Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction

Fraction size in radiation treatment for breast conservation in early breast cancer

BACKGROUND

Shortening the duration of radiation therapy would benefit women with early breast cancer treated with breast conserving surgery. It may also improve access to radiation therapy by improving efficiency in radiation oncology departments globally. This can only happen if the shorter treatment is as effective and safe as conventional radiation therapy. This is an updated version of the original Cochrane Review published in Issue 3, 2008.

OBJECTIVES

To determine the effect of altered radiation fraction size on outcomes for women with early breast cancer who have undergone breast conserving surgery.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Specialised Register, MEDLINE, EMBASE and the WHO ICTRP search portal to June 2009, reference lists of articles and relevant conference proceedings. We applied no language constraints.

SELECTION CRITERIA

Randomised controlled trials of unconventional versus conventional fractionation in women with early breast cancer who had undergone breast conserving surgery.

DATA COLLECTION AND ANALYSIS

The authors performed data extraction independently, with disagreements resolved by discussion. We sought missing data from trial authors.

MAIN RESULTS

Four trials reported on 7095 women. The women were highly selected: tumours were node negative and 89.8% were smaller than 3 cm. Where the breast size was known, 87% had small or medium breasts. The studies were of low to medium quality. Unconventional fractionation (delivering radiation therapy in larger amounts each day but over fewer days than with conventional fractionation) did not affect: (1) local recurrence risk ratio (RR) 0.97 (95% CI 0.76 to 1.22, P = 0.78), (2) breast appearance RR 1.17 (95% CI 0.98 to 1.39, P = 0.09), (3) survival at five years RR 0.89 (95% CI 0.77 to 1.04, P = 0.16). Acute skin toxicity was decreased with unconventional fractionation: RR 0.21 (95% CI 0.07 to 0.64, P = 0.007).

AUTHORS' CONCLUSIONS

Two new studies have been published since the last version of the review, altering our conclusions. We have evidence from four low to medium quality randomised trials that using unconventional fractionation regimens (greater than 2 Gy per fraction) does not affect local recurrence, is associated with decreased acute toxicity and does not seem to affect breast appearance or late toxicity for selected women treated with breast conserving therapy. These are mostly women with node negative tumours smaller than 3 cm and negative pathological margins. Long-term follow up (> 5 years) is available for a small proportion of the patients randomised. Longer follow up is required for a more complete assessment of the effect of altered fractionation.

[Certified breast centers in Germany : How much is plastic surgery involved?]

INTRODUCTION

This study was designed to assess the degree of cooperation between plastic surgeons and gynecologists in certified breast centers in Germany. The rate of breast reconstruction after mastectomy remains low at 8-13%. In certified breast centers plastic surgeons are often not members of the team.

METHODS

A total of 220 hospitals affiliated to the West German Breast Center (WBC) were contacted in 2007 and 80 breast centers and hospitals returned the questionnaire. This study is based on the data of approximately 24,000 patients.

RESULTS

At the time of the investigation 60 out of the 80 hospitals (75%) were certified breast centers. Many different criteria have been applied for certified breast centers: the state of Nordrhein-Westfalen, the DKG/DGS (German Cancer Society/German Society of Senology), EUSOMA and others. In 8 hospitals (10%) a plastic surgeon was part of the team in the breast center. Most breast centers (44 out of 80) function with 3-4 attending specialists for breast surgery.

DISCUSSION

The cooperation between gynecologists and plastic surgeons within a breast center can be strengthened. A microsurgical breast augmentation is not the ideal solution for every patient with a mastectomy but every patient has the right to obtain complete information about the whole spectrum of breast reconstruction including microsurgical free flap reconstruction.

[Experiences of mastectomised women. A phenomenological study]

OBJECTIVE

To understand the life experience of women with mastectomy in relation to their disease, analysing what leads some women to have breast reconstruction and others not to do so. Identify the situation of mastectomised women with lymphoedemas, alopecia and other problems.

METHOD

Phenomenological qualitative research. Twenty-nine in-depth interviews were conducted on the women through specific informants in the oncology services of the Hospital Vall d'Hebron; and the gynaecology unit at the Salud La Mina Primary Care Centre in Barcelona. The age range was between 20 and 69 years.

RESULTS

Through the analysis of the interviews it was possible to reveal the phenomenon in research. The following subjects were those of most relevance: there women with reconstructed and non-reconstructed breasts, and a mutilated body image through the loss of one or both breasts. Participation of women in social occasions, use of clothing and lifestyle. The cancer is visualised: lymphoedemas, loss of hair with an affect on the public image.

CONCLUSIONS

Younger women, graduates and middle class ladies and those over 40 with a primary education are those that have a breast reconstruction. Middle-high and high class graduates do not have a breast reconstruction. They negotiate their relationship with their partner in other ways.

Oncological and aesthetic considerations of conservational surgery for multifocal/multicentric breast cancer

Conventional indications for mastectomy (MX) reflect circumstances where breast conserving therapy (BCT) could compromise oncological or cosmetic outcome. MX continues to be recommended for the majority of women with multiple lesions within the same breast. In this article, we review the oncological safety and aesthetic considerations of BCT in the context of multifocal (MF) or multicentric (MC) breast cancer. Literature review facilitated by Medline and PubMed databases. Published studies have reported divergent results regarding the oncological adequacy of BCT in the management of MF or MC disease. Earlier studies demonstrated high rates of local recurrence (LR) for BCT. More recent series have found BCT to be comparable to MX in terms of LR, distant failure, disease free and overall survival. Few studies have adequately evaluated cosmetic outcomes following BCT for MF or MC breast cancer. Contemporary oncoplastic techniques have extended the clinical utility of BCT and are of particular relevance to breast conservation in the context of MF or MC lesions. Appropriate case selection, preoperative oncological and aesthetic planning, satisfactory clearance of the surgical margins and adjuvant radiotherapy are of paramount importance. In the absence of level-1 guidance concerning the management of women with MF or MC disease, each case requires discussion with regard to tumor and patient related factors in the context of the multidisciplinary team. In selected patients with MF or MC disease, BCT is oncologically safe and cosmetically acceptable. Uniformity of practice and the establishment of a standard of care will require an evidence-base from prospective studies.

