Higher Risk of Depression After Total Mastectomy Versus Breast Reconstruction Among Adult Women With Breast Cancer: A Systematic Review and Metaregression

Preoperative depression is an independent risk factor for short-term morbidities in autologous and implant-based breast reconstruction

BACKGROUND

Depression is notably common among patients who have undergone mastectomy. Several post-mastectomy patients opt for elective breast reconstruction. However, evidence on the influence of preoperative depression on breast reconstruction outcomes remains limited. This study aimed to evaluate the effect of preoperative depression on the short-term outcomes of autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR) using a comprehensive national registry.

METHODS

Patients who underwent ABR or IBR were identified from the national inpatient sample from Q4 2015-2020. Multivariable logistic regressions were used to compare in-hospital outcomes between the patients with and without depression, adjusted for demographics, primary payer status, hospital characteristics, and comorbidities.

RESULTS

Among the 12,984 patients who underwent ABR, 1578 (12 %) had depression whereas 1980 (11 %) out of 17,963 patients who underwent IBR had depression. In ABR and IBR, preoperative depression was associated with higher superficial wound complications (ABR, aOR = 1.386, 95 % CI = 1.035-1.856, p = 0.03; IBR, aOR = 1.281, 95 % CI = 1.001-1.638, p = 0.04), hemorrhage/hematoma (ABR, aOR = 1.164, 95 % CI = 1.010-1.355, p = 0.04; IBR, aOR = 1.614, 95 % CI = 1.279-2.037, p < 0.01), and longer hospital length of stay (p < 0.01). In ABR, patients with depression had higher incidences of infection (aOR = 1.906, 95 % CI = 1.246-2.917, p < 0.01) and sepsis (aOR = 15.609, 95 % CI = 1.411-172.65, p = 0.03). In IBR, patients with depression had higher risks of capsular contracture (aOR = 1.477, 95 % CI = 1.105-1.976, p = 0.01) and seroma (aOR = 1.489, 95 % CI = 1.005-2.208, p = 0.04).

CONCLUSION

Preoperative depression is independently associated with major morbidities after ABR and IBR. Preoperative screening for depression can be beneficial. Findings from this study can facilitate preoperative risk stratification and post-operative care for patients with depression.

Global prevalence and factors associated with preoperative depression in women undergoing breast surgery: a meta-analysis and meta-regression

PURPOSE

Depression is one of the main psychological responses experienced by patients with breast cancer perioperatively. Therefore, this review aimed to synthesize the prevalence rate of depression preoperatively among patients with breast cancer.

METHODS

Six databases were searched for published articles, which recruited female patients aged 18 years and above, diagnosed with breast cancer and planned for breast surgery. Grey literatures were searched from ProQuest Theses and Dissertations, Science.gov and CogPrints. Studies published in English from the inception of databases to January 2023 were considered. Two reviewers screened, extracted, and appraised the data independently. Joanna Briggs Institute data collection form was used for data collection. Hoy's Risk of Bias Tool was utilized to assess the individual study's quality. Review Manager 5.4 software was utilized for meta-analysis. Subgroup analyses were conducted to explore the reasons for any heterogeneity. Publication bias was evaluated by Egger's test and funnel plot.

RESULTS

Twenty studies involving 32,143 patients with breast cancer were included. Meta-analyses revealed an overall preoperative prevalence of 30% among all studies. Subgroup analyses showed that studies conducted in the Middle East and North Africa used purposive sampling, with patients undergoing mastectomy and lumpectomy and with moderate risk of bias reported higher prevalence of preoperative depression (54%, 44%, 40%, and 49%, respectively) as compared to other respective subgroups.

CONCLUSION

The high prevalence of preoperative depression among women with breast cancer indicated the need for health care professionals to provide more psychological support to them.

A Prospective Evaluation of the Quality of Life and Mental Health Implications of Mastectomy Alone on Women in sub-Saharan Africa

OBJECTIVE

Assess quality of life and mental health implications of mastectomy for breast cancer on sub-Saharan African women.

BACKGROUND

Mortality rates amongst women diagnosed with breast cancer in sub-Saharan Africa (SSA) are high, with disparities in survival relative to women in high income countries partly attributed to advanced disease at presentation. Fears of the sequelae of mastectomy are a prominent reason for presentation delays. There is a critical need to better understand the effects of mastectomy on women in SSA to inform preoperative counseling and education for women with breast cancer.

METHODS

Women with breast cancer in Ghana and Ethiopia undergoing mastectomy were followed prospectively. Breast related quality-of-life and mental health measures were evaluated preoperatively, 3 and 6 months postoperatively, using BREAST-Q, PHQ-9, and GAD-7. Bivariate and logistic regression analyses evaluated changes in these measures for the total cohort and between sites.

RESULTS

A total of 133 women from Ghana and Ethiopia were recruited. The majority of women presented with unilateral disease (99%) and underwent unilateral mastectomy (98%) with axillary lymph node dissection. Radiation was more common in Ghana ( P <0.001). Across most BREAST-Q subscales, women from both countries reported significantly decreased scores at 3 months postoperative. At 6 months, the combined cohort reported decreased scores for breast satisfaction (mean difference, -3.4). Women in both countries reported similar improvements in anxiety and depression scores postoperatively.

