A comparison of body image, self-esteem and social support in total mastectomy and breast-conserving therapy in Turkish women

As well as the medical outcomes of two distinct operations, namely total mastectomy and breast-conserving therapy, their impact on the psychic structuring of the patient may differ. A group of 40 woman with who had undergone mastectomy were therefore compared with another 40 with who had received breast-conserving therapy, with regard to the variables of body image, self-esteem and social support. The women who underwent breast-conserving therapy had a more positive body image (P < 0.001). The two groups showed a negligible difference with respect to self-esteem and social support (P > 0.05). A negative correlation was found between body image and social support (P < 0.05). Patients with total mastectomy therefore do have a more negative body image than patients receiving breast-conserving therapy. Self-esteem and social support in the postoperative period in two groups are comparable.

Breast conserving surgery and radiation in the treatment of operable breast cancer

Breast conserving treatment (BCT) is an alternative to mastectomy, and prospective randomized trials have demonstrated that BCT and radical mastectomy result in similar actuarial survival rates. BCT should fulfil two criteria: (1) it should afford the same local control of disease as radical mastectomy, and (2) it should offer clear cosmetic and psychological advantages. This paper reviews the current status of BCT in the treatment of breast cancer. The choice of a narrow marginal tumor excision with aggressive radiation versus a wide resection with a small dose of radiation is discussed. Although the narrower marginal excisions, such as tumorectomy or lumpectomy provide the best cosmetic results, they may not provide adequate local control even when combined with aggressive irradiation. Wide resections such as quadrantectomy combined with a smaller dose of radiation, results in adequate local control, but less satisfactory cosmetic results. Although body image is better preserved by BCT, a clear enhancement of the psychological well being has yet to be established. Nevertheless, with further improvement in surgical, radiological and chemotherapeutic techniques, BCT likely will be the treatment of choice in more and more patients with operable breast cancer.

Mastectomy versus conservative surgery and radiation therapy. Psychosocial consequences

BACKGROUND

Clinical trials comparing mastectomy to conservative surgery plus radiation therapy in the treatment of breast cancer have provided an opportunity to increase understanding of the biology of this disease and the psychological adaptation of the breast cancer patient. Because these local treatments appear to be equal in terms of survival, the question remains as to whether conservative surgery plus radiation therapy confers a measure of psychological comfort superior to that of mastectomy for women diagnosed with early-stage breast cancer.

METHODS

One hundred forty-two women participating in a clinical trial randomizing patients to mastectomy or lumpectomy and radiation therapy were prospectively evaluated for psychological response to their respective local therapy. A baseline assessment before randomization and subsequent questionnaires at 6, 12, and 24 months after treatment were completed by patients entered in the clinical trial.

RESULTS

At 6 months, mastectomy patients reported significantly less control over events in their lives (P = 0.003) and more problems with sexual relations (P = 0.021) than did their conservatively treated counterparts. In addition, there were marked differences between mastectomy patients and lumpectomy and radiation therapy patients in the degree of distress over their nude bodies, with P = 0.001 at 6 months, P = 0.019 at 12 months, and P = 0.057 at 24 months.

CONCLUSIONS

From our findings, it appears that breast conservation therapy protects women's perception of their body but does not, over time, contribute to a more positive sexual adjustment.

How breast cancer patients choose a treatment method

This paper discusses two treatment options for early stage breast cancer--modified radical mastectomy and lumpectomy plus radiation therapy--and examines the reasons why women choose one method of treatment over the other. In examining how women make their treatment decision, the paper reviews the literature regarding how psychological, emotional and psychosocial factors play a role in determining a method of treatment. It also discusses coping methods during breast cancer treatment, why women choose to undergo breast reconstruction and to whom they look for information when making health decisions.

Clinical note on the use of denial in patients undergoing surgery for breast cancer

44 patients awaiting surgery for breast cancer completed the Hospital Anxiety and Depression Scale. Thirteen patients had anxiety scores within the normal range, and five of them even scored extremely low in anxiety. These five and possibly all 13 patients were probably using denial as a defense against the stress of major surgery.

