognitive bias can impact patient and surgeon choice.

What did we do?

We used a cross-sectional survey data set of specialist surgeons (n = 53), breast care nurses (n = 101), and former or current breast cancer patients (n = 689). Data collected include participant demographics, medical history, a battery of cognitive bias tests, and a behavioral framing experiment.

What did we find out?

This study found statistically significant differences in breast reconstruction surgery preference by patients and nurses when decision options are framed in different ways (i.e., positively versus negatively). Our analysis of surgeons, nurses, and patients shows no statistically significant difference across eight common forms of cognitive bias. Rather, we found that the behavioral biases are prevalent to the same extent in each group. This may indicate that differences in experience and education seem not to mitigate biases that may affect patient choices and medical professional’s recommendations. Our multivariate analysis identifies patient age (p < 0.0001), body mass index, and self-perceived health (p < 0.05) as negative correlates for choice of implant-based reconstruction.

For surgeons, nurses, and patients, we found uniform evidence of cognitive bias; more specifically, for patients and nurses. We found inconsistency in preference for type of surgical therapy chosen when alternative procedures are framed in different ways (i.e., framing bias).


For more information about this project, please email:

Chief Investigators


Other Team Members

  • Raymond J. Chan
  • Jeremy Hunt
  • Tim S. Peltz


  • Whyte, S., Bray, L., Chan, H. F., Chan, R. J., Hunt, J., Peltz, T. S., Dulleck, U., Hutmacher, D. W.. (2022). Cognitive Bias and Therapy Choice in Breast Reconstruction Surgery Decision-Making. Plastic and Reconstructive Surgery.
  • Whyte, S., Bray, L. J., Chan, H. F., Chan, R. J., Hunt, J., Peltz, T. S., Dulleck, U., & Hutmacher, D. W. (2021). Knowledge, consultation time, and choice in breast reconstruction. British Journal of Surgery, znab013.