Risk Factors for Upper Extremity Impairment after Mastectomy: A Single Institution Retrospective Review

Background

Patients with breast cancer treated with mastectomy are more likely to develop upper extremity dysfunction compared with those treated with breast-conserving therapy. This study aimed to identify cancer and treatment characteristics that may be risk factors for development of upper extremity dysfunction in patients treated with mastectomy.

Methods

The authors performed a retrospective chart review of patients at the University of Chicago who were treated with a unilateral or bilateral mastectomy from 2010 to 2020 and developed upper extremity dysfunction based on International Classification of Disease-10 codes. Patients were analyzed by side of body (left or right). Patient demographics and treatment characteristics were extracted from the electronic medical record.

Results

In total, 259 patients met criteria and were included in our study. A total of 396 upper extremities were recorded as experiencing dysfunction and were analyzed. Mean age was 60 years (range = 28-96), and mean body mass index was 28.4 (SD = 7.5). An estimated 54% of patients underwent breast reconstruction. After multivariable analysis, chronic upper extremity pain was found to be associated with ipsilateral radiotherapy (P < 0.001) and ipsilateral in situ cancer (0.041). Limited range of motion was found to be associated with ipsilateral invasive cancer (P = 0.01), any ipsilateral mastectomy surgery (P < 0.001), and ipsilateral radiotherapy (P = 0.03). Musculoskeletal dysfunction was found to be associated with no ipsilateral modified radical mastectomy (P = 0.033). No oncological or treatment characteristics were found to be associated with decreased strength or adhesive capsulitis. Furthermore, breast reconstruction (implant or autologous tissue based) was not associated with upper extremity dysfunction.

Conclusion

Breast cancer characteristics and treatment modalities may predispose patients treated with mastectomy to developing types of upper extremity dysfunction.

A meta-analysis of randomized controlled trials comparing breast-conserving surgery and mastectomy in terms of patient survival rate and quality of life in breast cancer

The study aimed to assess the effects of breast-conserving surgery (BCS) versus mastectomy on survival and quality of life in Stages I, II, and III breast cancer, providing solid evidence for clinical decisions. We conducted a meta-analysis of randomized controlled trials on breast cancer treatments, searching databases such as PubMed and the Cochrane Library to compare BCS, and mastectomy's effects on survival and quality of life. A combined total of 16 734 patients in the control group and 17 435 patients in the experimental group were included in this analysis. This meta-analysis used RevMan 5.3 (Cochrane Collaboration, Copenhagen, Denmark) software for analysis. Our meta-analysis of 34 169 patients from 11 studies showed that BCS significantly reduced the overall recurrence rate at a median follow-up of 29 months, with a mean difference of 1.27 and a 95% confidence interval of 1.19-1.36, strongly supporting its effectiveness (P < .00001). Furthermore, our analysis found no significant increase in 5-year local recurrence rates for BCS versus mastectomy, indicating its long-term effectiveness with a mean difference of 1.13 (95% confidence interval: [1.03, 1.24], P = .01). Additionally, there was a notable decrease in tissue ischaemic necrosis among patients who had received BCS, with a mean difference of 0.37 (95% confidence interval: [0.33, 0.42], P < .00001), underscoring its benefits and long-term viability. BCS resulted in fewer cases of tissue ischaemic necrosis and higher body image scores compared with mastectomy, suggesting that it is a preferable option for better cosmetic outcomes and potentially favourable effects on prognosis and quality of life.

Quality of Life after Mastectomy with or without Breast Reconstruction and Breast-Conserving Surgery in Breast Cancer Survivors: A Cross-Sectional Study at a Tertiary Hospital in Ghana

(1) Background: Breast cancer is the leading malignancy worldwide, and in Ghana, it has a poor overall survival rate. However, approximately 50% of cases are cases of early-stage disease, and with advances in breast cancer treatment and improvements in survival, quality of life (QOL) is becoming as important as the treatment of the disease. (2) Methodology: This was a cross-sectional study of survivors who had breast-conserving surgery (BCS), mastectomy only (M) and mastectomy with breast reconstruction (BRS) from 2016 to 2020 at a tertiary hospital in Ghana, comparatively assessing their QOL using EORTC QLQ C-30 and EORTC QLQ BR-23. (3) Results: The study participants had an overall global health status (GHS) median score of 83.3 [IQR: 66.7-91.7] with no significant differences between the surgery types. The BRS group had statistically significant lower median scores for the functional scale (82.8 and 51.0) and the highest scores for the symptomatic scale (15.7 and 16.5). Body image was significantly lowest for the BRS group (83.3) [68.8-91.7] and highest (100) [91.7-100] for the BCS group (p < 0.001). (4) Conclusion: There is a need to develop support systems tailored at improving the QOL of breast cancer survivors taking into consideration the type of surgery performed.