Psychosocial and functional status of breast cancer patients. The influence of diagnosis and treatment choice

This exploratory study examined breast cancer patients' psychosocial and functional status at the time of diagnosis and during the initial phase of treatment. The purpose was to better understand the impact of diagnosis and treatment on patients' physical state and psychosocial well-being. A convenience sample was drawn from a population of newly diagnosed stage 1 and 2 breast cancer patients undergoing either modified radical mastectomy or lumpectomy with radiation. Subjects completed instruments designed to measure uncertainty, quality of life, functional status, and reaction to diagnosis on two separate occasions: at the time of diagnosis, but before treatment selection and then approximately 8 weeks after surgery. Data obtained from 52 subjects indicated that patients' perceptual uncertainty and various aspects of their functional status declined over the initial course of treatment, but that quality of life was unaffected. The results also showed no relationship between type of breast cancer treatment and patients' uncertainty, quality of life, and functional status. Mastectomy and lumpectomy patients also responded in similar ways to the cancer diagnosis. Both groups experienced the same amount of distress and used conformational coping strategies to similar degrees. Clinical implications are discussed and recommendations are made for future research.

Body image in women treated for breast cancer

Body image, as a component of self-concept, was compared in four groups of women (N = 257) who received the most common types of treatment for breast cancer: mastectomy, mastectomy with delayed reconstruction, mastectomy with immediate reconstruction, and conservative surgery. Data were collected by mailed questionnaires using self-report instruments. Comparison of groups using analysis of covariance with age as a covariate indicated that mean body image in the conservative surgery group was significantly more positive than in either the mastectomy group or in the mastectomy with immediate reconstruction group. No differences in self-concept were evident among the four groups.

Decision making by patients with breast cancer: the role of information in treatment selection

In recent years, patients have become more involved in the clinical decision-making process, yet the nature of this process, including the role of information, is poorly understood. The purpose of this exploratory study was to examine the relationship between information about breast cancer treatment alternatives and patients' choices of treatments. The target population was all patients with breast cancer in the process of deciding between breast conservation (lumpectomy plus irradiation) and more traditional management (modified radical mastectomy, with or without reconstruction). A convenience sample of 71 female patients with stage I or II breast cancer was drawn from a breast clinic affiliated with a 1,000-bed tertiary medical center. The amount of information provided to each subject and the nature of its presentation were recorded using an observer checklist. Recall of information and final treatment selection were ascertained during telephone interviews conducted six to eight weeks after surgery. The results indicate that subjects' choice of treatment was unrelated to the amount of information they received during the clinic visit. Manner of presentation also did not influence treatment selection. However, treatment selection was related to the amount of information subjects received prior to their clinic visit (p < 0.01). The results also indicate that patients' recall of information about treatments and associated risks is exceedingly poor. Clinical and legal implications are discussed and recommendations for further research are offered in this article.

The cosmetic outcome in early breast cancer treated with sector resection with or without radiotherapy. Uppsala-Orebro Breast Cancer Study Group

In a randomised trial, the cosmetic results after sector resection and axillary dissection with or without postoperative radiotherapy for early breast cancer were evaluated. The evaluations were made at 3, 12, 24 and 36 months (357, 326, 302 and 255 women, respectively) after treatment. Good to excellent cosmetic results were achieved in 84-90% of those in the group randomised to radiation and in 91-95% in the group allocated to surgery only, as judged by the women themselves, and in 81-86% and 87-93%, respectively, according to other observers. At 12 months the results in 290 patients were photographically documented and evaluated by a panel. The results were good to excellent in 35-84% of the irradiated group and in 62-93% of the non-irradiated group. Poor results followed the development of contour differences, breast oedema and mamillary deviation, which were the most important mediators of a poor cosmetic result after radiotherapy. We conclude that sector resection and axillary dissection can be performed with good cosmetic results. Doses to 54 Gy of radiotherapy influence the result negatively, but from a clinical standpoint to a moderate extent.

