Subtle differences in quality of life after breast cancer surgery

BACKGROUND

Lumpectomy with axillary dissection (LAD) has taken its place alongside mastectomy (M) as the treatment of choice for stage I and II breast cancer. Its appeal is based on lessening disfigurement and thus improving quality of life.

METHODS

We used the SF-36 Health Survey modified with ten questions relevant to breast cancer surgery to evaluate whether quality of life with LAD was better than with mastectomy in women with stage I and II disease. The additional questions addressed satisfaction with intimate relationships and sexuality, and explored impact on the way women dress, use bathing suits, hug people, are comfortable with nudity, and rate their sexual drive and sexual responsiveness.

RESULTS

LAD was not associated with statistically significant better quality-of-life scores on any SF-36 questions, except vitality (P = .02). No differences were noted in the areas of intimacy and sexual satisfaction. LAD patients reported significant differences in matters of dress, use of bathing suits, hugging, comfort with nudity, and sexual drive compared to patients undergoing mastectomy.

CONCLUSIONS

The SF-36 health survey detected few differences in quality of life measures between patients with LAD and those with mastectomy. However, LAD impacts favorably on the way women dress, on comfort with nudity, and on sexual drive.

Two models of care as evaluated by a group of women operated on for breast cancer with regard to their perceived well-being

The main aim of this study was to evaluate two different models of care for breast cancer patients with regard to the patients' perceived well-being. Twenty-nine patients were treated in an established care model and 115 patients were treated at a surgical breast clinic with an increased personnel continuity and a short hospital stay. Two questionnaires were used. The Sense of Coherence (SOC) Scale and a study-specific questionnaire concerning perceptions of the hospital stay, information received, body image, social support, pain, health and psycho-sociological well-being. Regression analyses were used to study the effects of the care models and the SOC on the patients' perceived well-being. The results showed that the care model with high personnel continuity had a significant positive effect on the patients' emotional state, mental well-being and perception of postoperative pain evaluated 1 year after surgery. The strongest predictors of the patients' well-being postoperatively were their perceived well-being before surgery. Furthermore, the stronger the SOC the more positive were the patients' emotional perceptions, perceived general health and mental well-being after surgery. The duration of the hospital stay did not show any effect on the patients' well-being. It is concluded that an early preoperative psycho-social assessment of the patients is of importance in planning the care, to help patients cope with the disease and its treatment. It is suggested that a care model with high personnel continuity for breast cancer patients could facilitate that assessment.

Type of mastectomy and quality of life for long term breast carcinoma survivors

BACKGROUND

Despite numerous studies of partial mastectomy and psychologic morbidity in the first 24 months following surgery, little is known about the long term psychosocial repercussions of partial and total mastectomy.

METHODS

The effect of the type of mastectomy on psychologic adjustment was assessed among 124 breast carcinoma survivors, 47 of whom underwent partial mastectomy and 77 of whom underwent total mastectomy, 8 years after initial treatment. Interviews were also conducted 3 and 18 months after surgery. Psychologic distress was assessed using the Psychiatric Symptom Index. Other outcomes included physical symptoms, patients' perceptions of their own health, satisfaction with the type of surgery performed and with the appearance of the scar, and marital and sexual adjustments.

RESULTS

No statistically significant differences between partial and total mastectomy were observed with respect to long term quality of life. Age at diagnosis modified the relation between the type of mastectomy and psychologic distress in both the short term and the long term (P = 0.04). Among women younger than 50 years, partial mastectomy appeared to be protective against distress when compared with total mastectomy. In contrast, among women age 50 years or older, partial mastectomy was associated with higher psychologic distress levels at all interviews.

CONCLUSIONS

Assessed globally, partial and total mastectomy appear to be equivalent treatments in terms of patients' long term quality of life. However, both short term and long term distress levels after partial and total mastectomy may depend on patients' age at diagnosis. The findings of this study suggest that the increased use of partial mastectomy may lessen the negative effects of breast carcinoma on younger survivors' quality of life. Nevertheless, total mastectomy may be an appropriate initial treatment for some women who truly choose it.