Preoperative depression and anxiety associated with younger age and receipt of immediate breast reconstruction

BACKGROUND

As survivorship for breast cancer continues to improve, emphasis of care falls upon improving patients' quality of life. Understanding physical and mental health in the preoperative period is needed to aid surgical decision making and improve patient experience.

METHODS

Consecutive patients awaiting total mastectomy (TM), TM with immediate breast reconstruction (IBR) and breast conserving surgery (BCS) were prospectively recruited. Scores for PHQ-9, GAD-7, Breast-Q, EQ5D(5L), PEG were collected preoperatively. Association was measured with multivariate analyses.

RESULTS

477 participants (374 BSC, 46 ​TM, 84 IBR) were included. Younger patients and those choosing IBR reported worse depression and anxiety symptoms. Clinical tumor features did not affect patient reported outcomes. Higher Breast-Q scores were seen with BCS and lower scores with TM.

CONCLUSIONS

Patients scheduled for IBR and younger patients reported worse symptoms of depression and anxiety, regardless of clinical features. This will help with surgical decision making and identify patients in need for additional perioperative supports.

What is the relationship between body image and the quality of life of women who underwent surgery for breast cancer? A scoping review

PURPOSE

This review aimed to identify, characterize, map, and summarize existing knowledge about the relationship of perceived body image with the quality of life (QoL) of women who have undergone surgical treatment for breast cancer.

METHODS

A scoping review was conducted following the PRISMA-ScR guidelines. PubMed, PsycINFO and Scopus databases were searched, and articles published until August 2022 were included.

RESULTS

The search resulted in 796 records, and 51 articles were included for analysis. A significant negative impact on body image perception and QoL after surgical treatment for breast cancer was found in the majority of studies. Sociodemographic variables such as age, education, socioeconomic status, unstable attachment styles and time after the surgery may have an effect on a worsening of the overall body image and QoL score of women. It was found that there was greater dissatisfaction with body image in women who underwent mastectomy compared to those who underwent conservative surgery.

CONCLUSION

Evidence has shown that breast cancer surgery affects the perceived body image and QoL of patients worldwide. Age, education, socioeconomic status, and the type of surgery are potential factors influencing these outcomes. It is worth noting that the review encompassed articles from various countries, reflecting a significant cultural diversity among the studied populations. However, most of these articles did not delve into an analysis of these cultural disparities. This review also indicated insufficient details regarding the assessment instruments used to assess perceived body image.

Outcomes of DCIS treated with breast conserving surgery without radiotherapy on recurrence, survival, and health-related quality of life

BACKGROUND

Sector resection for Ductal Carcinoma in Situ (DCIS) allows wide excision without compromising breast shape. There are concerns that radiotherapy for some DCIS after sector resection is unnecessary and reduces patient satisfaction and quality of life without affecting survival. This study aimed to investigate whether women with DCIS managed with sector resection without radiotherapy had acceptable rates of recurrence and health-related quality of life outcomes.

METHODS

Retrospective study of patients who underwent sector resection for DCIS without adjuvant radiotherapy from 1992 to 2021. Tumour size, grade, necrosis, margins, follow up and time to ipsilateral recurrence was recorded. Patients were posted a BREAST-Q to assess health-related quality of life.

RESULTS

One hundred and thirty-eight patients were treated for pure DCIS by two surgeons from 1992 to 2018. One hundred and sixteen patients underwent sector resection, 22 had mastectomy. Average age 61 years. Mean follow up 9.14 years. Recurrence rate after sector resection was 18.97%. 55% were DCIS. Annualized recurrence rate was 2.07%. There were no cancer-related deaths. BREAST-Q completion rate was 44%. Satisfaction with breasts, physical, psychosocial, and sexual well-being scores were significantly higher than normative Australian values and a mixed cohort of women who underwent breast conserving surgery with radiotherapy.

CONCLUSION

DCIS can be safely managed with sector resection without radiotherapy and regular long-term follow up. This approach results in low annualized recurrence rates, high levels patient satisfaction and health-related quality of life and should be considered a safe alternative for patients with DCIS to minimize morbidity without affecting cancer survival.