Quality of life measurement in breast cancer

Appropriate assessment of quality of life parameters should be a mandatory requirement when determining the outcome of different treatments for breast cancer. Such measures provide useful, sometimes counterintuitive information concerning treatment costs and benefits and can help guide the clinician with management decisions. It is important to choose well-validated measures of quality of life to enable comparison between studies assessing the impact of different therapeutic modalities and psychosocial interventions.

Framing and labelling effects in health descriptions: quality adjusted life years for treatment of breast cancer

At present there is a growing interest in the use of cost-utility analysis (CUA) to a point where it merits serious consideration by health care decision makers. However, there remain a number of theoretical and practical issues to be resolved including the way in which quality of life information is presented and described to subjects. Two potential sources of influence in the construction of the quality adjusted life year (QALY) values elicited for a recent Australian CUA of mammography screening have been investigated. 180 subjects were randomly allocated to nine different presentations of two breast cancer health descriptions to investigate the impact of some framing and labelling effects. No statistically significant differences were found in the valuations placed on these descriptions when framing and labelling effects were taken into account, either as separate framing and labelling factors or as interactions with one another. A significant difference was found in the particular values of descriptions that were written in the third person that differed in terms of whether the word "cancer" was used. The main contribution of these data is to the robustness of the health descriptions used in the cost-utility analysis of mammography screening.

Are modified radical mastectomies done for T1 breast cancers because of surgeon's advice or patient's choice?

Clinical trials show that T1 breast cancers are equally well treated with breast-conserving surgery as with modified radical mastectomy. However, the Colorado Central Cancer Registry indicates that, for the past 5 years, the majority of women (72%) with T1 breast cancer in Colorado have undergone modified radical mastectomies. A questionnaire was sent to 175 general surgeons to determine the reasons for the high number of modified radical mastectomies still being performed. The results indicate that one group of surgeons (34% of those responding) believes each type of surgery has equal survival rates but unknowingly influences the patient to choose modified radical mastectomy, with a subtly biased presentation. Education of both surgeons and patients is needed to increase the number of patients with T1 breast lesions who can benefit from breast-conserving therapy.

Psychological morbidity in the first year after breast surgery

In this prospective study, the psychological morbidity associated with the treatment of breast cancer was assessed. The study population comprised all patients referred to one centre with a recently diagnosed breast lump, who were to undergo surgery. Psychological morbidity was assessed preoperatively and at 6 and 12 months postoperatively by modified Rotterdam Symptom Checklist. Three hundred and twenty patients completed all three questionnaires: 93 women undergoing mastectomy, 73 women having conservation therapy for breast cancer and 156 women having biopsy for benign breast disease. Patients with a breast malignancy smaller than 4 cm in diameter were treated by lumpectomy and radiotherapy, anti-oestrogen therapy or chemotherapy alone or in combination. Psychological morbidity among patients with malignant disease was significantly greater than that seen in the group with benign disease. Among cancer patients, a significant decrease in anxiety and depression occurred during the year following surgery. The study failed to demonstrate any psychological advantage associated with breast conservation.

Effects of mastectomy versus lumpectomy on emotional adjustment to breast cancer: a prospective study of the first year postsurgery

PURPOSE

Procedure (mastectomy v lumpectomy) and choice of procedure were examined as predictors of adjustment to breast cancer in a prospective study of the experiences of the first year after surgery.

PATIENTS AND METHODS

Breast cancer patients were interviewed the day before surgery, 10 days after surgery, and at the 3-month, 6-month, and 12-month follow-ups. Patients included 24 women who received mastectomy on strong recommendation, 24 who chose mastectomy for other reasons, and 15 who chose lumpectomy. Subjective well-being was assessed in terms of mood disturbance, perceived quality of life, life satisfaction, marital satisfaction, perceptions of social support, and self-rated adjustment.