CONCLUSIONS

Women from Ghana and Ethiopia who underwent mastectomy experienced a decline in breast-related body image while also experiencing decreased levels of depression and anxiety.

Depression, happiness, and satisfaction with life in women newly diagnosed with breast cancer: Associations with device-measured physical activity and sedentary time

BACKGROUND

Few studies have examined depression after a cancer diagnosis and before initiating adjuvant or neoadjuvant systemic treatments. In this study, we present baseline data on device-measured physical activity, sedentary behaviour, depression, happiness, and satisfaction with life in newly diagnosed breast cancer survivors.

PURPOSE

To examine associations of accelerometer-assessed physical activity and sedentary time with depression symptoms and prevalence, happiness, and satisfaction with life.

METHODS

Shortly after diagnosis, 1425 participants completed depression, happiness, and satisfaction with life measures and wore an ActiGraph® device on their hip to measure physical activity and the activPALTM inclinometer on their thigh for 7 days to measure sedentary time (sitting/lying) and steps (1384 completed both device measures). ActiGraph® data were analysed using a hybrid machine learning method (R Sojourn package, Soj3x), and activPALTM data using activPALTM algorithms (PAL Software version 8). We used linear and logistic regression to examine associations of physical activity and sedentary time with depression symptom severity (0-27) and depression prevalence, happiness (0-100), and satisfaction with life (0-35). For the logistic regression analysis, we compared participants with none-minimal depression (n = 895) to participants with some depression (that is, mild, moderate, moderately-severe, or severe depression [n = 530]).

RESULTS

Participants reported a mean depression symptom severity score of 4.3 (SD = 4.1), a satisfaction with life score of 25.7 (SD = 7.2), and a happiness score of 70 (SD = 21.8). Higher moderate-to-vigorous physical activity (MVPA) was associated with reduced depression symptom severity scores (β = -0.51, 95% CI: -0.87 to -0.14, p = 0.007). A 1 hour increase in MVPA was associated with a reduced odds of at least mild or worse depression by 24% (Odds Ratio [OR] = 0.76, 95% CI: 0.62-0.94, p = 0.012). Higher daily step counts were associated with lower depression symptom severity scores (β = -0.16, 95% CI: -0.24 to -0.10, p < 0.001). Perceptions of happiness was associated with higher MVPA (β = 2.17, 95% CI: 0.17-4.17, p = 0.033). Sedentary time was not associated with depression severity, but higher sedentary time was associated with lower perceptions of happiness (β = -0.80, 95% CI: -1.48 to -0.11, p = 0.023).

CONCLUSIONS

Higher physical activity was associated with fewer depression symptom severity scores and reduced odds of mild or worse depression in women newly diagnosed with breast cancer. Higher physical activity and daily step counts were also associated with stronger perceptions of happiness and satisfaction with life, respectively. Sedentary time was not associated with depression symptom severity or odds of having depression, but was associated with stronger perceptions of happiness.

Effect of traditional Chinese medicine on postoperative depression of breast cancer: a systematic review and meta-analysis

Background: Depression is one of the common complications in patients with postoperative breast cancer (BC). Conventional therapies for postoperative depression of BC always have modest treatment outcomes and undesirable side effects. Clinical practice and many studies have shown that traditional Chinese medicine (TCM) has a good effect on postoperative depression of BC. This meta-analysis aimed to assess the clinical effect of TCM as an add-on treatment for postoperative depression of BC. Methods: A systematic and thorough search was conducted on eight online electronic databases up to 20 July 2022. The control group received conventional therapies, and intervention groups received what control groups received plus TCM treatment. Review Manager 5.4.1 was used for statistical analysis. Results: Nine RCTs involved 789 participants who met the inclusion standards. The results showed the intervention group was better at decreasing the score of the Hamilton rating scale for depression (HAMD) (mean difference, MD = -4.21, 95% CI -5.54 to -2.88) and the self-rating depression scale (SDS) (MD = -12.03, 95% CI -15.94 to -8.13), improving clinical efficacy (RR = 1.25, 95% CI 1.14-1.37), increasing the levels of 5-hydroxytryptamine (5-HT) (MD = 0.27, 95% CI 0.20-0.34), dopamine (DA) (MD = 26.28, 95% CI 24.18-28.77), and norepinephrine (NE) (MD = 11.05, 95% CI 8.07-14.04), and influencing the immune index, including the levels of CD3⁺ (MD = 15.18, 95% CI 13.61-16.75), CD4⁺ (MD = 8.37, 95% CI 6.00-10.74), and CD4⁺/CD8⁺ (MD = 0.33, 95% CI 0.27-0.39). The level of CD8⁺ (MD = -4.04, 95% CI -11.98 to 3.99) had no obvious difference between the two groups. Conclusion: The meta-analysis stated that a therapeutic regimen involving TCM could better improve the depression status in postoperative BC.

