Breast cancer surgery: comparing surgical groups and determining individual differences in postoperative sexuality and body change stress

Body change stress for women with breast cancer: the Breast-Impact of Treatment Scale

BACKGROUND

Body change stress refers to subjective psychological stress that accompanies women's negative and distressing thoughts, emotions, and behaviors resultant from breast cancer and breast surgeries. Body change stress is manifest with traumatic stress-like symptoms.

PURPOSE

The development of the Breast-Impact of Treatment Scale (BITS) is described. The construct is assessed with 13 items that comprise a one-factor solution.

METHODS AND RESULTS

Tests of convergent validity demonstrate the relationship, but not overlap, of the BITS with measures of stress, emotional distress, and sexuality. The BITS distinguishes between women receiving segmental mastectomy (lumpectomy) versus mastectomy. Incremental validity is shown with comparison to ratings of body satisfaction.

CONCLUSIONS

An early psychometric foundation enables use of the BITS to assess a common and distressing quality of life outcome for women with breast cancer.

Body image and sexual problems in young women with breast cancer

PURPOSE

The purpose of this study was to determine the frequency of body image and sexual problems in the first months after treatment among women diagnosed with breast cancer at age 50 or younger.

BACKGROUND

Breast cancer treatment may have severe effects on the bodies of younger women. Surgical treatment may be disfiguring, chemotherapy may cause abrupt menopause, and hormone replacement is not recommended.

METHODS

A multi-ethnic population-based sample of 549 women aged 22-50 who were married or in a stable unmarried relationship were interviewed within seven months of diagnosis with in situ, local, or regional breast cancer.

RESULTS

Body image and sexual problems were experienced by a substantial proportion of women in the early months after diagnosis. Half of the 546 women experienced two or more body image problems some of the time (33%), or at least one problem much of the time (17%). Among sexually active women, greater body image problems were associated with mastectomy and possible reconstruction, hair loss from chemotherapy, concern with weight gain or loss, poorer mental health, lower self-esteem, and partner's difficulty understanding one's feelings. Among the 360 sexually active women, half (52%) reported having a little problem in two or more areas of sexual functioning (24%), or a definite or serious problem in at least one area (28%). Greater sexual problems were associated with vaginal dryness, poorer mental health, being married, partner's difficulty understanding one's feelings, and more body image problems, and there were significant ethnic differences in reported severity.

CONCLUSIONS

Difficulties related to sexuality and sexual functioning were common and occurred soon after surgical and adjuvant treatment. Addressing these problems is essential to improve the quality of life of young women with breast cancer.

Sexual Problems in Younger Women After Breast Cancer Surgery

Purpose

To examine sexual problems in younger women diagnosed with breast cancer during the first year after surgery and to identify sociodemographic, medical, and psychosocial predictors of sexual problems.

Patients and Methods

Women diagnosed with breast cancer age ≤ 50 years completed surveys at three time points: within 24 weeks after initial surgery (baseline), 6 weeks after baseline, and 6 months later. Survey items included the Medical Outcomes Study Sexual Functioning Scale, satisfaction with sex life, feeling sexually attractive, body image, marital satisfaction, quality of life, medical history, symptoms, and sociodemographics. Prediagnosis sexual problems were retrospectively ascertained at the initial survey.

Results

Analyses included 209 women sexually active at baseline (78.6% of total sample). Sexual problems were significantly greater immediately postsurgery compared with retrospective reports before diagnosis (P < .0001). Although problems gradually decreased over time, they were still greater at 1 year postsurgery than before diagnosis. In multivariate analyses controlling for sexual problems at prediagnosis, vaginal dryness, and lower perceived sexual attractiveness were consistently related to greater overall sexual problems. Chemotherapy was related to sexual problems only at baseline except for women who became menopausal as a result of chemotherapy, who continued to have problems.

