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

Measuring quality of life in cosmetic and reconstructive breast surgery: a systematic review of patient-reported outcomes instruments

BACKGROUND

Patient-reported outcomes in cosmetic and reconstructive breast surgery are increasingly important for clinical research endeavors. Traditional surgical outcomes, centered on morbidity and mortality, remain important but are no longer sufficient on their own. Quality of life has become a crucial research topic augmenting traditional concerns focused on complications and survival. Given this, reliable and valid patient questionnaires are essential for aesthetic and reconstructive breast surgeons.

METHODS

The authors performed a systematic literature review to identify patient-reported outcome measures developed and validated for use in cosmetic and reconstructive breast surgery patients. Qualifying instruments were assessed for adherence to international guidelines for health outcomes instrument development and validation.

RESULTS

The authors identified 227 health outcomes questionnaires used in breast surgery studies. After 135 generic instruments, 65 ad hoc instruments, seven oncologic instruments, 11 education questionnaires, and two non-English-language questionnaires were excluded, seven measures remained. Detailed analysis revealed that six of the seven measures had undergone limited development and validation. Only one measure, the Breast-Related Symptoms Questionnaire, demonstrated adequate development and validation in its target population. It had, nevertheless, significant content limitations.

CONCLUSIONS

Valid, reliable, and responsive instruments to measure patient-reported outcomes in cosmetic and reconstructive breast surgery are lacking. To demonstrate the benefits of aesthetic and reconstructive breast surgery, future research to rigorously develop and validate new cosmetic and reconstructive breast surgery-specific instruments is needed.

A comparison of the cosmetic and psychological outcome of breast reconstruction, breast conserving surgery and mastectomy without reconstruction

METHOD

The cosmetic and psychological outcomes of patients who underwent reconstructive surgery, conservative surgery or simple mastectomy for breast cancer between 1995 and 2002 were compared.

RESULTS

There was a significant correlation between good psychological adjustment and good cosmetic outcome scores (p=0.01-0.05). There was no difference in cosmetic outcome between different reconstruction methods. Reconstruction patients rated their cosmetic outcome better than conservative surgery patients, and conservative surgery patients better than mastectomy patients. There were no differences in psychological outcome between patient groups.

CONCLUSION

Good perception of cosmetic outcome is associated with good psychological adjustment. There is no cosmetic advantage of one type of reconstruction over another. Reconstruction patients have a better body image compared with other treatment groups but there are no other psychological advantages of one type of treatment over another.

Association of information satisfaction, psychological distress and monitoring coping style with post-decision regret following breast reconstruction

Little is known of the psychosocial factors associated with decision regret in the context of breast reconstruction following mastectomy for breast cancer treatment. Moreover, there is a paucity of theoretically-based research in the area of post-decision regret. Adopting the theoretical framework of the Monitoring Process Model (Cancer 1995;76(1):167-177), the current study assessed the role of information satisfaction, current psychological distress and the moderating effect of monitoring coping style to the experience of regret over the decision to undergo reconstructive surgery. Women (N=123) diagnosed with breast cancer who had undergone immediate or delayed breast reconstruction following mastectomy participated in the study. The majority of participants (52.8%, n=65) experienced no decision regret, 27.6% experienced mild regret and 19.5% moderate to strong regret. Bivariate analyses indicated that decision regret was associated with low satisfaction with preparatory information, depression, anxiety and stress. Multinominal logistic regression analysis showed, controlling for mood state and time since last reconstructive procedure, that lower satisfaction with information and increased depression were associated with increased likelihood of experiencing regret. Monitoring coping style moderated the association between anxiety and regret (beta=-0.10, OR=0.91, p=0.01), whereby low monitors who were highly anxious had a greater likelihood of experiencing regret than highly anxious high monitors.

Psychological Status at Time of Diagnosis and Patients' Ratings of Cosmesis Following Radiation Therapy for Breast Cancer

This retrospective pilot study examined the relationship between psychological status at the time of breast cancer diagnosis and ratings of cosmetic outcome later. Sixty-three patients completed measures of depression, anxiety, and quality of life at the time of diagnosis. Following lumpectomy and radiation therapy, these patients and their radiation oncologists completed ratings of the quality of the cosmetic outcome (Cosmesis). The results indicated that both psychological distress and quality of life were related to patients' ratings of Cosmesis, while only patients' quality of life was related to physicians' ratings of Cosmesis. We conclude that Cosmesis is a multifaceted construct that incorporates both physical and psychological factors.

Short-Term and Long-Term Psychosocial Adjustment and Quality of Life in Women Undergoing Different Surgical Procedures for Breast Cancer

BACKGROUND

The various surgical procedures for early-stage breast cancer are equivalent in terms of survival. Therefore, other factors, such as the procedures' effect on psychosocial adjustment and quality of life (QOL), take on great importance. The aim of the current study was to prospectively examine the short- and long-term effects of mastectomy with reconstruction, mastectomy without reconstruction, and breast conservation therapy on aspects of psychosocial adjustment and QOL in a sample of 258 women with breast cancer.

METHODS

Participants completed questionnaires before surgery and then again 1, 6, 12, and 24 months after surgery. Questionnaires assessed depressive symptoms, anxiety, body image, sexual functioning, and QOL.

RESULTS

Adjustment patterns differed throughout the 2-year period after surgery. Some short-term changes in adjustment (less anxiety, less overall body satisfaction) were similar across surgery groups, whereas others (satisfaction with chest appearance, QOL in physical health domain) were higher for women who had breast conservation therapy. However, women who had mastectomy with reconstruction reported greater satisfaction with their abdominal area. During the long-term follow-up period (6 months to 2 years after surgery), women in all three groups experienced marked improvements in psychosocial adjustment (depressive symptoms, satisfaction with chest appearance, sexual functioning) and QOL in physical and mental health domains. In fact, the level for most variables returned to baseline levels or higher.

CONCLUSIONS

Overall, the general patterns of psychosocial adjustment and QOL are similar among the three surgery groups.

Psychological Factors Predict Patient Satisfaction with Postmastectomy Breast Reconstruction

BACKGROUND

This prospective study examined the contribution of psychological factors to the prediction of patient satisfaction with postmastectomy breast reconstruction surgery.