Health-related quality of life after breast-conserving surgery and intraoperative radiotherapy for breast cancer using low-kilovoltage X-rays

BACKGROUND

Intraoperative radiotherapy (IORT) is currently being evaluated as a novel approach during breast-conserving surgery (BCS). IORT can be used either as a tumor bed boost followed by external-beam radiotherapy (EBRT) or as a single treatment. In a matched-pair study, we assessed quality of life (QoL) in 69 patients with early breast cancer treated with BCS and/or IORT and/or EBRT.

METHODS

Patients were matched for age and time since BCS. IORT was provided with 50 kV x-rays (Intrabeam) delivering 20 Gy at the applicator surface. EBRT (46 to 50 Gy in 2-Gy fractions in the IORT with EBRT group, and 56 Gy in 2-Gy fractions in the EBRT group) was initiated after completion of wound healing and/or chemotherapy. The mailed questionnaires included the European Organization for the Research and Treatment of Cancer QLQ-C30 and BR23, FACT-F, HADS, Body Image Scale, and Rosenberg Self-Esteem Scale. At 18 to 70 months' follow-up (median 47 months), all patients were disease free.

RESULTS

We found only a few differences between the three groups. There was a trend toward more pain (mean ± standard deviation; 42.8 ± 32.9 vs. 27.5 ± 34.7) and reduced QoL (57.6 ± 20.7 vs. 70.3 ± 23.9) after IORT with EBRT compared with EBRT, respectively. IORT patients reported comparable QoL (70.3 ± 23.0), and less breast symptoms and body image concerns compared to EBRT (8.6 ± 12.3 vs. 19.2 ± 23.8, and 1.7 ± 3.3 vs. 3.4 ± 4.4, respectively). IORT alone resulted in significantly fewer breast symptoms (8.6 ± 12.3; P = 0.012) and less pain (23.9 ± 24.5, P = 0.041) compared with IORT with EBRT (26.1 ± 27.6; 42.8 ± 32.9, respectively).

CONCLUSIONS

Patients with early breast cancer after BCS and IORT with or without EBRT present with comparable QoL like patients receiving EBRT without a boost. IORT patients show the lowest rate of breast symptoms.

Clinical evaluation of the flotrac/Vigileo system for continuous cardiac output monitoring in patients undergoing regional anesthesia for elective cesarean section: a pilot study

BACKGROUND

Spinal anesthesia for cesarean delivery may cause severe maternal hypotension and a decrease in cardiac output. Compared to assessment of cardiac output via a pulmonary artery catheter, the FloTrac/Vigileo system may offer a less invasive technique. The aim of this study was to evaluate cardiac output and other hemodynamic measurements made using the FloTrac/Vigileo system in patients undergoing spinal anesthesia for elective cesarean section.

METHODS

A prospective study enrolling 10 healthy pregnant women was performed. Hemodynamic parameters were continuously obtained at 15 main points: admission to surgery (two baseline measurements), after preload, after spinal anesthesia administration and 4 time points thereafter (4, 6, 8 and 10 min after anesthesia), at skin and uterine incision, newborn and placental delivery, oxytocin administration, end of surgery, and recovery from anesthesia. Hemodynamic therapy was guided by mean arterial pressure, and vasopressors were used as appropriate to maintain baseline values. A repeated measures ANOVA was used for data analysis.

RESULTS

There was a significant increase in heart rate and a decrease of stroke volume and stroke volume index up to 10 min after spinal anesthesia (P < 0.01). Importantly, stroke volume variation increased immediately after newborn delivery (P < 0.001) and returned to basal values at the end of surgery. Further hemodynamic parameters showed no significant changes over time.

DISCUSSION AND CONCLUSIONS

No significant hemodynamic effects, except for heart rate and stroke volume changes, were observed in pregnant women managed with preload and vasopressors when undergoing elective cesarean section and spinal anesthesia.

The effect of immediate breast reconstruction with Becker-25 prosthesis on the preservation of proper body posture in patients after mastectomy

PURPOSE

This was a prospective study comparing coronal, sagittal and transverse plane body posture parameters in women after radical mastectomy and women after radical mastectomy with immediate breast reconstruction (IBR) for stage I and II breast cancer.

METHODS

The three studied groups were one that underwent Madden's radical mastectomy (n = 38), a second with skin sparing mastectomy with IBR with expander-prosthesis Becker-25 (n = 38), and the control (n = 38). All the women were examined to determine their body posture in the coronal, sagittal and transverse planes using three-dimensional (3D) body surface analysis before and 6, 12, 18 and 24 months after surgery.

RESULTS

There is a significant difference body posture in the coronal, sagittal and transverse planes between groups of patients after mastectomy with IBR comparing with patients after mastectomy alone. The women after radical mastectomy demonstrated the greatest postural changes in particular parameters of body posture in postsurgical months 18 and 24. The IBR group only demonstrated significant postural changes in one parameter, though as time after surgery increased, these changes decreased.

CONCLUSIONS

IBR after mastectomy has an impact on proper body posture. Photogrammetric examination revealed important body posture disturbances only in the radical mastectomy group. It gives useful information on body posture parameters in the evaluation of quality of life in breast cancer survivors. It appears that immediate breast reconstruction helps to preserve proper body posture after mastectomy.

Evaluation of quality of life after breast reconstruction using an autologous latissimus dorsi myocutaneous flap

AIMS

To evaluate the patients' satisfaction with breast reconstruction using the autologous latissimus dorsi technique and the impact of the procedure on the quality of life and body image of women who had mastectomy for breast cancer.