Conclusion

Findings substantiate the need to address potential sexual problems related to chemotherapy treatment and menopause among younger breast cancer survivors and to counsel women about possible remedies, particularly for vaginal dryness. Increasing feelings of sexual attractiveness may also help sexual problems, especially among women for whom these feelings were altered by surgery or treatment.

Psychosocial effect of mastectomy versus conservative surgery in patients with early breast cancer

PURPOSE

To compare the quality-of-life (QoL) and psychosocial changes in a group of patients with early breast cancer who underwent conservative surgery (BCS) or modified radical mastectomy(MRM).

METHODS

Self-administered questionnaire assessing body image perception, social habits, sexual attraction and self-consciousness with relatives/friends, was randomly assigned to 125 patients (61 BCS, 64 MRM; aged 53 +/- 8 and 50 + 9 years, respectively, p = NS).

RESULTS

MRM patients reported a significantly higher frequency of changes in body image perception and other related social behaviour such as avoiding going to the beach or using low-cut clothes, and reticence with friends. Conversely, no differences were found regarding sexuality, denial of the disease by the husband/partner, or concealing the disease from family members. Also, no significant differences were found between patients above and below the age of 50 years, for all variables studied after adjustment for surgical procedure.

CONCLUSIONS

Modified radical mastectomy has a negative effect on body image perception and in social behaviour patterns of patients and with a concomitant decrease in QoL. The sexuality of the patient is not significantly affected.

Psychological impact and cosmetic outcome of surgical breast cancer strategies

BACKGROUND

Current surgical treatment modalities for breast cancer include breast conserving surgery, mastectomy alone and mastectomy with breast reconstruction. There are recognized benefits of breast conservation and breast reconstruction over mastectomy but there are few studies assessing this area in Australia. The aim of the present study was to compare the various surgical strategies for breast cancer treatment in terms of quality of life, cosmesis and patient satisfaction.

METHODS

A chart analysis was conducted of all patients who underwent Breast Cancer Reconstruction at the Royal Adelaide Hospital Breast Unit between 1990 and 2002. Patients were then traced and asked to take part in an interview. Mastectomy and breast conservation patients who attended outpatient clinic for follow up were also approached. All three groups were interviewed and self-assessment quality of life questionnaires (Functional Assessment of Cancer Therapy-Breast, body image) were administered. The breast conservation and reconstruction groups also underwent assessment of satisfaction and cosmesis.

RESULTS

A total of 78 mastectomy, 109 breast conservation and 123 breast reconstruction patients were interviewed. Quality of life assessment was similar between the three groups but the breast conservation and reconstruction patients' body image scores were superior to the mastectomy group. Patient satisfaction was higher in the reconstruction group than the breast conservation group of patients, while cosmesis was similar.

CONCLUSION

While little difference was seen on quality of life assessment, body image is improved with the use of breast conservation and reconstruction. The high satisfaction and cosmesis scores in the breast reconstruction group are an indication of the superior results that can be achieved with breast reconstruction.

Optimistic personality and psychosocial well-being during treatment predict psychosocial well-being among long-term survivors of breast cancer

In considering well-being among survivors of life-threatening illnesses such as breast cancer, 2 important questions are whether there is continuity between initial adjustment and longer term adjustment and what role personality plays in long-term adjustment. In this research, a sample of 163 early stage breast cancer patients whose psychosocial adjustment was first assessed during the year after surgery completed the same measures 5-13 years after surgery. Initial reports of well-being were relatively strong predictors of follow-up well-being on the same measures. Initial optimism and marital status also predicted follow-up adjustment, even controlling for earlier adjustment, which exerted a substantial unique effect in multivariate analyses. In contrast, initial medical variables played virtually no predictive role. There is substantial continuity of subjective well-being across many years among survivors of breast cancer, rooted partly in personality and social connection.