METHODS

Women presenting for breast reconstruction were administered presurgical psychological inventories. Measures of affective distress, depressive symptoms, anxiety, somatization, and somatic preoccupation were obtained from standardized inventories. At 1-year (n = 295) and 2-year (n = 205) follow-up, subjects completed ratings of their satisfaction with both the general and aesthetic results of surgery.

RESULTS

After controlling for sociodemographic variables and both surgical procedure type and timing, multiple linear regression analyses indicated that at 1-year follow-up preoperative measures of affective distress, depression, somatization, and somatic anxiety predicted less general satisfaction with surgical outcome, while presurgical levels of affective distress, depression, anxiety, somatization, and somatic anxiety predicted decreased aesthetic satisfaction. At 2-year follow-up, only preoperative affective distress retained a significant association with lowered general satisfaction with reconstructive surgery. In addition, at 2-year reassessment, aesthetic quality of surgical outcome was inversely related to all the presurgical psychological variables.

CONCLUSIONS

Affective distress and somatic preoccupation negatively influence patient satisfaction with both aesthetic and general outcomes associated with postmastectomy breast reconstruction. Presurgical psychological screening and counseling of selected women who are being considered for breast reconstruction may be advisable to enhance patient satisfaction with reconstructive surgery.

Breast reconstruction following mastectomy for invasive breast cancer by free flaps from the abdomen is oncologically safe

AIMS

To report the long-term results of oncological safety of breast reconstruction by autologous tissue following mastectomy for invasive breast cancer.

METHODS

One-hundred-fifty-six consecutive patients with invasive breast cancer treated with mastectomy and reconstruction by autologous tissue were reviewed throughout (from 1987 to 2003 with median follow up time of 66 months).

RESULTS

Median patient age was 45.9 years (range 26-68). The 157 observed tumors had mean diameter of 25+/-19 mm, 70 of them were poorly differentiated, and 137 were invasive ductal carcinoma. Multifocal disease was present in 44 patients. Breast reconstruction was carried out only by autologous tissue (free flaps were used in 95% and free TRAM flap transfer was the most common reconstructive procedure). There was only one local recurrence as first site of recurrence, thus yielding a local recurrence rate of 0.6%.

CONCLUSIONS

Breast reconstruction by autologous tissue following mastectomy for invasive breast cancer is an oncologically safe procedure.

Post-mastectomy reconstruction: a comparative analysis on psychosocial and psychopathological outcomes

Although multiple benefits have been reported from post-mastectomy reconstruction and particularly from an immediate procedure, limited psychiatric evaluation has been published. The present study was planned to evaluate the psychosocial and psychopathological outcome in patients who had undergone post-mastectomy breast reconstruction. We also investigated if any psychopathological condition could significantly affect the benefits of the reconstructive procedure. We compared 33 breast-reconstructed patients with 33 patients with mastectomy alone and 33 healthy women. All women underwent a psychiatric interview with four questionnaire-based scales (SASS, QL-index, HAM-A, HAM-D) to assess social adaptation, quality of life, anxiety and depression. A 4-point scale evaluated reconstructed patients' satisfaction. After a year, there was no statistical difference in social, sexual relationships and quality of life among reconstructed patients and healthy women. Regarding anxiety, no statistical difference was found between reconstructed and mastectomy groups. Statistically different lower depression levels in the healthy group and higher levels in the mastectomy group were found. Depression in the reconstructed group decreased compared to the mastectomy group. Differences between timing and reconstructive techniques were not statistically validated. Eight patients were dissatisfied (24.2%). Immediate reconstructed patients who had pre-existing major depressive disorder were dissatisfied. Breast-reconstructed patients' quality of life, social and sexual relationships are not significantly different to those of healthy women. Anxiety does not decrease. Timing and techniques do not seem to influence, significantly, outcome and satisfaction. Pre-existing diagnosis of major depressive disorder may be a contraindication to immediate breast reconstruction.

Aesthetic outcome of different techniques of reconstruction following nipple-areola-preserving envelope mastectomy with immediate reconstruction

BACKGROUND

Nipple-preserving mastectomy and immediate reconstruction has further improved the aesthetic outcome of skin-sparing mastectomy. To investigate the effect of the type of reconstruction technique on aesthetic outcome, three different methods of reconstruction were compared using four evaluation modalities.

METHODS

Sixty-one cases of nipple-sparing envelope mastectomy with immediate reconstruction were studied, with a mean follow-up of 48 months. The methods of reconstruction used were implant-only reconstruction, pedicled latissimus dorsi muscle with implant, and deep inferior epigastric perforator flap. Evaluation methods were objective applanation tonometry, clinical evaluation, photography-based assessment, and patient satisfaction survey.

RESULTS

All three reconstruction methods achieved good evaluation scores in the four modalities. However, in patients who had postoperative radiotherapy, objective tonometry showed that the breast remained softer in deep inferior epigastric perforator flap reconstruction.

CONCLUSION

In patients who are undergoing nipple-preserving envelope mastectomy with immediate reconstruction and who are likely to have postoperative radiotherapy, deep inferior epigastric perforator flap reconstruction achieved a better aesthetic outcome.

Variables affecting patient satisfaction in breast surgery: a cross-sectional sample of Turkish women with breast cancer

OBJECTIVE

In Turkey, despite the fact that breast cancer accounts for 24.1% of all cancer in women, a very small number of these patients receive breast reconstruction. This low percentage would seem to indicate that there are several factors affecting the decision of which surgical procedure should be selected. The aim of this study was to establish the demographical, medical, and psychological factors associated with the breast cancer patient's decision-making process, and assess their satisfaction with the type of surgery received.

METHOD

We assessed long-term satisfaction with the type of surgery received; satisfaction with the information process by which the surgery decision is taken; feelings of ambivalence or regret regarding the type of surgery received in both mastectomy (n = 50) and breast reconstruction patients (n = 25). Additionally, breast cancer survivors were compared with age-matched healthy control volunteers (n = 50) in terms of demographics, body image and self-esteem, which could be expected to affect their preferences. We administered a demographical and medical information form, Structured Clinical Interview for DSM-IV, Clinical Version (SCID-I), the Body Cathexis Scale (BCS); and the Rosenberg Self-Esteem Scale (RSE).