METHODS

A retrospective transversal study was conducted at the Georges François Leclerc Cancer Care Center in Dijon, France. From 1990 to 2008, 193 women underwent reconstruction (RW), among these, 141 were matched for age at diagnosis and the date of the mastectomy with women who did not undergo reconstruction (NRW) identified using data from the Côte d'Or breast cancer registry. Questionnaires concerning quality of life, body image and satisfaction (MBROS-S, MBROS-BI, EORTC QLQ-C30, EORTC QLQ-BR23) were sent through the post following surgery.

RESULTS

The overall response rate was 77% and the mean (MBROS-S) satisfaction score was 3.36. The quality of life (EORTC QLQ-C30, EORTC QLQ-BR23) in RW was no better than that in NRW, but body image was better (p = 0.0247) especially before 60 years (p = 0.0192), in obese patients (p = 0.03) and when the breasts of RW were heavy (p = 0.0197). Moreover, when the time from the mastectomy was less than 4 years, body image (p = 0.0008) and the sexual activity score (p = 0.0078) were higher in RW.

CONCLUSIONS

The level of satisfaction was higher in RW, and breast reconstruction made a strong contribution in terms of improvement in body image. A prospective study to evaluate quality of life in the long term is now necessary.

Effects of mastectomy on shoulder and spinal kinematics during bilateral upper-limb movement

BACKGROUND

Shoulder movement impairment is a commonly reported consequence of surgery for breast cancer.

OBJECTIVE

The aim of this study was to determine whether shoulder girdle kinematics, including those of the scapula, spine, and upper limb, in women who have undergone a unilateral mastectomy for breast cancer are different from those demonstrated by an age-matched control group.

DESIGN

An observational study using 3-dimensional kinematic analysis was performed.

METHODS

Women who had a unilateral mastectomy on their dominant-arm side (n=29, mean [+/-SD] age=62.4+/-8.9 years) or nondominant-arm side (n=24, mean [+/-SD] age=59.8+/-9.9 years), as well as a control group of age-matched women without upper-limb, shoulder, or spinal problems (n=22, mean [+/-SD] age=58.1+/-11.5 years), were measured while performing bilateral arm movements in the sagittal, scapular, and coronal planes. All of the women were free of shoulder pain at the time of testing. Data were collected from the glenohumeral joint, the scapulothoracic articulation, and the spine (upper and lower thoracic and lumbar regions) using an electromagnetic tracking system.

RESULTS

Women following mastectomy displayed altered patterns of scapular rotation compared with controls in all planes of movement. In particular, the scapula on the mastectomy side rotated upward to a markedly greater extent than that on the nonmastectomy side, and women following mastectomy displayed greater scapular excursion than controls.

CONCLUSIONS

The findings suggest that altered motor patterns of the scapula are associated with mastectomy on the same side. Whether these changes are harmful or not is unclear. Investigation of interventions designed to restore normal scapulohumeral relationships on the affected side following unilateral mastectomy for breast cancer is warranted.

Second operation is not related to psychological outcome in breast cancer patients

To examine the effect of multiple surgical treatments on psychological outcomes in women with early stage breast cancer (BC) in a prospective follow-up study. Questionnaires for depressive symptoms (CES-D), fatigue (FAS), anxiety (STAI-State), physical health (WHOQOL-100), psychological health (WHOQOL-100) and overall quality of life and general health (WHOQOL-100) were completed before diagnosis (Time-1) and 1 (Time-2), 3 (Time-3), 6 (Time-4) and 12 (Time-5) months after the last surgical treatment. From the 217 participating women with early stage BC, 78 (35.9%) needed an additional surgical treatment. Using general linear model (repeated measures), psychosocial outcomes over time were investigated for the breast conserving therapy and mastectomy group, accounting for type of surgery, disease stage and hormonal therapy. Psychological outcomes did not significantly change over time, with the exception of anxiety [Wilks' Lambda = 0.72, F (4,86) = 8.55, p < 0.0001, partial eta squared = 0.29]. On average, women with 1 and women with 2 surgical treatments did not differ on any outcome measure. No interaction effects were found, indicating that changes in outcomes over time were the same for both groups. Women who had a repeat surgical treatment did not score differently on psychological outcome measures compared with women who were treated "efficiently."

Mastectomy versus conservative surgical treatment: the impact on the quality of life of women with breast cancer

OBJECTIVES: to compare the impact of mastectomy and conservative surgery on the quality of life of patients with breast cancer. METHODS: an assessment was made of the quality of life of patients undergoing mastectomy or segmentary mastectomy, at the Pouso Alegre Clinical Hospital, in the Brazilian State of Minas Gerais, using SF-36. The patients were grouped by age (<50 years and >50 years) and years of schooling (<8 years and >8 years). The Mann-Whitney test was used to compare the groups with regard to the age and schooling domains of SF-36. RESULTS: a significant difference between the two groups was found in the domains of "physical functioning" (p=0.04) and "pain" (p=0.01): with the patients undergoing a mastectomy registering the worst scores. Young patients who had undergone a mastectomy displayed the worst quality of life in terms of "physical functioning" (p=0.03), "pain" (p=0.01) and "social functioning" (p=0.01); those undergoing conservative surgery aged over 50 years scored worst on "role emotional" (p=0.05). Patients undergoing a mastectomy with lower levels of schooling scored lower in "physical functioning" (p=0.01), "role physical" (p=0.05) and "pain" (p=0.05). Among those who had attended school for more than eight years, those having undergone a mastectomy scored less in the "pain" domain (p=0.04). CONCLUSIONS: patients who had undergone a mastectomy had worse results in the physical component of the evaluation of quality of life and this negative impact was more strongly felt among younger patients and those with lower levels of schooling.