Psychological morbidity and quality of life in Australian women with early-stage breast cancer: a cross-sectional survey

OBJECTIVE

To determine the prevalence of psychological morbidity and describe quality of life in women with early-stage breast cancer.

DESIGN

Cross-sectional descriptive study (3 months after conservative breast surgery or mastectomy) of patients from nine general hospitals in Melbourne, Victoria, October 1994 to March 1997.

PARTICIPANTS

303 women with early-stage breast cancer entering a randomised trial of adjuvant psychological group therapy; mean age, 46 years (SD, 8).

MAIN OUTCOME MEASURES

Diagnostic and Statistical Manual of Mental Health (DSM)-IV psychiatric diagnoses generated by the Monash Interview for Liaison Psychiatry; quality-of-life data based on the the European Organization for Research and Treatment of Cancer quality-of-life questionnaire (QLQ)-C30 (core) and QLQ-BR23 (breast module) instruments.

RESULTS

45% of the women (135/303) had a psychiatric disorder; 42% (127) of the sample had depression or anxiety, or both; there was minor depression in 82 (27.1%), an anxiety disorder in 26 (8.6%), major depression in 29 (9.6%) and a phobic disorder in 21 (6.9%). 20% of women (61) had more than one disorder. On quality-of-life measures nearly one-third of the women felt less attractive and most had lost interest in sexual activity. There was substantial distress about hair loss. Symptoms of lymphoedema were described by 13 women (4.3%). Breast conservation surgery was associated with a better body image (P<0.01).

CONCLUSION

Women recently diagnosed with early-stage breast cancer have high rates of psychiatric and psychological disturbance. Quality of life is substantially affected. Clinicians should actively explore their patients' psychological adjustment to enable early recognition and treatment of these disorders.

Patient participation in treatment decision making and the psychological consequences of breast cancer surgery

Women in the early stages of breast cancer can be treated effectively with either modified radical mastectomy or tumor excision plus postoperative radiation therapy. Thus, breast cancer patients may be given a choice between these two modes of treatment. In some states, physician disclosure of such treatment alternatives for breast cancer is mandated by law. Despite the belief that patient participation in decision making is beneficial, the evidence is preliminary, although generally supportive. This study examined the extent to which patient participation in the choice of surgical options was related to psychological functioning, fear of cancer recurrence, and aspects of treatment satisfaction 3 and 13 months postoperatively. Few associations with degree of participation in treatment decision making or type of surgical treatment emerged after 3 months. After 13 months, however, women with greater levels of input into their treatment plan were more satisfied with their medical care, although they were not better off in terms of psychological functioning or fear of cancer recurrence. The positive effects of shared treatment decision making may be more closely related to aspects of longer term treatment satisfaction rather than a buffer against psychological distress resulting from breast cancer.

Explorations in body image care: Peplau and practice knowledge

Practitioners in mental health care have long utilized the work of Hildegard Peplau, both for nursing discourse and for practice. At a time when the role of theory in practice is once more being debated, and when theories are being applied in new contexts, this paper examines the contribution that Peplau's work may have to offer altered body image nursing care. A case study is used to highlight concepts in practice, the paper examining the ways in which Peplau's Theory of Interpersonal Relations complement the other elements of practice knowledge that the nurse uses to assist patients and lay carers alike.

Treatment decision making and adjustment to breast cancer: a longitudinal study

This study monitored women (N = 76) with breast cancer from diagnosis through 1 year, and tested constructs from subjective expected utility theory with regard to their ability to predict patients' choice of surgical treatment as well as psychological distress and well-being over time. Women's positive expectancies for the consequences of treatment generally were maintained in favorable perceptions of outcome in several realms (i.e., physician agreement, likelihood of cancer cure or recurrence, self-evaluation, likelihood of additional treatment, partner support for option, attractiveness to partner). Assessed before the surgical decision-making appointment, women's expectancies for consequences of the treatment options, along with age, correctly classified 94% of the sample with regard to election of mastectomy versus breast-conserving procedures. Calculated from the point of decision making to 3 months later, expectancy disconfirmations and value discrepancies concerning particular treatment consequences predicted psychological adjustment 3 months and 1 year after diagnosis.