RESULTS

Surgical groups differed in well-being in only one respect: lumpectomy patients reported a higher-quality sex life at 6 and 12 months postsurgery than mastectomy patients. Choice of surgical procedure predicted higher levels of life satisfaction at 3 months.

CONCLUSION

The lack of difference between surgical groups in areas other than sexual adjustment replicates previous findings, but extends them by (1) using a fully prospective design, (2) providing data on the period surrounding the surgery (as well as later periods), and (3) examining a broader range of indices of well-being than usual.

Fear of recurrence, breast-conserving surgery, and the trade-off hypothesis

Fear of recurrence has been at the heart of the controversy between surgeons favoring mastectomy versus those advocating a less radical operation. Breast-conserving surgery is thought to result in a better body image, but patients are expected to worry more about a cancer recurrence because only a small part of the breast is excised. To assess survival rates after breast-conserving intervention, patients were randomized into the National Surgical Adjuvant Breast Project (NSABP) prospective clinical trial (Protocol B06) with three treatment groups: total mastectomy, lumpectomy, and lumpectomy followed by radiation therapy. A fourth group was created to include patients who had a recurrence after their first operation and thus underwent a subsequent total mastectomy. Differences appeared, not according to the type of treatment, but with respect to the number of surgical interventions. Patients with multiple operations reported a greater fear of cancer recurrence and a worse body image, similar to those that underwent total mastectomy. Contrary to the trade-off hypothesis, patients who underwent radical surgery did not manifest less fear of recurrence. These results show unequivocally that the expected trade-off between breast conservation and fear of cancer recurrence does not occur. Those who undergo lumpectomy do not more express more fear of cancer than do patients who undergo mastectomy.

Breast conservation versus mastectomy. Is there a difference in psychological adjustment or quality of life in the year after surgery?

Women with a breast cancer diagnosis often are given a choice between breast conservation or mastectomy as the primary treatment for their cancer. Despite the high frequency of this cancer, there is little systemic information about the effect of surgical treatment on the quality of life or psychological adjustment of the patient. In this study, the authors prospectively evaluated quality of life, performance status, and psychological adjustment in 109 women who had primary breast cancer treatment. During the year of follow-up, no statistically significant differences in quality of life, mood disturbance, performance status, or global adjustment were found between the two surgical groups, and both groups of patients improved significantly during the year of observation (P = 0.0001). As was predicted, patients receiving mastectomy reported more difficulties with clothing and body image; however, these results apparently did not affect the assessment of mood or quality of life. The authors conclude that patients receiving breast conservation therapy do not experience significantly better quality of life or mood than patients having mastectomy; however, patients having breast conservation surgery have fewer problems with clothing and body image. Women receiving breast conservation therapy may require more intensive psychosocial intervention in the postoperative period because of the added burden of primary radiation therapy.

Mastectomy or conservation for early breast cancer: psychological morbidity

A consecutive series of 197 women under 70 years of age with operable breast cancer, randomised to treatment by a conservation technique in comparison to mastectomy, were assessed using structured interviews. The prevalence of cases of anxiety and depression was high before treatment commenced, there were fewer cases in the conservation group but no significant difference at 3 or 12 months in the number of new cases, social adjustment, or capacity to return to work. Attitudes to treatment showed significant differences between the groups, more women in the conservation group were able to wear their usual clothes and most women rated the cosmetic result highly. Patients were more likely to stop sexual intercourse completely after mastectomy. An effective conservation technique should be an attractive treatment choice available to selected women with early breast cancer.