Depression and conservative surgery for breast cancer

BACKGROUND

Depression is prevalent among women and associated with reduced quality of life, and therefore it is important to determine its incidence in adult women, especially in those with breast cancer.

OBJECTIVE

To determine the occurrence of depression in women who underwent conservative surgery for breast cancer with or without breast reconstruction.

METHODS

Seventy-five women aged between 18 and 65 years were enrolled. Patients had undergone conservative surgery for breast cancer with immediate breast reconstruction (n = 25) or without breast reconstruction (n = 25) at least one year before the study. The control group consisted of 25 women without cancer, but of similar age and educational level distribution as the other two groups. The Beck Depression Inventory was used to measure depression. The collected data were assessed using analysis of variance and the χ² test.

RESULTS

There were no significant differences between groups in age (p = 0.72) or educational level (p = 0.20). A smaller number of patients had undergone the menopause (p = 0.02) in the control group than in other groups. There were no significant differences in occurrence of depression between groups (χ² = 9.97; p = 0.126). CONCLUSÍON: Conservative surgery for breast cancer did not affect the occurrence of depression in women, regardless of whether breast reconstruction was performed.

Evolution of breast cancer management in Ireland: a decade of change

BACKGROUND

Over the last decade there has been a paradigm shift in the management of breast cancer, subsequent to revised surgical oncology guidelines and consensus statements which were derived in light of landmark breast cancer clinical trials conducted throughout the latter part of the 20th century. However the sheer impact of this paradigm shift upon all modalities of treatment, and the current trends in management of the disease, are largely unknown. We aimed to assess the changing practices of breast cancer management over the last decade within a specialist tertiary referral Breast Cancer Centre.

METHODS

Comparative analysis of all aspects of the management of breast cancer patients, who presented to a tertiary referral Breast Cancer Centre in 1995/1996 and 2005/2006, was undertaken and measured against The European Society for Surgical Oncology guidelines for the surgical management of mammographically detected lesions [1998].

RESULTS

613 patients' case profiles were analysed. Over the last decade we observed a dramatic increase in incidence of breast cancer [>100%], a move to less invasive diagnostic and surgical therapeutic techniques, as well as increased use of adjuvant therapies. We also witnessed the introduction of immediate breast reconstruction as part of routine practice

CONCLUSION

We demonstrate that radical changes have occurred in the management of breast cancer in the last decade, in keeping with international guidelines. It remains incumbent upon us to continue to adapt our practice patterns in light of emerging knowledge and best evidence.

Body image and self-esteem in somatizing patients

AIM

The aim of the present study was to determine dissatisfaction with body appearance and bodily functions and to assess self-esteem in somatizing patients.

METHODS

Body image and self-esteem were investigated in 128 women; 34 of those had diagnosed somatoform disorders, 50 were breast cancer patients with total mastectomy surgery alone, and 44 were healthy subjects. Body image and self-esteem were assessed using the Body Cathexis Scale and Rosenberg Self-Esteem Scale.

RESULTS

The two clinical groups did not differ from one another (z = -1.832, P = 0.067), but differed from healthy controls in terms of body image (somatizing patients vs healthy controls, z = -3.628, P < 0.001; total mastectomy patients vs healthy controls, z = -3.172, P = 0.002). They also did not differ significantly in terms of self-esteem (z = -0.936, P = 0.349) when depressive symptoms were controlled. No statistically significant difference was observed between total mastectomy patients and healthy controls in terms of self-esteem (z = -1.727, P = 0.084). The lower levels of self-esteem in somatizing patients were largely mediated by depressive symptoms. Depressed and non-depressed somatizing patients differed significantly from healthy controls with respect to their self-esteem and body image.

CONCLUSIONS

Somatizing patients who were dissatisfied with their bodily functions and appearance had lower levels of self-esteem and high comorbidity of depression. In clinical practice it is suggested that clinicians should take into account psychiatric comorbidity, self-esteem, and body image in somatizing patients when planning treatment approaches.

Oncoplastic breast surgery: a review and systematic approach

Oncoplastic breast surgery (OBS) is relatively new, but has made rapid progress from its tentative steps of infancy in the 1990s. The recent Milanese Consensus Conference on Breast Conservation concluded that, firstly, oncoplastic techniques are warranted to allow wide excision and clear margins without compromising cosmesis. Secondly, such surgery is ideally performed at the same time as oncological excision. Whilst technically more challenging than standard breast conserving therapy (BCT), OBS is well proven, if not yet widely practised, both oncologically and aesthetically and a review of the available techniques is perhaps timely. The roots of breast conserving therapy can be traced to the 1930s, actually due to advances made in radiotherapy, and the last 20 years have seen it become firmly established. This review aims to summarise the key historical developments and latest innovations in OBS. Not only are our patients, who expect not only safe cancer treatment but a satisfactory aesthetic outcome, increasingly informed and demanding, but longer follow up has stimulated surgeons to improve outcomes. In many cases, particularly with ptosis and macromastia, the cancer can be treated, usually with wider excision margins, simultaneously improving the aesthetic appearance. Present at the birth of OBS, the Institut Curie has continued to introduce innovative techniques over the last two decades and a systematic approach, comprising nine basic techniques, has evolved to allow high quality treatment of any and all breast cancers suitable for OBS.

Health-related quality of life assessment after breast reconstruction

Background

Health-related quality of life (HRQL) is an important outcome following breast reconstruction. This study evaluated current methods of HRQL assessment in patients undergoing latissimus dorsi breast reconstruction, hypothesizing that early surgical morbidity would be reflected by poorer HRQL scores.

Methods

Patients completed the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and breast module (QLQ-BR23), the Functional Assessment of Cancer Therapy (FACT) general measure, and breast module and arm subscale (FACT-B + 4), and the Body Image Scale and Hospital Anxiety and Depression Scale (HADS) 3 months after surgery. They also reported additional HRQL problems not included in the questionnaires. HRQL scores were compared between patients with and without early surgical morbidity.