Helping women select primary breast cancer treatment

Making a decision about breast cancer treatment is complex for women. Patients and caregivers are given a lot of information, then asked to make choices that affect their lives in many ways. Many are facing their mortality for the first time as well. Nurses are key players in providing information and support, and guiding patients in making treatment choices. However, the ultimate decision is up to the patient.

Effect of Nancy Reagan's mastectomy on choice of surgery for breast cancer by US women

CONTEXT

While the actions of popular figures are believed to influence the behavior of the general public, including health care decisions, little research has examined such an effect.

OBJECTIVE

To determine whether a temporal association exists between use of breast-conserving surgery (BCS) for treatment of breast cancer and Nancy Reagan's mastectomy in October 1987.

DESIGN/SETTING

Population-based observational cohort study.

PATIENTS

Two sources of data: (1) 82 230 women aged 30 years and older who were included in the Surveillance, Epidemiology, and End Results tumor registry because of a diagnosis of local or regional breast cancer from 1983 to 1990; and (2) 80057 female Medicare beneficiaries aged 65 to 79 years who received inpatient surgery for local or regional breast cancer in 1987 or 1988.

MAIN OUTCOME MEASURE

Percentage of use of BCS vs mastectomy over time.

RESULTS

Compared with women undergoing surgery for breast cancer in the third quarter of 1987 (just prior to Mrs Reagan's mastectomy), women were 25% less likely to undergo BCS in the fourth quarter of 1987 (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.66-0.85) and in the first quarter of 1988 (OR, 0.76; 95% CI, 0.67-0.86). In subsequent quarters, the rate returned to the baseline. In multivariate analyses, the decline was significant among white but not nonwhite women. It was most prominent among women aged 50 to 79 years in the central and southern regions of the country, and most sustained among women living in areas with lower levels of income and education.

CONCLUSIONS

Celebrity role models can influence decisions about medical care. The influence appears strongest among persons who demographically resemble the celebrity, and those of lower income and educational status.

The social construction of breast loss and reconstruction

Reconstructing the breasts of women with breast cancer is standard medical care. An exploratory, qualitative study of women with breast cancer demonstrates that breast reconstruction is not essential to the resolution of a breast cancer crisis. This article reveals that today's culture creates a social context in which breast loss appears to have dire consequences for women and then provides the medical care to redress the loss it has helped create. Interviews were held with 29 women to explore the psychosocial consequences of breast cancer on their health and lives. This study demonstrates that breast reconstruction fails to meet the expectations of these women with breast cancer because the women identify disjunctures between social expectation and their own interests in health and well-being.

A comparative study of post-operative psychosocial function in women with primary operable breast cancer randomized to breast conservation therapy or mastectomy

In a randomized patient series of 184 women suffering from primary operable breast carcinoma, psychosocial adjustment to breast-conserving therapy (BCT) vs mastectomy (M) was analysed retrospectively, including: (i) a comparison of intergroup characteristics; (ii) patient experience of the quality of professional pre-operative information; and (iii) the extent to which influence on choice of treatment was required. Using LASA (Linear Analogue Self-Assessment Scale), STAI (State-Trait Anxiety Inventory), and a semi-structured interview, no psychosocial benefits were found in BCT compared with M. Mean observation time was 31 months (range: 15-65). Body image was less impaired in BCT than in M. Both groups scored highly on professional information, but reported reduced ability to take in such information in the peri-operative period. Both groups tended to depend on the surgeon when choosing between surgical options. Irrespective of primary therapy, women must still confront the fact that they have had cancer, a life-threatening disease which may recur. A need for further research into peri-operative information procedures was demonstrated, and some suggestions were derived concerning the surgeon's role in deciding on surgical options.