RESULTS

In both groups, women with a low income and less education were more likely to experience decision regret or low satisfaction. Moreover, total mastectomy-alone patients had lower self-esteem compared to reconstructive surgery patients and healthy women.

CONCLUSION

Early stage breast cancer is a chronic disease and patients have to live with the consequences of their decision for many years. At the same time, the type of surgery is decided on when patients are in an acute phase and under intense pressure. Therefore, the decision making process needs to be explored more, especially breast cancer patients with less education and low income need better assistance and more detailed explanation of their options.

A review of current practices in breast conservation surgery in the UK

INTRODUCTION

The aim of this study was to assess whether surgeons in the UK were practising wide excision consistent with current guidelines and current evidence.

PATIENTS AND METHODS

Questionnaires were sent to 200 breast surgeons throughout the UK to determine current practices in breast conserving surgery.

RESULTS

When performing a wide excision for invasive cancer, 61% of respondents always remove full thickness of breast tissue and 37% usually do. Of surgeons, 60% rarely use specimen X-ray for palpable lesions. However, 91% always take specimen X-rays in impalpable lesions, but 9% do not always take specimen X-rays for impalpable lesions. In 93% of units, the pathologist always reports the distance to the nearest margin. For both invasive and in situ cancer, there is a wide variation in what is considered an adequate radial margin. There is wide variation in the practice of re-excision. Of surgeons, 50% indicated that they wish wider margins in the presence of an extensive in situ component and 39% wish wider margins in younger women.

CONCLUSIONS

The results show a large variation in practice with many surgeons not treating patients in accordance with current guidelines and evidence.

Breast Reconstruction following Mastectomy for Breast Cancer: The Decisions of Sexual Minority Women

BACKGROUND

Prior research on decision-making for reconstructive surgery after mastectomy has not addressed the specific considerations of sexual minority women (women who partner with women, and lesbian or bisexual identified women). The purpose of this study is to explore which issues sexual minority women considered when making decisions on reconstructive surgery and to understand the influence and perspectives of these women's most important support persons.

METHODS

Study participants were recruited through targeted community-based sampling. The authors conducted individual semistructured interviews with 15 sexual minority women who had been treated with mastectomy after breast cancer diagnosis and 12 support persons who were identified by these women as their most important source of support. Using qualitative data analysis software, transcribed interviews were analyzed. Through constant comparison methods, themes related to the decision on and experiences and satisfaction with reconstructive choice were identified from the narrative data.

RESULTS

The considerations of women who decided for or against reconstruction are rooted in a value system and body image shaped by their sexual minority identity. Women who chose reconstruction experienced difficulties and regrets, whereas women without reconstruction adjusted well after time. Partners of sexual minority women matched the level of satisfaction with reconstructive choice achieved by the women themselves.

CONCLUSION

Providers who treat sexual minority women might benefit from knowing about issues important to this population to provide more comprehensive care.

Recovery issues in cancer survivorship: a new challenge for supportive care

The growing population of cancer survivors represents a clear challenge to clinicians and researchers to look beyond the search for a cure and to address the multifaceted needs of those living with and beyond a cancer diagnosis. Common sequelae that disrupt the psychosocial aspects of life for adult cancer survivors after primary treatment include: fatigue; cognitive changes; body image; sexual health and functioning; infertility; fear of recurrence; PTSD and stress syndromes; family/caregiver distress; socioeconomic issues; and distress, anxiety, and depression. Psychosocial interventions, particularly group-based interventions and physical activity programs, have shown great promise in improving these outcomes. Future research will identify even better targeted, more efficacious, and more cost effective programs and disseminate them into cancer care settings. Healthcare providers must realize that they serve as vital gatekeepers to services that will help optimize cancer survivors' psychosocial as well as physical outcomes. Addressing these issues in the post-treatment period represents the new challenge to supportive care.

URBAN?RURAL DIFFERENCES IN THE MANAGEMENT OF SCREEN-DETECTED INVASIVE BREAST CANCER AND DUCTAL CARCINOMA IN SITU IN VICTORIA

BACKGROUND

At least one-third of primary breast cancers in Australia are discovered by population-based mammographic screening. The aim of this study was to determine whether there were any differences in the surgical treatment of women diagnosed with breast cancer by BreastScreen Victoria between urban and rural populations and to investigate temporal changes in their pattern of care.

METHODS

An analysis of women diagnosed with breast cancer (invasive and non-invasive) by BreastScreen Victoria from 1993 to 2000 was conducted. Descriptive analyses of the proportion of women undergoing each surgical treatment type over time were carried out. Logistic regression was used to assess the effect of urban-rural residence on each treatment outcome while accounting for possible confounding factors.

RESULTS

Rural women with invasive breast cancer were less likely to undergo breast-conserving surgery (BCS) compared with urban women (odds ratio, 0.42; 95% confidence interval, 0.35-0.50). The same was also true for rural women with ductal carcinoma in situ (odds ratio, 0.53; 95% confidence interval, 0.29-0.96). This difference was independent of patient and tumour characteristics, including tumour size, surgeon caseload, patient's age and socioeconomic status. It also persisted over time despite a steady overall increase in use of BCS for both invasive and non-invasive cancers over the study period.

CONCLUSIONS

Among Victorian women with screen-detected breast cancer, urban women consistently had higher rates of BCS compared with rural women despite increased overall adoption of BCS. Reasons for this disparity are still unclear and warrant further investigation.

Breast conservation: evolution of surgical strategies

The surgical strategy for breast cancer has changed considerably over the last decade. Breast-conserving therapy (BCT) is now standard treatment. Today, at least three out of four breast cancer patients are, in principle, eligible for BCT. However, several specific factors must be considered to choose the correct surgical strategy. This review provides a scientific overview of the history, surgical methodology, and specific aspects of BCT.

Envelope mastectomy and immediate reconstruction (EMIR), improving outcome without oncological compromise

AIM

To determine the long term oncological safety and aesthetic acceptability of envelope mastectomy and immediate reconstruction (EMIR).