Results

Sixty women completed the questionnaires, of whom 25 (42 per cent) experienced complications. All EORTC and FACT subscale and HADS scores were similar in patients with or without morbidity. Women with complications were twice as likely to report feeling less feminine and dissatisfied with the appearance of their scar than those without problems. Thirty-two women (53 per cent) complained of problems not covered by the questionnaires, most commonly donor-site morbidity.

Conclusion

Existing HRQL instruments are not sufficiently sensitive to detect clinically relevant problems following breast reconstruction.

Assessing the effect of beauty treatments on psychological distress, body image, and coping: a longitudinal study of patients undergoing surgical procedures for breast cancer

INTRODUCTION

Women with breast cancer may have significant problems adjusting to disease and therapy due to their association with significant changes in body image and sexuality. The aim of this study was to evaluate the effect of beauty treatments in combination with routine cancer care.

METHODS

One hundred women with breast cancer were randomly assigned to a group receiving beauty treatments during hospitalization or a control group. Psychological distress, body image and coping were assessed twice during the hospitalization period: the day before surgery (baseline) and 6 days later (Time 1). A follow-up assessment was performed three months later (Time 2).

RESULTS

Three months after surgery, patients who had received beauty treatments reported higher body-image scores than the control group, but there was no effect in psychological distress. Helplessness/hopelessness increased over time in the control group but not in the group receiving beauty treatments.

CONCLUSION

Overall, this study provides evidence of the usefulness of beauty treatments for breast-cancer patients, in combination with routine care. Although these treatments did not seem to alleviate psychological distress directly, they had a beneficial impact on body image and may strengthen patients' social support and self-esteem.

The association of perceived partner-related social support with self-reported outcomes in women post-mastectomy

Marital satisfaction is an important indicator of adaptation in patients with cancer; however, its relationship to medium-to-long-term health-related outcomes is less well understood. Married women (N = 152) at least six months post-mastectomy were surveyed to determine whether marital satisfaction predicted non-weight-related body image distress (BID), pain impact, and mood, or whether the directionality of this association operated in reverse. Structural equation modeling indicated that the model predicting medium-to-long-term health-related outcomes from satisfaction better fit the data and that time influences mood.

Impact of Breast Cancer Surgery on the Self-Esteem and Sexual Life of Female Patients

Patient satisfaction with cosmetic outcome and the psychological impact of breast cancer surgery were evaluated. A total of 207 patients with primary breast cancer, treated with either breast-conserving surgery ( n = 83), modified radical mastectomy without reconstruction ( n = 108), or mastectomy with delayed breast reconstruction ( n = 16) rated their cosmetic outcome and satisfaction following surgery, and the impact of surgery on their self-esteem and sexual life, by questionnaire. Patients undergoing breast-conserving surgery were most satisfied with their surgery and body image, followed by those treated with mastectomy with delayed reconstruction. Although diagnosis of breast cancer had a negative impact on the psychology of all patients, those undergoing breast-conserving surgery or mastectomy with delayed reconstruction were more satisfied and reported a lower impact on their self-esteem and sexual life versus those who only had mastectomy. Diagnosis of breast cancer has a negative psychological impact on the patient, but the type of surgery has a significant role in post-operative self-esteem and sexual life.

Single-stage immediate breast reconstruction using a skin-sparing incision and definitive saline implants compared with a two-stage reconstruction using tissue expansion plus implants

BACKGROUND

Losing a breast to cancer has significant psychological ramifications, and it has been shown that minimizing this loss can have a profound impact. As a result, breast-conserving therapy or mastectomy followed by breast reconstruction have become the preferred surgical treatments for breast cancer. Limited available breast skin following mastectomy has traditionally necessitated the use of autologous tissue or tissue expansion; however, when reconstructing larger breasts, autologous tissue grafts rarely provide enough tissue and tissue expanders can often take several months to achieve the necessary tissue volume. The skin-sparing mastectomy offers a solution to this lack of skin, and as a result many new options for immediate breast reconstruction have presented. The present pilot study looks at a new method of immediate breast reconstruction involving a Wise pattern skin-sparing mastectomy with placement of a definitive, submuscular saline implant as a way to maintain a large breast size without requiring the patient to undergo a long and painful tissue expansion process.

METHODS

A retrospective, case-control study was performed on 12 women who had undergone bilateral mastectomies with immediate reconstruction either with a tissue expander and later placement of definitive saline implant (control group) (n=5) or who had undergone a single-stage reconstruction involving the placement of a definitive submuscular saline implant (experimental group) (n=7). Patients were compared with respect to change in breast size, number of reoperations and operations in total, as well as satisfaction with their reconstruction.

RESULTS

Patient satisfaction in both groups was relatively high and there was no statistically significant difference found between the two groups. The experimental group decreased in bra size by 1.4 cup sizes on average whereas the control group experienced no change on average; however, one-third of patient data had to be discarded for various reasons, making the change in size measurement inconclusive. Finally, the average number of reoperations was higher in the experimental group than the control (1.57 versus 1.00); however, the total number of operations required was less (2.57 versus 2.80).

CONCLUSIONS

Immediate breast reconstruction using a definitive submuscular saline implant is a viable option for reconstruction in women with larger breasts that deserves further study on a larger scale. Although limited by sample size, the present pilot study showed, with a large effect size, that this new procedure reduces the total number of operations required for reconstruction when compared with a tissue expander followed by an implant while maintaining an equally high level of patient satisfaction.