Mastectomy versus breast conservation surgery: Mental health effects at long-term follow-up

Between 1984 and 1989, 129 Stage 1 and Stage 2 breast cancer patients were entered into a behavioral study in Pittsburgh. Approximately 70% of these patients had elected to have breast conservation (lumpectomy) surgery, with the remainder choosing mastectomy. Using the Profile of Mood States, a measure of perceived social support, and Karnofsky ratings of physical functional status, patients were assessed 3 to 5 days following surgery and again 3 and 15 months following surgery. The data were analyzed using a repeated-measures analysis of covariance, adjusting for aggressiveness of chemotherapy. Compared to mastectomy patients, patients who received breast conservation surgery were rated as more functional by observers, but they perceived themselves as having less energy and less emotional support, especially over the first 3 months of the recovery period. Because there is accumulating evidence that emotional support may act as a stress buffer in various populations and may have survival value, these findings may be particularly troublesome. This study shows that breast conservation surgery is not a psychosocial panacea. Patients whose breasts are spared, especially younger patients, have psychological symptoms that appear acutely worse in the short run and, in the end, are similar to those of patients who elect to have mastectomies. Therefore, patients choosing lumpectomies are not necessarily psychosocially better off than those electing to have mastectomies. Additionally, these patients, particularly younger patients, may require greater social support and potential mental health interventions than they seem to be receiving.

Psychosocial aspects of breast cancer

In the past year, there have been timely and important reports on psychosocial aspects of breast cancer screening. Noteworthy papers have also been published on the psychologic sequelae of mastectomy compared with breast conservation, quality-of-life-adjusted survival analysis with breast cancer adjuvant therapy, and the relative importance to patients with metastatic breast cancer of quality-of-life dimensions.

[Coping with illness and body image following different surgical techniques in breast cancer]

Coping and body image were studied in 80 patients with breast cancer. We compared three groups, who had undergone different operative strategies: temporary expander prothesis (n = 19), excisional biopsy (n = 20) and modified radical mastectomy (n = 40). Instruments were: the Herschbach coping questionnaire, the Strauss and Appelt body image questionnaire and a semi-structured interview. Patients after excisional biopsy showed significantly less illness-related stress than the other two groups, both in the number of all items named (p less than 0.02) and in the weighted total (p less than 0.05). Patients after modified mastectomy had chosen a different, "unfavourable" pattern of coping mechanisms than patients after expander prothesis or excisional biopsy: more resignation (p less than 0.05), less fighting and talking (p less than 0.05, respectively). In the body image questionnaire, no significant difference was found. However, in the semi-structured interview, patients after mastectomy mentioned more frequently that they avoided looking at the scar (p less than 0.05). These results underline the importance of preoperative counselling.

Psychosocial and sexual impact of diagnosis and treatment of breast cancer

Psychosocial and sexual disturbances are common sequelae to a diagnosis of breast cancer and its treatment. The intuitively plausible hope that the advent of breast conserving techniques would prevent the psychological distress experienced following mastectomy has not been realised. Studies comparing psychosocial outcome of mastectomy with lumpectomy and radiotherapy reveal some advantage to women treated with breast conserving procedures in terms of body image, but very little difference in terms of psychiatric morbidity or sexual dysfunction. Whatever the primary therapy, women must still confront the fact that they have had cancer, a life-threatening disease which may recur. In this chapter the research comparing psychological outcome between mastectomy and lumpectomy is critically reviewed and the implications that these data have for clinical practice are discussed.

Relationships between emotional control, adjustment to cancer and depression and anxiety in breast cancer patients

The possible relationship between psychological responses among breast cancer patients and disease outcome continues to be an area of controversy and debate. Two parallel findings are reported separately in the literature: first, that emotional control is more common among women with breast cancer than in women with benign breast disease or in healthy controls and second, that a helpless attitude towards the disease is related to a poor prognosis. These previously unrelated psychological responses are examined here in a group of women (N = 359) with early stage breast cancer, who were seen one to three months after diagnosis. The relationships between emotional control, adjustment to cancer and psychological morbidity were examined. Prevalence levels of 16 and 6% were observed for anxiety and depression respectively, which are lower than reported more generally in the literature. The results indicated a highly significant association between scores for the tendency to control emotional reactions and a fatalistic attitude toward cancer. A significant association was observed between anger control and a helpless attitude. Psychological morbidity was also linked to type of adjustment to cancer. The data are interpreted in terms of a process model of psychological responses which suggests that emotional control (an important component of the Type C behaviour pattern) fatalism, helplessness and psychological morbidity are linked.