Dynamic changes in quality of life, psychological status, and body image in women who underwent a mastectomy as compared with breast reconstruction: an 8-year follow up

BACKGROUND

Surgical decisions and methods of surgery highly influence long term QoL for breast cancer (BC) survivors. This study is aimed towards an exploration of the dynamic changes in quality of life (QoL), anxiety/depression status, and body image (BI) among women with BC who received a mastectomy compared with those receiving breast reconstruction (BR) within an 8-year follow-up period.

METHODS

Women with major BC surgeries were invited to complete the World Health Organization Quality of Life-Brief (WHOQOL-BREF), the European quality of life five dimensions questionnaire (EQ-5D), and a body image scale within 8 years of surgery. Kernel smoothing methods were applied to describe dynamic changes in QoL, anxiety/depression, and BI at different time points. Linear mixed effects models were constructed to identify the interaction between time, different types of surgery, and the determinants of QoL in these patients.

RESULTS

After 1:10 propensity score matching, a total of 741 women who had undergone a BR and mastectomy were included. The BR group exhibited a high WHOQOL QoL score one to five years after surgery with some fluctuations. The mastectomy group had comparatively stable QoL scores on WHOQOL items and were less depressed/anxious. The BR group generally showed fluctuating, higher BI scores two years after surgery, but they exhibited more anxiety/depression during follow up for 8 years. Medical comorbidities, the status of anxiety/depression, and BI were the major factors influencing all domains and items of the WHOQOL BREF among women with BC.

CONCLUSION

The mastectomy group showed a decreased trend toward depression in patients with BC. The BR group showed a significant improvement in QoL in the first 5 years with massive fluctuations. These findings should be considered and discussed in patient participatory decision-making and promotion of QoL for breast cancer survivors.

Does breast oncoplastic surgery improve quality of life?

Breast Oncoplastic Surgery (OS) has established itself as a safe procedure associated with the treatment of breast cancer, but the term is broad, encompassing procedures associated with breast-conserving surgeries (BCS), conservative mastectomies and fat grafting. Surgeons believe that OS is associated with an increase in quality of life (QOL), but the diversity of QOL questionnaires and therapeutic modalities makes it difficult to assess from the patient's perspective. To answer this question, we performed a search for systematic reviews on QOL associated with different COM procedures, and in their absence, we selected case-control studies, discussing the main results. We observed that: (1) Patients undergoing BCS or breast reconstruction have improved QoL compared to those undergoing mastectomy; (2) In patients undergoing BCS, OS has not yet shown an improvement in QOL, a fact possibly influenced by patient selection bias; (3) In patients undergoing mastectomy with reconstruction, the QoL results are superior when the reconstruction is performed with autologous flaps and when the areola is preserved; (4) Prepectoral implants improves QOL in relation to subpectoral implant-based breast reconstruction; (5) ADM do not improves QOL; (6) In patients undergoing prophylactic mastectomy, satisfaction is high with the indication, but the patient must be informed about the potential complications associated with the procedure; (7) Satisfaction is high after performing fat grafting. It is observed that, in general, OS increases QOL, and when evaluating the procedures, any preservation or repair, or the use of autologous tissues, increases QOL, justifying OS.

Invited Discussion on: The Impact of Reconstructive Modality and Postoperative Complications on Decision Regret and Patient-Reported Outcomes following Breast Reconstruction

One in eight women will have a lifetime diagnosis of confirmed breast cancer, and one in three of these women will undergo a mastectomy. About half of women undergoing mastectomies will opt for some type of breast reconstruction. Breast cancer itself and breast reconstruction bring physical changes that are accompanied by psychological changes of varying degrees. The decision process about cancer treatment and whether or not to perform breast reconstruction brings suffering. In the case of choosing to perform the reconstruction, deciding when to perform it and which surgical technique to choose from among several available is quite complex, and may result in regret. The author provides a brief literature review on this subject and comments on the work carried out by Cai and Momeni, comparing data and results.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Prevalence and Persistence of Anxiety and Depression over Five Years since Breast Cancer Diagnosis-The NEON-BC Prospective Study

Anxiety and depression are frequent among patients with breast cancer (BCa). Evidence of the persistence and recovery from these conditions and their determinants is scarce. We describe the occurrence of clinically significant anxiety and depression symptoms and their associated factors among BCa patients. A total of 506 women admitted in 2012 at the Portuguese Institute of Oncology of Porto were evaluated before treatment and after one, three, and five years (7.9% attrition rate). The five-year prevalence of anxiety and/or depression (Hospital Anxiety and Depression Scale, subscores ≥ 11) was 55.4%. The peak prevalence for anxiety was before treatment (38.0%), and after one year for depression (13.1%). One in five patients with anxiety/depression at baseline had persistent anxiety/depression over time, while only 11% and 22% recovered permanently from anxiety and depression, respectively, during the first year. Higher education, higher income, practicing physical activity, and adequate fruit and vegetable intake were protective factors against anxiety and/or depression. Loss of job and income, anxiolytics and antidepressants, cancer-related neuropathic pain, and mastectomy were associated with higher odds of anxiety and/or depression. These results highlight the importance of monitoring anxiety/depression during the first five years after cancer diagnosis and identify factors associated with these conditions.