Living with mastectomy and breast conservation treatment: who suffers more?

Sixty-five patients who underwent modified radical mastectomy were compared with 55 breast conservation patients, all of whom were in stage I, II or III of breast cancer and were under treatment at an oncology clinic in northern Israel. The main findings indicate no differences between the groups in physical, psychosocial, marital or medical interaction, according to the CARE scale. These findings reflect the results of similar comparative studies conducted during the 1980s and 1990s as documented in the literature. Sexual interaction showed statistical differences favoring the women who had undergone mastectomies.

Patient participation in deciding breast cancer treatment and subsequent quality of life

This investigation of patients with early breast cancer examined relationships among patient involvement in deciding treatment (i.e., whether to undergo breast removal or breast conservation), perceptions of control over treatment decisions, and subsequent health-related quality of life. It was predicted 1) that patients who more actively participated in consultations to decide treatment would perceive more decision control than would more passive patients and 2) that patients who perceived greater decision control would report better health-related quality of life following treatment than would patients perceiving less decision control. Sixty patients with stage I or II breast cancer allowed their consultations with surgeons to be audiorecorded. Following these visits, patients reported on their involvement in the consultation, optimism for the future, knowledge about treatment, and two aspects of perceived decision control, the perception of having a choice for treatment and the extent to which the doctor or patient was responsible for the decision. Six and 12 months postoperatively, 51 patients (85%) returned a follow-up survey assessing perceived decision control and health-related quality of life. The first prediction received some support. The patients who had more actively participated in their consultations, particularly in terms of offering opinions, assumed more responsibility for treatment decisions during the year following surgery than did less expressive patients. Also, the patients who reported more involvement in their consultations later believed they had had more of a choice for treatment. The second hypothesis was partially supported. Six and 12 months following treatment, the patients who believed they were more responsible for treatment decisions and believed they had more choice of treatment reported higher levels of quality of life than did the patients who perceived themselves to have less decision control. However, perceived control at the time of treatment did not predict later quality of life. Theoretical and clinical implications are discussed.

[Psychosocial acceptance of surgical interventions of the breast in oncological gynecology]

In a retrospective analysis of 197/600 women (33%) treated for primary breast cancer at the Department of Obstetrics and Gynecology at the University of Münster (1984 to 1994) the psycho-social acceptance of mastectomy vs. breast conservative treatment (BET) was evaluated. Mean age was 59 years (range, 31-87 yrs.). BET was performed in 58% (n = 114), modified radical mastectomy (MRM) in 42% (n = 83). Reconstructive surgery after MRM was performed in 40% (n = 33) either as primary procedure in 39% (n = 14) or as secondary procedure in 61% (n = 20). In addition to somatic patterns, features of pre- and postoperative coping, individual psycho-social burden, cosmetic results, contentment of treatment, social rehabilitation and quality of life were evaluated. Performance status and quality of human relations are discussed. In terms of psycho-social acceptance the results of BET are in general not superior to MRM at a mean follow-up of six years. Coping and postoperative quality of life are almost similar within the two groups. Although the alteration of body image after BET is less compared to MRM, the psychologic burden of postoperative radiotherapy and the fear of local recurrence are experienced worst compared to all other features analyzed after BET.

[Quality of life in relation to patient education regarding surgical procedures in primary breast carcinoma]