Improving Long-Term Projection in Nipple Reconstruction Using Human Acellular Dermal Matrix

Reconstructed nipples rapidly lose projection. We describe the use of human acellular dermal matrix (ADM) to improve long-term projection of nipple flaps. Athymic rats were randomized to 3 groups; each received 2 nipples: bell flap (control, n = 16 nipples), bell flap with a cylinder of implanted ADM (n = 24), or bell flap with intraflap injection of micronized ADM (MADM) (n = 10). Seven of 24 ADM nipples extruded (30%). By 12 weeks, the control nipples maintained 44% of initial projection compared with 70% for ADM nipples (P = 0.000025). The MADM nipples maintained 49% of initial projection after 12 weeks (P = 0.55 compared with control). No MADM nipples extruded. ADM grafts maintain long-term projection better than local tissue flaps alone. We hypothesize that MADM may limit extrusion and allow for serial injection of nipples. Based on the promising results of this study, clinical trials are warranted using human ADM and/or human MADM for nipple reconstruction.

Perceived partner reactions to diagnosis and treatment of breast cancer: impact on psychosocial and psychosexual adjustment

Two studies examined breast cancer patients' perceptions of their partners' reactions to their diagnosis and treatment as influences on 3 aspects of patients' well-being: psychosexual adjustment, emotional distress, and marital satisfaction. Study 1, cross-sectional, indicated that partner initiation of sex, frequency of sex, a positive 1st sexual experience after treatment, and especially perception of the partner's emotional involvement in the relationship, were relevant to these outcomes. Study 2, longitudinal, confirmed many of these findings in prospective tests across 1 year of recovery after surgery. Partner involvement prospectively predicted all 3 outcomes. Partner initiation of sex predicted greater marital satisfaction; partner adverse reaction to the scar predicted less marital satisfaction. Rated quality of the 1st sexual experience after treatment predicted less distress. The pattern suggests that women's impressions of their partners' emotional involvement after surgery for breast cancer forecast their adjustment in sexual, marital, and emotional arenas over the following year.

United we stand? The effects of a couple-coping intervention on adjustment to early stage breast or gynecological cancer

Cancer diagnosis affects the psychological well-being of both patients and their partners, and effective coping has been suggested to be a conjoint process of mutual support. Ninety-four married women with early stage cancer and their partners were randomly assigned to couples-based coping training (CanCOPE), individual coping training for the woman, or a medical education control. Couples' observed support communication and self-reported psychological distress, coping effort, and sexual adjustment were assessed at diagnosis, after cancer surgery, and at 6- and 12-month follow-ups. CanCOPE produced significant improvements in couples' supportive communication, reduced psychological distress and coping effort, and improved sexual adjustment. Training in couples rather than individual coping was more effective in facilitating adaptation to cancer.

Avaliação psicológica de pacientes em reconstrução de mama: um estudo piloto

O presente trabalho objetivou identificar e avaliar ansiedade e depressão pré- e pós-reconstrução mamária. Participaram do estudo dez mulheres atendidas no ambulatório de cirurgia plástica. Os instrumentos utilizados foram: Inventário Beck de Depressão e Inventário de Ansiedade Traço-Estado. Os resultados demonstraram sofrimento psicológico e alterações nos índices de ansiedade e depressão no pré e pós-operatório. A sensibilidade erógena não foi identificada antes da reconstrução mamária, entretanto, depois dela, 40% a identificaram. A maioria relatou, no pré-operatório, o desejo de melhorar a auto-imagem, e, após a cirurgia, 90% estavam satisfeitas. Após a reconstrução mamária, houve melhora no relacionamento conjugal. São necessárias mais pesquisas para identificar e comparar ansiedade e depressão, através de grupos-controle, para avaliar as diferentes variáveis que interferem na reconstrução mamária.

Breast Cancer Treatment in Older Women: Does Getting What You Want Improve Your Long-Term Body Image and Mental Health?

Purpose

Little is known about the impact of surgical treatment on body image and health outcomes in older breast cancer patients. The purpose of this article is to evaluate whether concordance between treatment received and treatment preferences predicts posttreatment body image and whether body image, in turn, affects mental health in older women with breast cancer 2 years after treatment.