PATIENTS AND METHODS

A retrospective review of 71 cases was carried out. Oncological assessment was by clinical examination, mammography, ultrasound, and, where indicated, MRI scan. Aesthetic assessment was based on detailed clinical examination as well as subjective self-assessment of the outcome.

RESULTS

During follow-up (mean 48 months), there were three local recurrences, only one involving the nipple-areolar complex. The mean aesthetic score was 0.75 (out of 1), representing a good aesthetic outcome and patient satisfaction.

CONCLUSION

Nipple-areolar complex preservation is a safe option and EMIR produced a good aesthetic outcome, which is oncologically safe. Furthermore, it does not preclude post-operative radiotherapy.

Factors affecting patients' perceptions of choice regarding adjuvant chemotherapy for breast cancer

INTRODUCTION

Patients' perceptions of having had freedom of choice in treatment decision-making are shown to have implications for their quality of life. It is, therefore, important to determine what factors underlie these perceptions. One factor that has been studied is whether or not patients believed that their doctor had offered choice of treatment. However, even when choice is actually offered, patients may still feel that they have no choice. Little attention has been paid to other factors that may contribute to patients' perceptions of having had no choice. Our purpose was to explore (1) whether early-stage breast cancer patients perceived to have had a choice with regard to adjuvant chemotherapy, and (2) their reasons for having perceived no choice.

PATIENTS AND METHODS

The determinants of no choice that we examined were: (1) (preferred) involvement in treatment decision-making, (2) perceived clinical benefits of chemotherapy (e.g., cure), (3) perceived psychological benefits (e.g., less worries), and (4) perception of being able to cope with the side effects. All predictors, as well as patient and clinical characteristics, were entered simultaneously in a multiple logistic regression analysis and non-significant predictors were removed step-by-step, until only significant predictors (p<0.05) remained. Because determinants may differ between patients with experience of chemotherapy and those without, both treatment groups were analyzed separately.

RESULTS

Four hundred and forty-six patients filled out the questionnaire (62%). Sixty-six percent of patients who had been treated with chemotherapy and 86% of inexperienced patients had perceived no treatment choice. In both treatment groups, patients who preferred a shared role or a passive role in treatment decision-making were statistically significantly more likely to have perceived no treatment choice than patients who preferred an active role. Surprisingly, beliefs about the clinical and psychological benefits of chemotherapy did not influence patients' perceptions of having had choice of treatment.

CONCLUSION

If we adhere to patient autonomy and shared decision making, we may consider the perception of no treatment choice as a negative outcome of treatment decision-making. However, if this is the result of the patients' preference for less active involvement in treatment decision-making, the topic of perception of no treatment choice may be viewed in a different light.

Demand for plastic surgical operations after primary breast cancer surgery

BACKGROUND AND AIMS

The aim of this study is to evaluate the demand for plastic operations after primary breast cancer surgery. In addition, this study aims to increase knowledge on factors affecting the wish of women for breast reconstruction.

MATERIAL AND METHODS

A questionnaire was sent to some 111 patients who had undergone either mastectomy or breast conserving surgery. The response rate was 76%. The questionnaire consisted of 20 structured questions. The data was analysed statistically using the t test and the chi-square test.

RESULTS

28% of the mastectomized patients wanted a breast reconstruction. Factors found to affect the patient's wish for reconstruction were age (p < 0.001) and whether the patient had received radio- (p < 0.05) or chemotherapy (p < 0.05). A difference was found between the mastectomy group and the breast conserving surgery group as to satisfaction in the general (p < 0.05) and the cosmetic (p < 0.05) outcome of the surgery, as well as patient's expectations regarding the outcome (p < 0.01).

CONCLUSIONS

Rather fewer mastectomized patients wanted a reconstruction. The proportion, however, grew significantly larger in the younger age groups. This study also shows that receiving radio- or chemotherapy seems to predict a woman's choice against a reconstruction. Patients who receive radio- or chemotherapy may consider their illness more severe and life-threatening than those not receiving such treatments.

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.

Multiple Predictors of Health-Related Quality of Life in Early Stage Breast Cancer. Data from a Year Follow-up Study Compared with the General Population

Prospective longitudinal health-related quality of life (QOL) data from 161 women newly diagnosed with breast cancer were compared to age-adjusted mean QOL scores from a general female population (n=949). In addition, multiple factors (demographic, personality trait, participation in treatment decision-making, information satisfaction, and medical data), which previous research has indicated affect the QOL of breast cancer patients, were simultaneously investigated in a multivariate model, in order to determine which of these variables have the strongest influence on QOL one year after surgery. QOL was evaluated with the EORTC QLQ-C30 at time of diagnosis, three- and 12-months postoperatively. Women with breast cancer scored significantly lower on emotional, cognitive, and social functioning (p < 0.01) at time of diagnosis compared to the general female population, and continued to score lower on cognitive (p=0.008) and social (p=0.009) functioning one-year after surgery. In addition to the initial QOL, breast conservation surgery was predictive of better physical functioning (p=0.01) and body image (p < 0.0001), while chemotherapy was predictive for poorer role functioning (p=0.01) one year after surgery. Dispositional optimism was predictive for better emotional (p=0.003) and social functioning (p=0.01) one year after surgery. At time of diagnosis and throughout the post-diagnosis period, dispositional optimism was associated with better QOL and fewer symptoms.

Quality of life and patient satisfaction in breast cancer patients after immediate breast reconstruction: a prospective study

The aim of immediate breast reconstruction is to improve well-being and quality of life for women undergoing mastectomy for breast cancer. This prospective study used the SF-36 Health Survey questionnaire to assess quality of life before and 12 months after mastectomy and immediate breast reconstruction together with patients' expectations of and satisfaction with the immediate breast reconstruction with implant. Scores for 76 participants were compared with those in 920 age-matched women from the general population. Preoperative scores for emotional well-being and physical role functioning were lower than in the reference population, while after 12 months the scores in all domains had improved and were comparable with those in the reference population. The most common reason for immediate reconstruction was the desire to avoid an external prosthesis. Most women were satisfied with immediate reconstruction, and the major determinant of aesthetic satisfaction was completion of the procedure. Although many factors may influence quality of life, 1 year after breast cancer surgery with immediate reconstruction scores are equivalent to those of the normal population.