Reduced psychological morbidity after breast conservation

Psychological morbidity was compared in 52 patients treated by mastectomy and 67 patients treated by lumpectomy for early breast cancer. An informal counselling service was provided for all patients. Morbidity was measured at 6, 9 and 12 months after surgery with two self-rating scales: the general health questionnaire and the Leeds depression and anxiety scales. There was a significant excess of severe depression in the mastectomy group. In contrast to the findings of previous research, this result suggests that breast conservation reduces psychological morbidity.

[Perioperative subjective emotional state]

The aim of adequate preoperative medication is to minimize the patient's anxiety level. Preoperative anxiety can be consciously and specifically orientated or it can be masked. This double-blind study was performed to evaluate the effects of an anxiolytic drug in comparison with a placebo perioperatively and to assess the post-operative course of the important factors anxiety, depression and asthenia. The Mannheim inventory for subjective state and STAI (State-Trait-Anxiety-Inventory) were offered. The study was undertaken in 60 female patients, who were operated for suspected carcinoma of the breast. We conclude that in such a specific group of patients extensive preoperative psychological preparation must be backed up by the administration of an anxiolytic drug.

Mastectomy or breast conservation in the management of primary breast cancer: psychosocial factors

A diagnosis of breast cancer causes significant emotional, social, and vocational upheaval which diminishes over time. However, newly diagnosed breast cancer patients are mentally capable of making treatment decisions and should be offered the available treatment options. A significant proportion of patients who have the option of breast conservation will choose mastectomy instead. Saving the breast does not significantly alter adjustment problems.

Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial

OBJECTIVES

To assess outside a clinical trial the psychological outcome of different treatment policies in women with early breast cancer who underwent either mastectomy or breast conservation surgery depending on the surgeon's opinion or the patient's choice. To determine whether the extent of psychiatric morbidity reported in women who underwent breast conservation surgery was associated with their participation in a randomised clinical trial.

DESIGN

Prospective, multicentre study capitalising on individual and motivational differences among patients and the different management policies among surgeons for treating patients with early breast cancer.

SETTING

12 District general hospitals, three London teaching hospitals, and four private hospitals.

PATIENTS

269 Women under 75 with a probable diagnosis of stage I or II breast cancer who were referred to 22 different surgeons.

INTERVENTIONS

Surgery and radiotherapy or adjuvant chemotherapy, or both, depending on the individual surgeon's stated preferences for managing early breast cancer.

MAIN OUTCOME MEASURES

Anxiety and depression as assessed by standard methods two weeks, three months, and 12 months after surgery.

RESULTS

Of the 269 women, 31 were treated by surgeons who favoured mastectomy, 120 by surgeons who favoured breast conservation, and 118 by surgeons who offered a choice of treatment. Sixty two of the women treated by surgeons who offered a choice were eligible to choose their surgery, and 43 of these chose breast conserving surgery. The incidences of anxiety, depression, and sexual dysfunction were high in all treatment groups. There were no significant differences in the incidences of anxiety and depression between women who underwent mastectomy and those who underwent lumpectomy. A significant effect of surgeon type on the incidence of depression was observed, with patients treated by surgeons who offered a choice showing less depression than those treated by other surgeons (p = 0.06). There was no significant difference in psychiatric morbidity between women treated by surgeons who offered a choice who were eligible to choose their treatment and those in the same group who were not able to choose. Most of the women (159/244) gave fear of cancer as their primary fear rather than fear of losing a breast. The overall incidences of psychiatric morbidity in women who underwent mastectomy and those who underwent lumpectomy were similar to those found in the Cancer Research Campaign breast conservation study. At 12 months 28% of women who underwent mastectomy in the present study were anxious compared with 26% in the earlier study, and 27% of women in the present study who underwent lumpectomy were anxious compared with 31% in the earlier study. In both the present and earlier study 21% of women who underwent mastectomy were depressed, and 19% of women who underwent lumpectomy in the present study were depressed compared with 27% in the earlier study.)