Breast conserving therapy is seen as a profit according to life quality. The patients have been subjected to the surgeon suggestions during decision-making about the primary therapy. The purpose of this study was to examine the relationship between the degree of preoperative information of breast cancer therapy and patients' choices of treatments in cases suited for breast conserving therapy. 138 recurrence free patients after breast conserving therapy (BCT) or mastectomies (ME) due to a breast cancer staged as pT1-2N0-1M0 and missing contraindication to BCT were interviewed using an observer checklist. The degrees of preoperative information, reasons for decision to mastectomy, though BCT was possible, were correlated with the postoperative life quality. Patients decided for BCT were averaging 56.0 + 12.3 years and significantly (p < 0.05) younger than patients decided for ME (60.4 + 10.5), whereas tumor size, nodal status and adjuvant therapies were comparable. The results indicate, that subjects' choice of treatment was unrelated to the amount of information. 87% (BET) respectively 78.3% (ME) patients evaluated, that preoperative information was enough (p = 0.19). The most frequent reasons for preference of mastectomy were the "perception that survival would be diminished if mastectomy was not done" (93.5%), "avoidance of radiotherapy" (60.9%) and "no partner" (34.8%). According to expectation the body image in the BCT-group (84.8%) was significantly (p = 0.0007) more positive than in the ME-group (58.9%). Nevertheless only 5 (10.9%) patients after ME have felt sorry for their earlier decision. There were no significant differences between the two groups with regard to partner- and sexual adjustment as well as physical well-being. Despite being fully informed of treatment possibilities and no medical contraindications to BCT nearly one third preferred mastectomy due to different reasons. When the patient was involved in the clinical decision-making process the mastectomy indicates not generally a loss of life quality, though nearly 40% are dissatisfied with their nude body image.

[Quality of life of over 60-year-old patients with breast and uterine carcinoma, 5 years after primary operation]

In the 5-year follow-up period, we studied the quality of life of 145 patients who were at least 60 years old at the time of primary operation. Of the patients, 70 women had breast cancer and 75 endometrium cancer. We used the questionnaire "short form health survey: medical outcomes study". The areas which were analyzed were stress due to therapy, body image/femininity and social contacts. The Karnofsky-Index was determined by the physician. In both groups, most stress was felt due to the operation and at the first knowledge of the diagnosis. In the area of emotional stress 1/3 of the patients of both groups declared continuous stress due to feelings of fear, helplessness and passivity. In the area of body image/femininity half the patients with breast cancer and 2/3 with endometrial cancer felt stress. In the area of social contact 2/3 of the patients felt uncertainty in contact with others and this led to social retreat in 1/3 of the women. The Karnofsky-Index of all patients was between 50-100%. Our study supports the view that older patients with cancer should also be offered psychosocial counseling.

Are coping strategies related to disease outcome in early breast cancer?

A consecutive series of 107 women with early breast cancer were investigated for coping strategies and disease outcome 5 to 6 years after primary surgical treatment (mastectomy or lumpectomy). Coping was assessed several times during a 3-year investigation period by the Zurich and Freiburg Questionnaires of Coping with Illness (ZQCI, FQCI). Data analysis revealed no significant correlations between coping strategies and the target variable "death from breast cancer". However, significant relations were found between postsurgical tumour size (p < or = 0.01), positive histological node status (p < or = 0.01) and death from breast cancer. The results of a discriminant analysis also indicated that somatic parameters are more important for the course of breast cancer disease than psychological aspects of coping. The role of psychosocial variables for the outcome of cancer disease remains unclear and further studies in this field are necessary.

Effect of season and climate on choice of therapy for breast cancer in older women

OBJECTIVES

We and others have previously found a relative underutilization of breast-conserving surgery with adjuvant radiation therapy in older women diagnosed with early stage breast cancer. Because adjuvant radiotherapy involves daily trips to a facility for 6 weeks, we reasoned that season and climate might influence choice of therapy. Specifically we hypothesized that in northern states, a lower proportion of women would receive breast-conserving surgery plus radiation in the winter months than in summer, whereas in sunbelt states there would be no relationship between season and therapy.

DESIGN

Analysis of national Medicare billing tapes for 1990 and SEER tumor registry data for 1983-1990.

PARTICIPANTS

43,083 women aged 65 to 79, diagnosed with local or regional breast cancer in 50 states or Washington, DC, who underwent mastectomy or breast-conserving surgery in 1990, and 32,502 women aged 65 to 79 who underwent mastectomy or breast-conserving surgery from 1983 to 1989 at any of the nine SEER sites.

RESULTS

Using a variety of analytical approaches, we could find no consistent effect of cold winter climate on choice of breast cancer therapy.