Quality of Life and Affective Distress in Women Seeking Immediate versus Delayed Breast Reconstruction after Mastectomy for Breast Cancer

BACKGROUND

This study compared the presurgical psychosocial and functional status of 238 women seeking breast reconstruction, either at the time of their mastectomy (immediate) (n = 151) or after prior mastectomy (delayed) (n = 87). Delayed subjects were further categorized in groups of time-since-mastectomy to examine the effects of time on postmastectomy psychosocial adjustment.

METHODS

Presurgical measures of quality of life, psychological distress, and somatic anxiety were obtained.

RESULTS

The results revealed relative impairment of quality of life and psychosocial functioning for immediate compared with delayed subjects. Immediate subjects reported greater disturbance in general mental health functioning, more severe impairment in emotional well being related to their cancer diagnosis, and higher levels of anxiety. Immediate subjects also reported a trend toward greater disturbance in work and daily activities, more frequent interference in social activities, and less vitality. Similarly, it was noted that the immediate group reported greater impairment in physical and functional well being related to their cancer adjustment. On psychological assessment, immediate subjects were more likely to report higher levels of affective distress, depressive symptoms, and obsessive-compulsive traits. For the delayed group, no statistically significant differences in the dependent measures were obtained when comparing subjects at 1 year, 2 years, and more than 2 years after mastectomy.

CONCLUSIONS

Women seeking immediate reconstruction at the time of mastectomy show a relatively higher incidence of psychosocial impairment and functional disability. Women who undergo mastectomy demonstrate early restoration of psychosocial health within the first year after surgery. Patient preoperative psychosocial distress may have important implications for clinical decision-making and surgical outcome for women seeking combined mastectomy and breast reconstruction.

Religiosity, depression and pain in patients with breast cancer

There is a growing body of evidence that religiosity can buffer depression and support the healing process. Our objective was to assess the relationship between religiosity, depression and pain in patients with breast cancer. Participants in our study were 115 breast cancer female patients recruited from a radiotherapy unit of a cancer teaching hospital, surveyed during the course of 6 months. The assessment used the Santa Clara Strength of Religious Faith Questionnaire as the measure of religiosity, and the subjects were categorized into low-, moderate- and high-religiosity groups according to its score. Depression was measured with the Center for Epidemiologic Studies Depression Scale, a 20-item self-report scale. The score of >or=16 indicated clinically relevant depression. A visual analogue scale was used for the assessment of pain. High religiosity was associated with a significantly lower prevalence of depression (chi(2)=6.635; df=2; P=.036), but religiosity was not related to the intensity of pain perception. Higher religiosity was associated with older age, lower education, unemployment and more children. Depression was associated with a higher pain level (U=1027.5; P=.004). The type of operation and tumor stage were not associated with categories of depression or religiosity, but mastectomized patients who belonged to the high-religiosity group were significantly less depressed (chi(2)=9.552; df=2; P=.008).

QUALITATIVE ASSESSMENT OF BREAST RECONSTRUCTION IN A SPECIALIST BREAST UNIT

BACKGROUND

Breast reconstruction is an integral part of the surgical management of women with breast cancer. It is often performed by plastic surgeons but, in some centres, it is performed by breast surgeons trained in breast reconstruction and oncoplastic surgery. We evaluated the objective and subjective outcomes of reconstruction for breast cancer at the Royal Adelaide Hospital Breast Unit (Adelaide, Australia) between 1990 and June 2002.

METHODS

A chart analysis was conducted of all patients who underwent breast cancer reconstruction at the Royal Adelaide Hospital Breast Unit with analysis of type of reconstruction and complications. Patients were interviewed and self-assessment quality of life questionnaires (FACT-B, body image), and overall satisfaction with reconstruction using an analogue scale were performed. Three observers carried out photographic analysis of the reconstructions. A comparison was then made between the different forms of reconstruction used.

RESULTS

One hundred and ninety-two patients underwent a total of 219 breast reconstructions during this period. The reconstructions included 18 latissimus dorsi mini flaps, 83 tissue expander/implants, 43 latissimus dorsi flaps and 75 TRAM flaps. There were no perioperative deaths. Significant systemic complications occurred in four patients (2%). Significant implant related complications occurred in four patients (3.2% of patients with implants). Total flap loss occurred in four patients (2.9% of flaps). One hundred and twenty-three patients were able to be contacted and completed the questionnaires. Overall 77% of patients were highly satisfied with breast reconstruction and 82% scored a satisfactory result on photographic analysis. All four forms of reconstruction rated highly with respect to quality of life, body image, patient satisfaction and photographic assessment.

CONCLUSIONS

Breast reconstruction undertaken by breast surgeons trained in breast reconstruction and oncoplastic techniques has been performed with an acceptable rate of complications and a high level of patient satisfaction. Satisfaction with breast reconstruction was similar across the four methods of reconstruction used.

A 1-year prospective study of individual variation in distress, and illness perceptions, after treatment for breast cancer

OBJECTIVE

The primary objective was to conduct a detailed analysis of individual variation in psychological morbidity in the year following surgery for breast cancer. The salience of the patients' "illness perceptions" to morbidity was examined as a secondary objective.

METHODS

Psychological morbidity was assessed with the General Health Questionnaire (GHQ-28) in a prospective study of 371 women having surgery for primary breast cancer. Patients also completed the Illness Perception Questionnaire (IPQ), Mental Adjustment to Cancer Scale (MAC) and the Eysenck Personality Scales (EPS). Assessments were made postoperatively and at 3, 6 and 12 months after surgery.

RESULTS

Whilst descriptive statistics indicated a general reduction in mean distress over the 12-month follow-up, close analysis showed that a quarter of all patients maintained clinically significant levels of distress throughout the period. Patients with chronically elevated distress were characterised by higher levels of neuroticism, greater symptom awareness, more pain and poorer self-rated general health. In the regression analysis, psychological morbidity across the 1-year follow-up was predicted principally by the immediate postoperative state of distress, IPQ symptom awareness and the perceived time line of the illness, general health and, to a more minor extent, by neuroticism.