CONCLUSIONS

There is still no evidence that women with early breast cancer who undergo breast conservation surgery have less psychiatric morbidity after treatment than those who undergo mastectomy. Women who surrender autonomy for decision making by agreeing to participate in randomised clinical trials do not experience any different psychological, sexual, or social problems from those women who are treated for breast cancer outside a clinical trial.

Informational and psychosocial needs of women choosing conservative surgery/primary radiation for early stage breast cancer

Recent advances in the treatment of early stage breast cancer give women a choice of treatments. Prospective and retrospective studies demonstrate the comparable efficacy of treatment with a modified radical mastectomy and treatment with conservative surgery and primary radiation. While the number of women with early stage breast cancer choosing the latter treatment continues to increase, there is a paucity of information in the nursing literature assessing the informational and psychosocial needs of this group. This article reports the results of a questionnaire assessing the informational and psychosocial needs of patients choosing breast conservation surgery, and the future implications of these results for the nursing profession.

Psychological effects of breast-conserving cancer treatment and mastectomy

Patients in the early stages of breast cancer were studied one year after treatment to ascertain the psychological effects of mastectomy and a breast-conserving alternative, lumpectomy plus radiation therapy. Patients who had had a mastectomy felt less attractive, less sexually desirable, and more ashamed of their breasts. They also experienced less enjoyment in their sexual relationships than they had before treatment. Patients who had radiation therapy experienced no changes in these areas. For these reasons, half of the mastectomy patients regretted not having chosen the breast-conserving alternative.

The patients perception of her breast following radiation and limited surgery

Seventy-four patients followed from 1 to 8 years post completion of breast-conserving surgery and radiation for early-stage breast cancer were asked to answer a questionnaire exploring their perception and awareness of the treated breast. The questionnaire was divided into several sections, including "Daily Activities", Pre-menstrual Changes", "Sexual Activities", and a summary "Satisfaction Index" section; when appropriate, comparisons were sought between the treated and untreated breasts. Preliminary results from this study indicate that 70% of all patients are aware of their treated breast in some way during everyday activities. The "Satisfaction Index" of this patient group is very high, with 75% rating their cosmetic result, and 81% their functional result "8" or higher on a scale of "0" to "10","10" indicating "best" or "normal".

Psychosocial outcomes of breast cancer therapies: lumpectomy versus mastectomy

The psychological status of 50 patients who had been treated for breast cancer was assessed an average of 21 months after treatment. The patients were grouped according to major treatment modalities: mastectomy with breast reconstruction, mastectomy without breast reconstruction, or lumpectomy. Lumpectomy patients had a significantly more intact body image (p less than .008) and a greater sense of sexual desirability (p less than .009) than patients in the other groups. The patients did not differ on frequency of sexual relations or on emotional symptomatology. The results of this study generally validate those found in comparable studies showing that lumpectomy promotes a more intact body image but that no surgical procedure either produces or inhibits psychological symptomatology.

Psychosocial adjustment after mastectomy and breast-conserving treatment

The possible advantages of breast-conserving surgery over mastectomy with respect to psychosocial adjustment were assessed in an interview study. Consecutive patients 40 to 80 years of age with invasive breast cancer of Stages I and II were eligible for the study. Of 161 women, 99 agreed to participate; 37 received breast-conserving treatment and 62 received a modified radical mastectomy. The study method consisted of a semistructured interview at 4 and 13 months after primary treatment based on the Social Adjustment Scale (SAS) and two scales for the estimation of anxiety, depression, and adjustment to a sexual relationship. The women's ratings in the SAS inventory for adjustment to work, social life, marriage, sexual relationship, and parental role showed no statistically significant differences between the two groups. In the interviewer's global rating in the SAS protocol of the overall adjustment after 13 months, 22.0% of the women in the mastectomy group versus 5.4% of those with a preserved breast were rated as having significant disturbances. A statistically nonsignificant tendency (P greater than 0.05) emerged for the other ratings in the interviewer's assessment in SAS and in the estimation of anxiety, depression, and adjustment to sexual relationships. The consistent tendency indicates that there might be clinically important differences in the psychosocial adjustment after the two treatment methods. Larger trials focused more sensitively on the problems after breast loss versus breast preservation in breast cancer surgery are needed to further explore this field.