CONCLUSION

Bad weather does not appear to discourage the choice of breast-conserving treatment. It is not known if bad weather influences actual receipt of radiotherapy.

A comparison of the effects of lumpectomy versus mastectomy on sexual behaviors

The purpose of this study was to investigate the effects of lumpectomy and mastectomy on female sexual behaviors. It is assumed frequently that lumpectomy causes fewer sexual sequelae for the patient. Although review of the literature indicated consensus regarding the advantage of lumpectomy in preserving body image, no such consensus exists regarding preservation of female sexuality. The literature also was unclear regarding treatment and demographic factors that may be useful in identifying patients at risk for sexual difficulties. A convenience sample of 165 women participated in the study. Data were collected using the Sexual Behaviors Questionnaire and the Watts' Sexual Functioning Questionnaire. Findings indicate that no significant difference existed in sexuality between women treated by lumpectomy and those treated by mastectomy. Other factors with a significant positive effect on sexuality included a history of minimal alcohol use, absence of chemotherapy treatment, and tamoxifen use. Counseling women and their partners about the sexual side effects of cancer treatments is an important part of the health professional's role.

Prospective hospital-based survey of attitudes of Southern women toward surgical treatment of breast cancer

BACKGROUND

Breast-conserving surgery is equivalent to total mastectomy in the treatment of breast cancer. The Southern part of the United States has a low rate of breast conservation.

METHODS

We surveyed 300 women: 100 hospital personnel, 100 cancer clinic patients, and 100 non-cancer clinic patients. The women were asked about their attitudes toward breast cancer, surgery preferences, and factors that might influence their decisions.

RESULTS

One hundred eighty-nine chose mastectomy as the best operation, 106 women chose lumpectomy, and five women were undecided. There was no difference in mean age, racial distribution, education level, income level, percentage of women who considered themselves Southern women, concerns about breast cancer, recent mammograms, previous breast surgery, previous breast cancer treatment, or acquaintances with breast cancer between the mastectomy and the lumpectomy groups. Women interested in saving the breast were more likely to pick lumpectomy (35 vs. 84%, p = 0.001). A fear of cancer recurrence played a role in the decision (88 vs. 40%, p = 0.001). Fear of radiation therapy (76 vs. 57%, p = 0.002) and of the side effects (80 vs. 63%, p = 0.005) was a significant factor.

CONCLUSIONS

The choice of surgery for breast cancer is an individual process between a woman and her surgeon. Attitudes and fears regarding cancer recurrence and radiation therapy may make women select mastectomy over lumpectomy.

The Pope's confessor: a metaphor relating to illness in the analyst

This paper examines some of the internal and external eventualities in the situation of illness in the analyst. The current emphasis on the use of the self as part of the analyzing instrument makes impairments in the analyst's physical well-being potentially disabling to the analytic work. A recommendation is made for analysts, both individually and as a professional group, to always consider this aspect of a personal medical problem.

[Psychological disease adjustment in breast cancer patients]

In a prospective follow-up study, attention was focused on adjustment to disease in breast cancer patients one year after diagnosis. Prebioptic data was collected in the original patient group consisting of 95 women with mammary tissue findings that required clarification. Twenty-nine women with histological confirmation of breast cancer and 37 patients of the control group with benign histological findings were recontacted after an interval of one year. Data was collected by means of psychological test questionnaires (STAI, SVF, FPI, CIP-DS), the patients with breast cancer were given an additional problem-oriented questionnaire about coping with disease, compiled by the author. Most denied having disease-related fears-progression of the disease, premature death; instead, marked sleep disturbances, regularly, recurring nightmares, and depressed states of mind characterized the psychosomatic correlate of the mental burden. The psychological consequences of cancer are related to some extent to the stage of tumour growth at the time of diagnosis; the process of social reintegration appears to be facilitated in women whose biopsy operation did not involve removal of a breast. An clear characterization of breast cancer patients could not be established using psychological testing procedures one year after diagnosis of the disease.