Breast-conservation treatment outcomes: a community hospital's experience

In the United States, the majority of early breast cancer patients choose breast-conserving treatment in the community setting, yet there is a paucity of literature describing outcomes. In this paper, we describe our experience with breast-conserving treatment in a small community hospital. Our hospital tumor registry was used to identify breast cancer cases diagnosed at our hospital between 1997 and 2003. We limited our study to those women with initial attempts at breast-conserving surgery (BCS) who had follow-up oncology treatment at on-campus affiliated oncological services. We looked at factors that influence survival for early stage 0-II disease such as tumor and patient characteristics, completeness of local surgical tumor excision, and adjuvant treatment. We also evaluated the percentage of cases in which the initial BCS did not achieve adequate surgical oncological results and the number and type of subsequent surgeries that were required to achieve this goal. There were 185 cases with a median patient age of 55 and a median follow-up time of 53 months. Most tumors were stage 0-I (68%) or stage II (23%). A single surgery was deemed sufficient to achieve the desired oncological outcome in 54% of cases; the remaining cases (46%) required additional surgeries. A final margin of 5 mm or greater was successfully achieved in 81% of cases. Ninety-two percent of the patients underwent radiotherapy, 65% received hormonal therapy, and 49% underwent chemotherapy. One hundred and sixty one patients had successful breast-conserving surgeries (87%) and 24 patients (13%) ultimately required mastectomy. There were four loco-regional recurrences and 19 deaths during the study period. Our disease-free survival rate for early-stage cancer (stage 0-II) was 91% at 5 years. Our study shows that high-quality patient outcomes for breast-conserving treatment can be achieved in the community setting.

High satisfaction rates in women after DIEP flap breast reconstruction

BACKGROUND

Breast reconstruction (BR) is aimed at improving quality of life (QoL) after mastectomy. Patient satisfaction is an important indicator to evaluate the success of BR. This study explored patient satisfaction and its determinants in women undergoing deep inferior epigastric artery perforator (DIEP) flap BR as well as the impact of the procedure on body image, sexuality and QoL.

METHODS

Patient satisfaction and QoL were studied in 72 women who underwent DIEP flap BR using a study-specific questionnaire as well as the Short Form-36 (SF-36).

RESULTS

Patient satisfaction was very high. Approximately 90% of the patients reported that they had been sufficiently informed about the procedure and its consequences, that their preoperative expectations had been met, that the reconstructed breast felt like their own and that they would choose the same procedure again and would recommend this procedure to a friend. Patient satisfaction was positively and significantly related to the reconstructed breast(s) feeling like their own. Women with secondary reconstructions were more positive about changes in sexuality and femininity than women with primary BRs. There were no clinically relevant differences in QoL between our study population and a random sample of Dutch females.

CONCLUSIONS

Women with DIEP flap BRs reported high satisfaction rates. However, to compare these satisfaction rates with other forms of BR, prospective studies in comparable groups are necessary.

Does nipple preservation in mastectomy improve satisfaction with cosmetic results, psychological adjustment, body image and sexuality?

We investigated the influence of nipple areolar complex (NAC) sparing in mastectomy, on patient satisfaction with cosmetic results, body-image, sexuality and psychological well-being. We developed a specific questionnaire and compared two groups of women who underwent radical mastectomy with immediate breast reconstruction (IBR). Between 2004 and 2006, 310 women with NAC preservation and 143 patients with successive NAC reconstruction were mailed the questionnaire at follow-up 1 year after definitive complete breast reconstruction surgery. 256 questionnaires was available. Our results showed significant differences in favour of the NAC sparing group regarding body image (difficulty in looking at themselves naked and being seen naked by their partners after surgery, P = 0.001 and P = 0.003, respectively); regarding satisfaction with the appearance of the nipple (P < .0001) and with the sensitivity of the nipple (P = 0.001); regarding the feeling of mutilation (P = 0.003). NAC sparing in mastectomy has a positive impact on patient satisfaction, body image and psychological adjustment.

Body image issues in women with breast cancer

Diagnosis and treatment of breast cancer affects women physically as well as psychologically. There are many obvious and real factors that are related to psychological distress in women coping with breast cancer, such as facing a life-threatening illness, painful and impairing treatments, and significant role changes. Although these factors are clearly important, issues related to body image in women faced with breast cancer can also add to psychological distress. Women, in general, are concerned with their appearance, their weight, and their body, with recent studies suggesting 89% of women reported concerns with weight. Such premorbid concerns are often deeply ingrained and can contribute to psychological distress in women treated for breast cancer. The present article is a summary of the literature that has examined body image issues and related psychological adjustment in women with breast cancer. Implications for clinical practice and recommendations for future investigations are discussed.

Defining the role for autologous breast reconstruction after mastectomy: social and oncologic implications

Breast reconstruction plays a significant role in the management of breast cancer. The removal of a breast has implications for the psychologic, social, and sexual well-being of the patient, establishing the need for discussion of postmastectomy breast reconstruction with suitable patients. However, operative morbidity and the potential for diminished oncologic safety are ongoing issues of contention. A Medline literature review was performed to evaluate the interplay between the psychosocial need for breast reconstruction in patients after mastectomy and the issues surrounding its oncologic safety. Immediate breast reconstruction does not impair the oncologic safety of breast cancer management, with no increase in local recurrence rates, and no delays in the initiation of adjuvant chemotherapy or radiation therapy (RT). Immediate breast reconstruction in the setting of chemotherapy is not associated with greater complication rates; however, there is some evidence for increased complications in the setting of adjuvant RT. Breast reconstruction has a positive effect on the psychosocial outcomes of mastectomy and is oncologically safe in the immediate and delayed settings. Ultimately, the decision-making process of whether to reconstruct, how to reconstruct, and when to reconstruct requires a multidisciplinary approach, with the patient, plastic surgeon, oncologic surgeon, medical oncologist, and radiation oncologist all contributing.

