The Architecture of Shared Decision-Making in Postmastectomy Breast Reconstruction: A Systematic Review of Concepts, Measures, and Clinical Realities

Background Shared decision-making (SDM) is central to postmastectomy breast reconstruction (PMBR), yet its conceptualization, implementation, and evaluation remain heterogeneous. This study aimed to systematically synthesize the evidence on SDM processes, interventions, measurement approaches, and implementation in PMBR.Methods Following a preregistered protocol (OSF; https://osf.io/mu9hv ), we searched PubMed, Embase, Web of Science, Scopus, Trip, and Cochrane from inception to November 2025. Eligible studies included original quantitative, qualitative, or mixed-methods research evaluating SDM in women considering or undergoing PMBR. Methodological quality was assessed using QualSyst, and findings were narratively synthesized within a thematic framework.Results Fifty-six studies met the inclusion criteria. Randomized and quasi-experimental studies generally reported improvements in patient knowledge and values clarification following decision-support interventions, although effects on decisional conflict and preference concordance were heterogeneous. PMBR decisions were influenced by patient preferences, cultural factors, and clinical context. Major implementation barriers included time constraints, workflow limitations, and variable clinician engagement.Conclusions SDM can facilitate informed and preference-concordant PMBR decisions but remains inconsistently implemented. Greater integration of structured decision-support strategies and standardized outcome measurement may strengthen its implementation in routine practice.