A body image scale for use with cancer patients

The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy

OBJECTIVE

To compare the effects of laparoscopic hysterectomy and abdominal hysterectomy in the abdominal trial, and laparoscopic hysterectomy and vaginal hysterectomy in the vaginal trial.

DESIGN

Two parallel, multicentre, randomised trials.

SETTING

28 UK centres and two South African centres.

PARTICIPANTS

1380 women were recruited; 1346 had surgery; 937 were followed up at one year. Primary outcome Rate of major complications.

RESULTS

In the abdominal trial laparoscopic hysterectomy was associated with a higher rate of major complications than abdominal hysterectomy (11.1% v 6.2%, P = 0.02; difference 4.9%, 95% confidence interval 0.9% to 9.1%) and the number needed to treat to harm was 20. Laparoscopic hysterectomy also took longer to perform (84 minutes v 50 minutes) but was less painful (visual analogue scale 3.51 v 3.88, P = 0.01) and resulted in a shorter stay in hospital after the operation (3 days v 4 days). Six weeks after the operation, laparoscopic hysterectomy was associated with less pain and better quality of life than abdominal hysterectomy (SF-12, body image scale, and sexual activity questionnaires). In the vaginal trial we found no evidence of a difference in major complication rates between laparoscopic hysterectomy and vaginal hysterectomy (9.8% v 9.5%, P = 0.92; difference 0.3%, -5.2% to 5.8%), and the number needed to treat to harm was 333. We found no evidence of other differences between laparoscopic hysterectomy and vaginal hysterectomy except that laparoscopic hysterectomy took longer to perform (72 minutes v 39 minutes) and was associated with a higher rate of detecting unexpected pathology (16.4% v 4.8%, P = < 0.01). However, this trial was underpowered.

CONCLUSIONS

Laparoscopic hysterectomy was associated with a significantly higher rate of major complications than abdominal hysterectomy. It also took longer to perform but was associated with less pain, quicker recovery, and better short term quality of life. The trial comparing vaginal hysterectomy with laparoscopic hysterectomy was underpowered and is inconclusive on the rate of major complications; however, vaginal hysterectomy took less time.

Impact of skin-sparing mastectomy with immediate reconstruction and breast-sparing reconstruction with miniflaps on the outcomes of oncoplastic breast surgery

BACKGROUND

The aim of this study was to compare the outcomes of skin-sparing mastectomy (SSM) with immediate myocutaneous flap reconstruction and partial mastectomy with latissimus dorsi miniflap reconstruction (LDMF) for breast cancer.

METHODS

Some 106 disease-free patients (57 SSM, 49 LDMF) who had breast reconstruction between 1991 and 1999 participated in this retrospective review. The mean duration of follow-up was 42 (range 6-102) months. Measured outcomes included surgical complications, functional disability, cosmetic result and psychological morbidity.

RESULTS

SSM outcomes were less favourable than LDMF outcomes with regard to postoperative complications (14 versus 8 per cent), further surgical interventions (79 versus 12 per cent), nipple sensory loss (98 versus 2 per cent), restricted activities (73 versus 54 per cent) and cosmetic outcome by panel assessment. Anxiety about residual cancer and ease of breast self-examination were similar in both groups.

CONCLUSION

LDMF was associated with fewer adverse surgical and physical sequelae than SSM, without compromising local control or cosmetic outcome. Both operations were associated with low psychological morbidity.

The psychological effect of mastectomy with or without breast reconstruction: a prospective, multicenter study

A multicenter, prospective study ( = 103) examined the psychological implications of women's decisions for or against breast reconstruction. Recognized measures of anxiety, depression, body image, and quality of life were completed before the operation, and 6 and 12 months later. A reduction in psychological distress over the year following the operation was evident in each surgical group (mastectomy alone or immediate or delayed reconstruction), indicating that reconstructive surgery can offer psychological benefits to some women; however, others report improved psychological functioning without this surgical procedure. In contrast to existing retrospective research, the prospective design enabled the process of adjustment during the first year after the operation to be examined. The results indicate that breast reconstruction is not a universal panacea for the emotional and psychological consequences of mastectomy. Women still reported feeling conscious of altered body image 1 year postoperatively, regardless of whether or not they had elected breast reconstruction. Health professionals should be careful of assuming that breast reconstruction necessarily confers psychological benefits compared with mastectomy alone.