Delayed breast reconstruction with implants after invasive breast cancer does not impair prognosis

We investigated if delayed breast implant reconstruction after breast cancer impairs prognosis. Using data from the Danish Breast Cancer Cooperative Group register, we identified all women <70 years who underwent breast reconstruction with implants after mastectomy after invasive breast cancer during 1978 to 1992, on average 2.2 years (range, 3 days-9.4 years) after mastectomy. The reconstructed women were closely matched to breast cancer patients without reconstruction on age and calendar time of diagnosis, tumor size, regional lymph node involvement, and adjuvant radiation therapy. Overall, 580 reconstructed women and 1158 individually matched controls were followed-up for disease-free survival within the first 10 years and for overall survival for an average of 20.1 year (range, 12.8-27.5 years). Disease-free survival was significantly improved hazard ratio 0.78; 95% confidence interval 0.64-0.95 and overall survival was nonsignificantly improved (hazard ratio, 0.90; 95% confidence interval 0.76-1.06) among the breast reconstructed women. This is likely because of differences in socioeconomic and health factors.

Fraction size in radiation treatment for breast conservation in early breast cancer

BACKGROUND

Shortening the duration of radiation therapy would benefit women with early breast cancer treated with breast conservation. It may also improve access to radiation therapy by improving efficiency in radiation oncology departments globally. This can only happen if the shorter treatment is as effective and safe as conventional radiation therapy.

OBJECTIVES

To assess the effects of altered fraction size on women with early breast cancer who have undergone breast conserving surgery.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Specialised Register (June 2006), MEDLINE (November 2006), EMBASE (November 2006), reference lists for articles, and relevant conference proceedings. No language constraints were applied.

SELECTION CRITERIA

Randomised controlled trials of unconventional versus conventional fractionation in women with early breast cancer who had undergone breast conserving surgery.

DATA COLLECTION AND ANALYSIS

Data extraction was performed independently by the authors with disagreements resolved by discussion. Missing data was sought by contacting the authors concerned.

MAIN RESULTS

Two trials were included and reported on 2644 women. The women were highly selected with node negative tumours smaller than 5 cm and negative pathological margins; 46% of the women had a cup separation size of less than 25 cm. The studies were of high quality. Data for local recurrence and breast appearance were not available in a form which could be combined. Unconventional fractionation (delivering radiation therapy in larger amounts each day but over fewer days than with conventional fractionation) did not appear to affect: (1) local-recurrence free survival (absolute difference 0.4%, 95% CI -1.5% to 2.4%), (2) breast appearance (risk ratio (RR) 1.01, 95% CI 0.88 to 1.17; P = 0.86), (3) survival at five years (RR 0.97, 95% CI 0.78 to 1.19; P = 0.75), (4) late skin toxicity at five years (RR 0.99, 95% CI 0.44 to 2.22; P = 0.98, or (5) late radiation toxicity in sub-cutaneous tissue (RR 1.0, 95% CI 0.78 to 1.28; P = 0.99).

AUTHORS' CONCLUSIONS

We have evidence from two high quality randomised trials that the use of unconventional fractionation regimes (greater than 2 Gy per fraction) does not affect breast appearance or toxicity and does not seem to affect local recurrence for selected women treated with breast conserving therapy. These are women with node negative tumours smaller than 5 cm and negative pathological margins. Two new trials have been published in March 2008. Their results are consistent with our findings. The results of these trials will be incorporated in the next update of this review.

Correlates of the desire for improved cosmetic results after breast-conserving therapy and mastectomy in breast cancer patients

The aim of this survey was to evaluate correlates for the patient's desire for surgical improvement of the cosmetic outcome after the primary operation for breast cancer. A cross-sectional study was carried out in a single follow-up outpatient clinic using a questionnaire. Patients were asked to assess their degree of satisfaction with the cosmetic results of their primary surgery and to state if they would like to undergo a further breast surgery to improve the appearance. Patients' characteristics were correlated with this desire. After breast-conserving surgery, 21.6% of the patients stated that they desired surgical improvement, in comparison with 29.8% of the patients who underwent mastectomy. In the latter group, the desire for improvement remained constant up to 5years after the initial operation, whereas it declined in the group of patients after breast-conserving surgery. Furthermore, a younger age and the perception that the appearance negatively influences femininity, partnership or sexual life were associated with a desire for further surgery. Breast reconstruction after mastectomy can be discussed with the patients even after a long follow-up, especially when the appearance seems to influence partnership issues.

Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study

OBJECTIVE

To prospectively evaluate the psychosocial outcomes and body image of patients 2 years postmastectomy reconstruction using a multicenter, multisurgeon approach.

BACKGROUND

Although breast reconstruction has been shown to confer significant psychosocial benefits in breast cancer patients at year 1 postreconstruction, we considered the possibility that psychosocial outcomes may remain in a state of flux for years after surgery.

METHODS

Patients were recruited as part of the Michigan Breast Reconstruction Outcome Study, a 12 center, 23 surgeon prospective cohort study of mastectomy reconstruction patients. Two-sided paired sample t tests were used to compare change scores for the various psychosocial subscales. Multiple regression analysis was used to determine whether the magnitude of the change score varied by procedure type.

RESULTS

Preoperative and postoperative year 2 surveys were received from 173 patients; 116 with immediate and 57 with delayed reconstruction. For the immediate reconstruction cohort, significant improvements were observed in all psychosocial subscales except for body image. This occurred essentially independent of procedure type. In the cohort with delayed reconstruction, significant change scores were observed only in body image. Women with transverse rectus abdominis musculocutaneous flaps had significantly greater gains in body image scores (P = 0.003 and P = 0.034, respectively) when compared with expander/implants.

CONCLUSIONS

General psychosocial benefits and body image gains continued to manifest at 2 years postmastectomy reconstruction. In addition, procedure type had a surprisingly limited effect on psychosocial well being. With outcomes evolving beyond year 1, these data support the need for additional longitudinal breast reconstruction outcome studies.