Patients and Methods

A longitudinal cohort of 563 women who were 67 years old or older and who had stages I and II breast cancer were surveyed by telephone at 3, 12, and 24 months after surgery. All women were clinically eligible for breast conservation. Body image was measured using questions adapted from the Cancer Rehabilitation Evaluation System–Short Form, and mental health was evaluated using a Medical Outcomes Study subscale.

Results

Body image was an important factor in treatment decisions for 31% of women. Women who received breast conservation had better body image 2 years after treatment than women who had mastectomies (P < .0001). Women who preferred breast conservation but received mastectomy had the poorest body image. Using generalized estimating equations, we found that body image, in turn, predicted 2-year mental health.

Conclusion

Body image is important for many older women, and receiving treatment consistent with preferences about appearance was important in long-term mental health outcomes. Health professionals should elicit preferences about appearance from women and provide treatment choices in concordance with these preferences. Enhancing shared decision making has the potential to improve mental health in older breast cancer survivors.

Autobiographical memories in patients treated for breast cancer

OBJECTIVE

Previous research has shown that several clinical groups have difficulties with generating specific autobiographical memories. The aim of this study was to investigate autobiographical memory function in women who had been treated for breast cancer and to compare those patients who had undergone mastectomy only with those who had undergone breast reconstruction surgery after mastectomy.

METHOD

A sample of 26 women treated for breast cancer were tested via telephone using the Autobiographical Memory Test (AMT).

RESULTS

Breast cancer patients had difficulty retrieving specific autobiographical memories compared to a group of age-matched controls without any history of breast cancer. There were essentially no differences between the two patient groups.

CONCLUSION

Since breast cancer patients are vulnerable to emotional distress, autobiographical memory deficits should be investigated further.

Racial and Body Image Differences in Coping for Women Diagnosed With Breast Cancer

Although more White women develop breast cancer, African American women more frequently die of the disease (American Cancer Society, 2003). Despite higher morbidity among African American women, few studies have included racially diverse samples. The purposes of this study were to explore racial and body image differences in coping and self-efficacy in coping and racial differences in body image perceptions among breast cancer patients. The 92 participants ranged in age from 28 to 86 years (M=57.64, SD=12.48). Participants with higher body image perceptions had significantly higher self-efficacy in coping compared with participants with lower body image perceptions. There were no significant racial or ethnic differences in coping, self-efficacy in coping, or body image perceptions.

Assessment of long-term nipple projection: a comparison of three techniques

Nipple-areola reconstruction represents the final stage of breast reconstruction, whereby a reconstructed breast mound is transformed into a breast facsimile that more closely resembles the original breast. Although numerous nipple reconstruction techniques are available, all have been plagued by eventual loss of long-term projection. In this report, the authors present a comparative assessment of nipple and areola projection after reconstruction using either a bell flap, a modified star flap, or a skate flap and full-thickness skin graft for areola reconstruction. The specific technique for nipple-areola reconstruction following breast reconstruction was selected on the basis of the projection of the contralateral nipple and whether or not the opposite areola showed projection. Patients with 5 mm or less of opposite nipple projection were treated with either the bell flap or the modified star flap. In patients where the areola complex exhibited significant projection, a bell flap was chosen over the modified star flap. In those patients with greater than 5-mm nipple projection, reconstruction with a skate flap and full-thickness skin graft was performed. Maintenance of nipple projection in each of these groups was then carefully assessed over a 1-year period of follow-up using caliper measurements of nipple and areola projection obtained at 3-month intervals. The best long-term nipple projection was obtained and maintained by the skate and star techniques. The major decrease in projection of the reconstructed nipple occurred during the first 3 months. After 6 months, the projection was stable. The loss of both nipple and areola projection when using the bell flap was so remarkable that the authors would discourage the use of this procedure in virtually all patients.