Update on anorexia and cachexia

Declining physical, emotional, and social function as a result of anorexia and cachexia are considerable contributors to discomfort for cancer patients and their families, and they impair the patient's ability to express optimal physical and psychosocial potential as long as possible. This decline no longer has to be accepted as an indispensable sequel to advanced cancer, just as pain is no longer considered to be unavoidable. A routine screening for anorexia and cachexia and associated symptoms is necessary, as is a careful, comprehensive assessment, because the condition is not always obvious. Decisions about anorexia and cachexia treatment are guided by prioritizing the different, concurrent physical, psychosocial, and existential problems and by considering the natural course of the cancer and the effects of antineoplastic therapies. Reversible causes for anorexia and cachexia need to be identified and treated, if appropriate. Nutritional interventions are often indicated; patients with a predominant starvation component and without inflammation may profit the most. New pharmacologic therapies for primary anorexia and cachexia syndrome are expected to enter clinical practice soon; however, until then, treatment with corticosteroids, progestins, or prokinetics may be indicated for some patients. To understand a multicausal syndrome, multimodal and interdisciplinary therapy is required. Specialist palliative care services can be helpful to provide, hand-in-hand with the disease specialists [172], assessment and management of psychophysical symptoms and sociospiritual needs of patients during the course of the illness and at the end of life [173]. Research efforts aim to better characterize subgroups of patients suffering from secondary causes of anorexia and cachexia and to elucidate the mechanisms involved in the primary anorexia and cachexia syndrome. Increasingly individualized treatments are expected with combination treatments that involve different mechanisms including nutrition.

The psychosocial impact of bilateral prophylactic mastectomy: prospective study using questionnaires and semistructured interviews

OBJECTIVES

To investigate the psychosocial impact of bilateral prophylactic mastectomy for women with increased risk of breast cancer and to identify, preoperatively, risk factors for postoperative distress.

DESIGN

Prospective study using interviews and questionnaire assessments.

SETTING

Participants' homes throughout the United Kingdom.

PARTICIPANTS

143 women with increased risk of developing breast cancer who were offered bilateral prophylactic mastectomy and who accepted or declined the surgery; a further 11 were offered surgery but deferred making a decision.

MAIN OUTCOME MEASURES

Psychological and sexual morbidity.

RESULTS

Psychological morbidity decreased significantly over time for the 79 women who chose to have surgery (accepters): 58% (41/71) preoperatively v 41% (29/71) 6 months postoperatively (difference in percentages 17%, 95% confidence interval 2% to 32%; P=0.04) and 60% (39/65) preoperatively v 29% (19/65) 18 months postoperatively (31%, 15% to 47%; P<0.001). Psychological morbidity in the 64 women who declined surgery (decliners) did not decrease significantly: 57% (31/54) at baseline v 43% (23/54) at 6 months (14%, 0% to 29%; P=0.08) and 57% (29/52) at baseline v 41% (21/52) at 18 months (16%; -2% to 33%; P=0.11). Greater than normal proneness to anxiety was more common in the decliners than in the accepters: 78% (45/58) v 56% (41/73) (22%, 6% to 38%; P=0.006). Accepters were more likely than decliners to believe it inevitable that they would develop breast cancer (32% (24/74) v 10% (6/58) (difference in percentages 22%, 9% to 35%; P=0.003)), and decliners were more likely to believe that screening could help (92% (55/60) v 74% (55/74) (18%, 5% to 31%; P=0.007)). Level of sexual discomfort and degree of sexual pleasure did not change significantly over time in either of the two groups.

CONCLUSIONS

Bilateral prophylactic mastectomy may provide psychological benefits in women with a high risk of developing breast cancer.

Imagen Corporal y su Influencia en la Calidad de Vida en mujeres con mastectomía. Comparación entre mujeres con reconstrucción inmediata, reconstrucción diferida o sin reconstrucción

Objetivo: Analizar Imagen Corporal y su influencia en Calidad de Vida en mujeres que han tenido una mastectomía para el tratamiento del cáncer de mama, con reconstrucción inmediata, reconstrucción diferida o sin reconstrucción mamaria. Método: Se administró la Escala de Imagen Corporal (S-BIS) y el Inventario de Influencia de imagen corporal sobre calidad de vida (BIQLI-SP) a 30 mujeres, divididas en tres grupos: Reconstrucción inmediata (n=10); Reconstrucción diferida (n=10) y Sin reconstrucción (n=10). Resultado: Las mujeres con reconstrucción inmediata obtuvieron valores inferiores de problemática con la imagen corporal y superiores en calidad de vida relacionada con imagen corporal. Y aquellas sin reconstrucción obtuvieron valores superiores respecto a problemática con la imagen corporal e inferiores en calidad de vida relacionada con imagen corporal. Las diferencias entre los grupos no alcanzaron significación estadística. En ambos instrumentos aparece la sexualidad como área afectada. Finalmente, se encontraron correlaciones significativas negativas entre Imagen Corporal y Calidad de Vida relacionada con imagen corporal en dos subgrupos: Reconstrucción inmediata y Sin reconstrucción. Conclusiones: Aquellas mujeres que tuvieron reconstrucción mamaria tras la mastectomía presentan mejor ajuste que aquellas sin reconstrucción. Y, entre los tipos de reconstrucción, quienes accedieron a reconstrucción inmediata presentan menor deterioro de imagen corporal. Sin embargo, algunas mujeres demuestran haber integrado los cambios en una nueva imagen corporal sin necesidad de reconstrucción. Entonces, elegir no reconstruir puede ser una opción saludable y adecuada para muchas mujeres. Lo importante es que toda mujer, independientemente de sus circunstancias, pueda acceder a las mismas opciones para atravesar esta situación.