Concordance between patients' desired and actual decision-making roles in breast cancer care

This study explored breast cancer patients' preferences and experiences for participation in treatment decision making as well as the concordance between patients' actual and desired decision making. The interplay between depression, anxiety and decision-making preferences was also examined.A consecutive sample of primary breast cancer patients was recruited within a week of either surgery or the beginning of neo-adjuvant chemotherapy in two breast cancer centres in Germany. Women were asked to complete a self-explanatory questionnaire. Most patients (40.2%) of the 137 participants preferred the physician to make the treatment decision. A total of 63.4% were able to fulfil their preferred decision-making role. Breast cancer patients who wanted the physician to make the decision and patients who wanted to make the decision on their own were more likely to have their preferences met than patients who wished to share the decision (p < 0.01). Availability of treatment choice and the level of depression influenced the preferred decision-making preference. Limited concordance between desired and actual decision making of patients with collaborative decision-making preferences suggests the need for better communication and physician training on shared decision making.

Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging: systematic review and meta-analysis in detection of multifocal and multicentric cancer

PURPOSE We review the evidence on magnetic resonance imaging (MRI) in staging the affected breast to determine its accuracy and impact on treatment. METHODS Systematic review and meta-analysis of the accuracy of MRI in detection of multifocal (MF) and/or multicentric (MC) cancer not identified on conventional imaging. We estimated summary receiver operating characteristic curves, positive predictive value (PPV), true-positive (TP) to false positive (FP) ratio, and examined their variability according to quality criteria. Pooled estimates of the proportion of women whose surgery was altered were calculated. Results Data from 19 studies showed MRI detects additional disease in 16% of women with breast cancer (N = 2,610). MRI incremental accuracy differed according to the reference standard (RS; P = .016) decreasing from 99% to 86% as the quality of the RS increased. Summary PPV was 66% (95% CI, 52% to 77%) and TP:FP ratio was 1.91 (95% CI, 1.09 to 3.34). Conversion from wide local excision (WLE) to mastectomy was 8.1% (95% CI, 5.9 to 11.3), from WLE to more extensive surgery was 11.3% in MF/MC disease (95% CI, 6.8 to 18.3). Due to MRI-detected lesions (in women who did not have additional malignancy on histology) conversion from WLE to mastectomy was 1.1% (95% CI, 0.3 to 3.6) and from WLE to more extensive surgery was 5.5% (95% CI, 3.1 to 9.5). CONCLUSION MRI staging causes more extensive breast surgery in an important proportion of women by identifying additional cancer, however there is a need to reduce FP MRI detection. Randomized trials are needed to determine the clinical value of detecting additional disease which changes surgical treatment in women with apparently localized breast cancer.

Prevalence and risk of depressive symptoms 3-4 months post-surgery in a nationwide cohort study of Danish women treated for early stage breast-cancer

BACKGROUND

Elevated levels of depressive symptoms are generally found among cancer patients, but results from existing studies vary considerably with respect to prevalence and proposed risk factors.

PURPOSE

To study the prevalence of depressive symptoms and major depression 3-4 months following surgery for breast cancer, and to identify clinical risk factors while adjusting for pre-cancer sociodemographic factors, comorbidity, and psychiatric history.

PATIENTS AND METHODS

The study cohort consists of 4917 Danish women, aged 18-70 years, receiving standardized treatment for early stage invasive breast cancer during the 2 1/2 year study period. Of these, 3343 women (68%) participated in a questionnaire study 12-16 weeks following surgery. Depressive symptoms (Beck's Depression Inventory II) and health-related behaviors were assessed by questionnaire. The Danish Breast Cancer Cooperative Group (DBCG) and the surgical departments provided disease-, treatment-, and comorbidity data for the study cohort. Information concerning sociodemographics and psychiatric history were obtained from national longitudinal registries.

RESULTS

The results indicated an increased prevalence of depressive symptoms and major depression (13.7%) compared to population-based samples. The pre-cancer variables: Social status, net-wealth, ethnicity, comorbidity, psychiatric history, and age were all independent risk factors for depressive symptoms. Of the clinical variables, only nodal status carried additional prognostic information. Physical functioning, smoking, alcohol use, and BMI were also independently associated with depressive symptoms.

CONCLUSION

Risk factors for depressive symptoms were primarily restricted to pre-cancer conditions rather than disease-specific conditions. Special attention should be given to socio-economically deprived women with a history of somatic- and psychiatric disease and poor health behaviors.

Risk factors and blood flow in the free transverse rectus abdominis (TRAM) flap: smoking and high flap weight impair the free TRAM flap microcirculation

Mastectomy patients may have significant psychologic-related problems. Breast reconstruction provides in these cases substantial benefits in restoring body image and health-related quality of live. Autologous free tissue transfer is the treatment of choice due to excellent outcome. The purpose of this study was to elucidate the effect of the risk factors on the microcirculation and clinical outcome. In this prospective study, 21 patients with a free transverse rectus abdominis (TRAM) flap breast reconstruction were included. Patient demographics and flap characteristics were recorded. Blood flow was recorded in the central part (zone I) and the distal part (zone IV) of the flap with the laser Doppler flowmetry (LDF; Perimed). In this study, increased flap complications were seen in smokers when compared with nonsmokers (P < 0.000). LDF was higher in the older patient population (P = 0.008) in zone IV. Smoking, especially in combination with a high flap weight (HFW), revealed lower blood-flow values (P = 0.020) in zone IV. Other possible influencing risk factors such as a HFW and history of radio- and chemotherapy did not alter the microcirculation. Patients with smoking and a HFW did also show decreased blood flow but also more severe flap complications.Smoking, especially in patients with a HFW, impairs the free TRAM flap microcirculation in zone IV. In our opinion, these patients can still be included for reconstruction. However, extra care has to be taken during flap design to minimize disturbed wound healing.