Threat and loss in breast cancer

The psychological well-being of forty-four breast cancer patients was assessed shortly before and after surgery, and at three and twelve months post-operatively. Regression analysis revealed type of treatment, control over treatment and concern for appearance as significant predictors of nature of subsequent mood state. Results are discussed with reference to the theoretical position that type of severe life event can predict the nature of ensuing psychological disorder.

Psychological factors in the choice of treatment for breast cancer

For several years women with an early diagnosis of breast cancer have been able to choose between two equally effective treatments: modified radical mastectomy and the breast-conserving treatment of lumpectomy plus radiation therapy. This study investigated the psychological factors that become involved when a woman chooses between treatments. Many more anticipatory concerns about body image, disfigurement, femininity, and the ability (or inability) to handle emotionally a mastectomy were expressed by lumpectomy/radiation therapy patients than by mastectomy patients. Those lumpectomy-radiation therapy patients who chose the treatment against medical advice were also found to be more concerned than the others about treatment effects on sexuality.

Depression after surgery for breast cancer. Comparison of mastectomy and lumpectomy

The impact of the loss of the breast in women undergoing surgical treatment for breast cancer is subordinated to the confrontation with the diagnosis of a malignancy in causing depression. The equal distribution of depression in mastectomy and in lumpectomy patients supports the hypothesis that it is the confrontation with the potentially lethal outcome of the diagnosis which is decisive in causing depression. The grief reaction following mastectomy has two components: a depressive reaction to the loss of the breast and an anticipatory grief for anticipation of the potentially lethal outcome. Psychosocial therapeutic support in breast malignancy must give priority to coping with the diagnosis of cancer over the loss of the breast.

Psychological distress after initial treatment for breast cancer: a comparison of partial and total mastectomy

This study of the relation between type of mastectomy and psychological distress was based on all newly diagnosed breast cancer patients with localized or regional disease who were surgically treated in seven Quebec City hospitals in 1984. Among 235 eligible patients, 227 (96%) participated in a home interview 3 months after diagnosis and 205 of these women gave a second interview approximately 15 months later. The Psychiatric Symptom Index (PSI) was used to measure the severity of symptoms of psychological distress. At 3 months, 38.8% of partial mastectomy patients had high PSI scores compared to 25.8% of women treated by total mastectomy (OR = 1.8, p = 0.044). Fifteen months later, percentages with high scores were identical, 35.1%, in the two treatment groups. Age appeared to modify the surgery-distress relation. These results suggest that partial mastectomy does not protect against psychological distress after breast cancer. Moreover, they highlight the importance of adequate preparation and support for all breast cancer patients, regardless of type of initial surgery.

Standardization of the surgical technique in breast-conserving treatment of mammary cancer

A number of designations--for example excision, wide excision, lumpectomy, tylectomy, extended tylectomy, partial mastectomy, tumorectomy, segmental resection and quadrantectomy--have been applied to operative procedures aimed at treating mammary carcinoma with preservation of the breast. None of them, however, has been explicitly linked to a defined surgical technique and there is no consensus about the terminology. We propose a simple classification system for breast-conserving procedures, which can facilitate the communication between surgeons and the interpretation and exchange of scientific data. We also describe a strictly defined and locally radical partial mastectomy--a sector resection--which has been used at several centres in Sweden for more than 5 years with a favourable outcome so far in terms of local tumour control and the cosmetic result.