CONCLUSION

There is marked individual variation in psychological morbidity in the year following breast cancer surgery, which is reliably predicted by the patient's immediate postoperative state of distress, her perception of the impact of the symptoms and the time line of the disease. Subgroups of patients with chronically high distress are characterised by factors including personality and negative perceptions and beliefs about their illness.

Predicting psychological morbidity in Chinese women after surgery for breast carcinoma

BACKGROUND

Between 30% and 70% of western women experience psychological morbidity after undergoing surgery for breast carcinoma; however, the rates and risk factors among Chinese women are unknown. Identifying at-risk women enables preventive intervention.

METHODS

Among 430 Chinese women who were approached within 1 week after undergoing surgery for early-stage breast carcinoma (baseline), 405 women (94%) completed measures of self-efficacy and psychological morbidity (the Chinese Health Questionnaire 12-item instrument [CHQ12]) and completed retrospective measures of treatment decision-making (TDM) difficulties, satisfaction with TDM involvement, and satisfaction with consultation and treatment outcome expectations. One-month postsurgery follow-up (follow-up), CHQ12 scores for 367 of 405 women (91%) were adjusted for concurrent physical symptom distress and trait optimism (the revised Chinese Life Orientation Test) and baseline predictors using stepwise multivariate regression.

RESULTS

At baseline 28% of women evidenced mild psychological morbidity, and 42% of women evidenced moderate-to-severe psychological morbidity: At follow-up, the respective rates were 32% and 36%. Preferred TDM involvement was associated with lower psychological morbidity (F = 6.702; P < 0.001). Baseline CHQ12 scores were predicted by outcome expectancies and TDM difficulties (adjusted regression coefficient [R(2)] = 0.192). Baseline CHQ12 scores and follow-up chemotherapy, in turn, predicted physical symptom distress at follow-up. After adjustment, high physical symptom distress, baseline psychological morbidity, low optimism, and no chemotherapy independently predicted follow-up CHQ12 scores (adjusted R(2) = 0.585).

CONCLUSIONS

Psychological morbidity was linked to women's TDM difficulties, their inability to anticipate treatment effects accurately, and physical symptom distress, possibly exacerbated by symptom misattribution. Optimizing TDM support and helping women accurately determine outcomes in terms of symptom experience and meaning and physical appearance may help to reduce psychological morbidity. Women who have TDM difficulties should be considered to be at high risk for psychological distress.

Satisfaction with breast reconstruction in women with bilateral prophylactic mastectomy: a descriptive study

Prophylactic bilateral mastectomy is an option for women who are at an increased risk of developing breast cancer. Prophylactic mastectomy is often performed with immediate reconstruction (i.e., at the same time and under the same anesthetic as the mastectomy). Satisfaction with reconstruction has been described previously for women with mastectomy for breast cancer. However, the authors know of no previous research that has reported on satisfaction with reconstruction in patients who have electively sought mastectomy for the prevention of breast cancer. Women in the province of Ontario who had undergone prophylactic bilateral mastectomy plus breast reconstruction between 1991 and 2000 were asked to rate their level of satisfaction with the cosmetic results of their mastectomy and reconstruction and their overall satisfaction with their decision to have prophylactic mastectomy. Women were also asked whether they experienced complications associated with their surgery and what types of complications they experienced. Thirty-seven women completed questionnaires for this study, and all of them had immediate breast reconstruction after prophylactic mastectomy. The majority of women (70.3 percent) reported being satisfied or extremely satisfied with the cosmetic results of their breast reconstruction. Women with self-reported postsurgical complications (16.2 percent) were significantly less satisfied with reconstruction than those who did not report complications (p = 0.009). Personal subjective risk of breast cancer before prophylactic mastectomy was negatively correlated with satisfaction with reconstruction (r = -0.38, p = 0.024) and with subjective risk estimation after prophylactic surgery (r = -0.54, p = 0.001). Women who did not worry about developing breast cancer after prophylactic mastectomy had significantly higher levels of satisfaction with breast reconstruction than those who continued to worry (p < 0.001). Women who reported an improved body image after reconstruction were significantly more likely to report higher levels of satisfaction than those who reported a diminished body image (p = 0.007). The majority of women were satisfied with the cosmetic results of breast reconstruction after prophylactic mastectomy. Women who overestimated their breast cancer risk had lower satisfaction levels. Correcting overestimation of breast cancer risk in women who have prophylactic mastectomy may improve satisfaction with reconstruction following prophylactic mastectomy.

A comparative study of envelope mastectomy and immediate reconstruction (EMIR) with standard latissimus dorsi immediate breast reconstruction

BACKGROUND

Latissimus dorsi breast reconstruction has problems with scars at the donor site and on the reconstructed breast. We report the feasibility and aesthetic results of Envelope Mastectomy and Immediate Reconstruction (EMIR), which utilises a single lateral mammary fold incision.

PATIENTS AND METHODS

Between 2001 and 2002, 20 EMIRs were performed in 19 patients, one as a staged bilateral procedure. Twenty consecutive patients, matched for body habitus, who had undergone standard latissimus dorsi breast reconstruction by the same surgeon from 1996 to 2000 were used as controls. Patient satisfaction was assessed using a validated Body Image Scale. Standard post-operative photographs were scored by three independent observers.

RESULTS

Length of stay and complication rates were equivalent between both groups. Cosmetic self-assessment scores on the Body Image Scale and scores by the independent observers were satisfactory for both groups but no statistically significant difference was observed between groups.

CONCLUSIONS

EMIR is a technically feasible and cosmetically acceptable method of immediate breast reconstruction.