Biobehavioral outcomes following psychological interventions for cancer patients

Psychological interventions for adult cancer patients have primarily focused on reducing stress and enhancing quality of life. However, there has been expanded focus on biobehavioral outcomes--health behaviors, compliance, biologic responses, and disease outcomes--consistent with the Biobehavioral Model of cancer stress and disease course. The author reviewed this expanded focus in quasiexperimental and experimental studies of psychological interventions, provided methodologic detail, summarized findings, and highlighted novel contributions. A final section discussed methodologic issues, research directions, and challenges for the coming decade.

Quality of life after postmastectomy breast reconstruction

PURPOSE/OBJECTIVES

To explore women's expectations about postmastectomy reconstruction and factors affecting their quality of life after reconstruction.

DESIGN

Qualitative focus group study.

SETTING

Integrated healthcare system in a midwestern suburban community.

SAMPLE

17 women who had undergone mastectomies with immediate reconstruction between 1.4 and 5 years previously and had participated in a study of women newly diagnosed with breast cancer.

METHODS

An experienced focus group moderator conducted two focus group sessions. Comments from the sessions were audiotaped and transcribed verbatim. The sessions involved semistructured, open-ended questions about perceptions of preparation, experience, and satisfaction regarding postmastectomy reconstruction. Thematic content analysis began with open coding at the level of individual comments and proceeded through two levels of higher-order categorization.

FINDINGS

Although women felt well informed about breast surgery, they wished they had been more informed about some issues. Ratings of satisfaction generally were high despite some concerns about cosmetic outcome and persistent anxiety about recurrence.

CONCLUSIONS

Reconstruction allows women to feel comfortable in clothing, but recovery can be difficult, and reconstruction does not neutralize the biggest emotional challenge of breast cancer: fear of recurrence.

IMPLICATIONS FOR PRACTICE

Women appreciate thorough information to prepare them for reconstruction and recovery. For aspects of recovery in which substantial variation exists, the range of experiences should be provided.

Psychosocial issues in breast cancer

The breast cancer experience can bring with it a broad range of emotional sequelae for the woman, her spouse/partner, and her family. Often, patients bear these emotional burdens silently and miss opportunities for the physician and health care team to offer recommendations and interventions for her and her family. The proactive physician evaluating these potential difficulties and using the strength a good relationship with the patient in making appropriate referrals for counseling or support group does much to help the woman embrace as full a recovery as possible. Recommendations presented by the woman's physician are most often heeded. The physician must intervene on behalf of the woman to ensure that psychosocial support needs are met. Physicians are encouraged to adopt this orientation and to use an integrated approach in caring for the woman with breast cancer. (6)

Correlates of surgical treatment type for women with noninvasive and invasive breast cancer

There is concern that breast-conserving surgery is underused in some breast cancer patient subpopulations, including women with ductal carcinoma in situ (DCIS), an early-stage form of the disease. We conducted a population-based study to identify correlates of surgical treatment type and patient satisfaction, comparing women with DCIS and those with invasive disease. We used telephone interview and mailed survey of 183 women recently diagnosed with breast cancer (oversampling for women with DCIS), identified from the Metropolitan Detroit Cancer Surveillance System (response rate 71.2%). Overall, 52.5% of study subjects received a mastectomy (48.9%, 45.8%, and 73.5% of women with DCIS, local disease, and regional disease, respectively, p < 0.05). One third of women did not perceive that they were given a choice between surgical types, and an additional one third of women received a surgeon recommendation, most of whom received the treatment recommended. Patient attitudes, such as concerns about the clinical benefits and risks of specific surgery options, were important correlates of treatment choice but did not vary by stage of disease. Knowledge about differences in clinical benefits and risks between surgery options was low. Finally, satisfaction with the decision-making process was significantly lower in women who did not perceive a choice between surgery options. Correlates of breast cancer surgery type appeared to be similar for women with DCIS and invasive breast cancer, with surgeons playing a dominant role in the process. Results also suggested that the decision-making process may be as important for patient satisfaction as the treatment chosen.