The impact of the perception of treatment choice on satisfaction with treatment, experienced chemotherapy burden and current quality of life

Previous research has shown that involving patients in the decision-making process may improve their quality of life (QoL). Our purposes were to assess: (1) whether early-stage breast cancer patients perceived that they had treatment choice with regard to adjuvant chemotherapy, (2) what reasons patients provide for their perception of having had no choice of treatment and (3) whether the perception of treatment choice is related to satisfaction with the assigned treatment, experienced chemotherapy burden and current QoL. A total of 448 patients, treated between 1998 and 2003, filled in the questionnaire (response rate: 62%). Patients who indicated that they had not perceived a choice regarding chemotherapy could tick off one or more reasons out of 10 reasons, or provide their own reason(s). Quality of life was measured on a Visual Analogue Scale, by means of the EuroQol, and by means of the Hospital Anxiety and Depression Scale. Of the 405 patients who had answered the question on treatment choice, 316 patients (78%) had perceived no choice. The most frequently indicated reason for lack of choice was: ‘I follow the doctor's advice.’ We found no differences in the levels of satisfaction with assigned treatment and in how much of a burden they found chemotherapy between patients who perceived a choice of treatment and those who did not. In general, the perception of choice seemed to have no impact on QoL. However, we found an interaction effect, which indicated that the impact of perception of treatment choice on QoL was dependent upon whether the patient had been treated with chemotherapy or not. Within the group of patients who had not been treated with chemotherapy, the perception of having had a choice was related to lower current QoL. In cases when the decision to be treated or not has potential consequences for the chance of survival, patients' QoL may not be improved by the perception of having had a choice of treatment.

Determinants of patients' choice of reconstruction with mastectomy for primary breast cancer

BACKGROUND

The aim of the study was to measure women's decisions about breast reconstruction (BR) after mastectomy and to assess the factors contributing to their decisions, in a context involving shared decision-making and maximum patient autonomy.

METHODS

Women who were about to undergo mastectomy for primary breast cancer were systematically offered choices concerning BR and time of reconstruction (intervention always covered by the French National Insurance System). Self-administered questionnaires were used prior to the operation.

RESULTS

Among the 181 respondents, 81% opted for BR and 19% for mastectomy alone. In comparison with those who chose mastectomy alone, those opting for BR more frequently recognized the importance of discussing these matters with the surgeon and their partner (adjusted odds ratio [OR(adj)] = 13.45 and 3.59, respectively; P <.05) and realized that their body image was important (OR(adj) = 10.55, P <.01); fears about surgery prevented some of the women from opting for BR (OR(adj) = 0.688, P <.05). Among the women opting for BR, 83% chose immediate breast reconstruction (IBR) and 17% chose delayed breast reconstruction (DBR). The preference for IBR was mainly attributable to the fact that these women had benefited more frequently from doctor-patient discussions (OR(adj) = 3.49, P <.05) but was also attributable to the patients' physical and functional characteristics: they were in a poorer state of health (P <.05). The surgeons predicted their patients' preferences fairly accurately.

CONCLUSIONS

In a context of maximum autonomy, the great majority of the women chose IBR. The patients' choices were explained mainly by their psychosocial characteristics. The indication for BR should be properly discussed between patients and surgeons before mastectomy.

Reconstructions mammaires après mastectomie pour cancer du sein : quelles indications retenir ?

Post-mastectomy breast reconstruction represents a surgical option that may improve psychosocial outcome without modifying patients' survival. Psychosocial impact of used surgical technique and moment of realization of breast reconstruction remains unclear. However, complications are negatively related to patients' satisfaction. There is no guideline for BR indications. Therefore, a review of clinical and cosmetic outcomes of different breast reconstruction modalities was necessary. It permitted to propose a shared decision-making algorithm for the choice of moment and technique of BR according to the presence of radiotherapy that appears to be the main risk factor of clinical outcome of breast reconstruction. It also disclosed some limits in information reliability about clinical outcome of particular associations of breast reconstruction and radiotherapy. Proportion of women pursuing breast reconstruction, and particularly immediate breast reconstruction, is rising. Clinical surveys assessing relation between radiotherapy and clinical and psychosocial outcome of breast reconstruction are urgently expected.

Quality of Life Following Breast-Conserving Therapy or Mastectomy: Results of a 5-Year Prospective Study

There are many conflicting results in the literature comparing quality of life following breast-conserving therapy (BCT) and mastectomy. This study compared long-term quality of life between breast cancer patients treated by BCT or mastectomy in three age groups. Patients (n = 990) completed a quality of life survey, including the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), at regular intervals over 5 years. In the cross-sectional data, mastectomy patients had significantly (p < 0.01) lower body image, role, and sexual functioning scores and their lives were more disrupted than BCT patients. Emotional and social functioning and financial and future health worries were significantly (p < 0.01) worse for younger patients. There were no differences in body image and lifestyle scores between age groups. There was also no interaction between age and surgery method. Even patients > or =70 years of age reported higher body image and lifestyle scores when treated with BCT. The repeated measures analysis indicated that four functioning scores, half the symptom scores, future health, and global quality of life improved significantly (p < 0.01) over time. All these variables increased significantly for BCT patients and those 50 to 69 years of age. Body image, sexual functioning, and lifestyle disruption scores did not improve over time. BCT should be encouraged in all age groups. Coping with appearance change should be addressed in patient interventions.

Breast cancer treatment in clinical practice compared to best evidence and practice guidelines

There is sparse evidence on community practice patterns in treating women with breast cancer. This study compared care of women with breast cancer with evidence from meta-analyses and US National Comprehensive Cancer Network (NCCN) clinical guidelines. Records of 4395 women with breast cancer were abstracted from practices of 19 surgeon oncologists in six specialty practices in the Philadelphia region during 1995–1999. Patients were followed through December 2001. Low-frequency data were obtained on all patients. All other data were from a random sample of 464 women, minimum of 50 patients per practice. Actual care provided was compared to NCCN guidelines and results of meta-analyses. Fewer than half the women received treatments reflecting meta-analysis results or NCCN guidelines, by disease stage/TNM status. Adherence to either standard varied from 0% for LCIS to 87% for stages IIA or IIB node positive. There are multiple interactive reasons for low adherence to guidelines or meta-analyses results, including insufficient health system supports to clinicians, inadequate organisation and delivery systems and ineffective continuing medical education. The paucity of written information from patient records on physician/patient interactions limits the understanding of treatment decisions.

Psychosocial impact of breast cancer surgeries in Chinese patients and their spouses

BACKGROUND AND PURPOSE

This pilot study assesses the psychosocial impact of different modalities of breast cancer surgery in Chinese patients and their husbands.

METHODS

Thirty-six patients who underwent conservative breast therapy (BCT) for breast cancer were compared with 36 women who underwent total mastectomy (TM) on four aspects of psychosocial adjustment. They were matched in pairs in terms of stage of disease, age and time since surgery. Where available, their husbands were also consented for similar assessment.

RESULTS

Women who underwent BCT showed a significantly better response to their body and sexual image than those who underwent TM. This difference did not translate into any significant difference in terms of emotional and symptomatic aspects, daily activities, or fear of recurrences. The husbands of patients in the TM group showed significantly more emotional and symptomatic distress and greater change in the perception of their wives' body and sexual images.

CONCLUSION

This is the first of such study conducted in a Chinese population. The lack of differences in certain psychosocial aspects may indicate a generally good adjustment in the TM patients after their surgery. It may also relate to the fact that volunteers for the study were themselves representative only of the patient population who adapted well to the surgery, and those patients who were emotionally distressed tended to decline to participate. Psychosocial disruption in the patients' families is reflected in our study where patients' husbands in the TM group were significantly more disturbed. However, due to the limited number of patients studied, the findings are not yet conclusive and require further studies for confirmation.

Breast reconstruction in Nova Scotia: Rate, trends and influencing factors

BACKGROUND

During their lifetime, approximately 10% of Canadian women will develop breast cancer. An increased awareness of breast reconstruction in patients undergoing mastectomy appears to have increased the demand for breast reconstructive surgery.

OBJECTIVES

To study the rate of breast reconstructive surgeries performed in the province of Nova Scotia to determine whether the breast reconstructive services now offered are adequate to meet the needs of the population of this area.

METHODS

The number of breast reconstruction procedures and mastectomies completed in the province of Nova Scotia during the time period of 1992 to 2001 was reviewed. The data were obtained from Maritime Medical Care Incorporated, the provincial medical plan. Information available on patients coded as undergoing breast surgeries was reviewed (n=10,056). The data on the trends and demographics of the Nova Scotia population were obtained from Statistics Canada. The data on incidence, prevalence and trends of breast cancer were obtained from the Canadian Cancer Society and the National Cancer Institute of Canada.

RESULTS AND CONCLUSIONS

There is strong evidence of an increasing trend in the number of reconstructive surgeries among the women who underwent mastectomy. The number of breast reconstruction procedures increased 15 fold during the study period. This is mainly attributed to the increased awareness of women undergoing mastectomy and improved education by surgeons, family physicians and breast cancer support groups. Health sector employees must evaluate these trends to determine if the breast reconstructive services currently offered in this region are adequate. Reconstructive surgery was negatively associated with increasing age. Place of residency (urban versus rural) seems to play a role in women's decisions to proceed with breast reconstruction.

Better cosmetic results and comparable quality of life after skin-sparing mastectomy and immediate autologous breast reconstruction compared to breast conservative treatment

Preoperative chemotherapy (PCT) can be used in large primary breast cancer to facilitate breast conservative surgery (BCS). Cosmetic results of BCS are influenced by the size of the residual tumour, relative to the size of the breast. After mastectomy, immediate breast reconstruction (IBR) with autologous tissue provides excellent cosmetic outcome and has proven to be safe in breast cancer patients. Besides improving overall and disease free survival, Quality of Life (QoL), body image and cosmetic outcome are also important issues after treatment for breast cancer. In this study, Health-Related-Quality of Life (HRQL) and body image were evaluated, in patients treated with PCT, followed by BCS, or skin-sparing mastectomy (SSM) and perforator-flap breast reconstruction. Additionally, clinical observers assessed cosmetic outcome. All participants were evaluated by the Medical Outcomes Study (MOS) 36-item Short Form Health Status Survey (SF-36, 36 items) and a study-specific questionnaire. An external panel evaluated standardised photographs of the breasts. For all patients, norm-based scores of physical and mental health state are comparable with the general population, except for vitality (VT) score, which is somewhat lower. No significant differences can be observed between both groups. The majority of the patients were satisfied with the appearance of their breasts. The cosmetic results, assessed by the clinical team, were significantly better for patients having IBR, compared to BCS. The mean score was 7.5/10 for IBR, versus 6.0/10 for BCS (p<0.0001).Breast conserving treatment or mastectomy with reconstruction may yield comparable results of QoL, but cosmetic outcome is better after SSM and perforator-flap reconstruction. Patients must be offered both options, and clinicians should stress that both are equally effective.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Postmastectomy breast reconstruction: current techniques

BACKGROUND

The techniques of breast reconstruction have evolved and matured over the past 25 years. Recent studies have proven the benefit of breast reconstruction for breast cancer patients.

METHODS

The authors reviewed the recent literature on the techniques of breast reconstruction and the effects of reconstruction on patients following surgery for breast cancer. The findings in recent studies are correlated with the experience of the authors.

RESULTS

A better understanding has been gained regarding surgical techniques of breast reconstruction as well as the proper indications for the various methods. The criteria of patient benefit have been defined by recent long-term studies.

CONCLUSIONS

Breast reconstruction following mastectomy has been proven to be a safe and beneficial procedure.

Magnifying endoscopic observation of the gastric mucosa, particularly in patients with atrophic gastritis

The gastric mucosal surface was observed using the magnifying fibergastroscope (FGS-ML), and the fine gastric mucosal patterns, which were even smaller than one unit of gastric area, were examined at a magnification of about 30. For simplicification, we classified these patterns by magnifying endoscopy in the following ways; FP, FIP, FSP, SP and MP, modifying Yoshii's classification under the dissecting microscope. The FIP, which was found to have round and long elliptical gastric pits, is a new addition to our endoscopic classification. The relationship between the FIP and the intermediate zone was evaluated by superficial and histological studies of surgical and biopsy specimens. The width of the band of FIP seems to be related to the severity of atrophic gastritis. Also, the transformation of FP to FIP was assessed by comparing specimens taken from the resected and residual parts of the stomach, respectively. Moreover, it appears that severe gastritis occurs in the gastric mucosa which shows a FIP. Therefore, we consider that the FIP indicates the position of the atrophic border.