Sometimes it is better to just make it simple. De-escalation of oncoplastic and reconstructive procedures

Simple breast conservation surgery (sBCS) has technically advanced onto oncoplastic breast procedures (OBP) to avoid mastectomy and improve breast cancer patients' psychosocial well-being and cosmetic outcome. Although OBP are time-consuming and expensive, we are witnessing an increase in their use, even for cases that could be managed with sBCS. The choice between keeping it simple or opting for more complex oncoplastic procedures is difficult. This review proposes a pragmatic approach in assisting this decision. Medical literature suggests that OBP and sBCS might be similar regarding local recurrence and overall survival, and patients seem to have higher satisfaction levels with the aesthetic outcome of OBP when compared to sBCS. However, the lack of comprehensive high-quality research assessing their safety, efficacy, and patient-reported outcomes hinders these supposed conclusions. Postoperative complications after OBP may delay the initiation of adjuvant RT. In addition, precise displacement of the breast volume is not effectively recorded despite surgical clips placement, making accurate dose delivery tricky for radiation oncologists, and WBRT preferable to APBI in complex OBP cases. With a critical eye on financial toxicity, patient satisfaction, and oncological outcomes, OBP must be carefully integrated into clinical practice. The thoughtful provision of informed consent is essential for decision-making between sBCS and OBP. As we look into the future, machine learning and artificial intelligence can potentially help patients and doctors avoid postoperative regrets by setting realistic aesthetic expectations.

Partial breast reconstruction of 30 cases with peri-mammary artery perforator flaps

BACKGROUND

Volume replacement is one of the vital techniques of oncoplastic surgery (OPS) when applying breast-conserving surgery. The clinical application of peri-mammary artery perforator flaps for this indication is uneven in China. Here, we describe the results of our clinical experience with peri-mammary artery flaps for partial breast reconstruction.

METHODS

In this study, 30 patients underwent partial breast resection for quadrant breast cancer followed by partial breast reconstruction with peri-mammary artery perforator flaps, which included the thoracodorsal artery perforator flap (TDAP), anterior intercostal artery perforator flap (AICAP), lateral intercostal artery perforator flap (LICAP), and lateral thoracic artery perforator flap (LTAP). All the patients' operation plans were discussed comprehensively and were performed by sticking to every step. The satisfaction outcome was assessed with the extracted version of the BREAST-Q version 2.0, Breast Conserving Therapy Module Preoperative and Postoperative Scales both preoperatively and postoperatively.

RESULTS

According to the study outcomes, the mean flap size was 5.3*4.2*2.8 cm (3.0-7.0*3.0-5.0*1.0-3.5 cm). The mean surgical time was 142 min (100-250 min). No partial flap failure was detected, and no severe complications were observed. Most patients were satisfied with the outcomes regarding the dressing, sexual life, and breast shape postoperation. Furthermore, the sensation of the surgical area, scar satisfaction, and recovery state gradually improved. Overall, LICAP and AICAP had higher scores when different flaps were compared.

CONCLUSIONS

Based on this study, we found that peri-mammary artery flaps had significant value in breast-conserving surgery, especially in patients with small or medium-sized breasts. Perforators could be detected by vascular ultrasound before the operation. More than one perforator could be found most of the time. No severe complications occurred when performing a suitable plan, including discussing and recording the operation procedure; the focus of care, the choice for precise and proper perforators, and the mechanism for hiding the scars were all considered and recorded in a specific chart. Patients were satisfied with the reconstruction technique of peri-mammary artery perforator flaps after breast-conserving, and the satisfaction of AICAP and LICAP was higher. In general, this technique is suitable for partial breast reconstruction and has no negative impact on patient satisfaction.

Impact of Immediate and Delayed Breast Reconstruction on Quality of Life of Breast Cancer Patients

A mastectomy affects the psychological, social, and sexual well-being of patients. Research has confirmed that breast reconstruction is important for improving the quality of life in patients with breast cancer. The aim of this study was to assess the quality of life of patients who underwent a mastectomy followed by immediate or delayed breast reconstruction. This prospective study was conducted from January 2018 to March 2020 at the Clinical Hospital Center Osijek, using the health questionnaire SF-36. The study included 79 patients. The results of the study showed that patients who underwent a mastectomy had the lowest scores in the domain of restriction due to physical difficulties, 18.8 (6.3−31.3), in physical functioning and limitation due to emotional difficulties, 16.7 (8.3−33.3), in mental health. In immediate breast reconstruction, patients rated better physical health (p < 0.001), while patients who underwent delayed breast reconstruction rated their mental health worse (p < 0.001) as measured by the SF-36 questionnaire. Conclusion: The results of this study show that patients without breast reconstruction rated their quality of life worse than patients who underwent immediate and delayed breast reconstruction after mastectomy. There is no difference in the quality of life between patients who underwent immediate and delayed breast reconstruction after mastectomy.

Comparison of patient-reported outcomes among different types of oncoplastic breast surgery procedures

BACKGROUND

This study aims to compare patient-reported outcomes (PROs) after different types of oncoplastic surgery (OPS) procedures and correlate the results with previously published normative data from women with no prior history of breast cancer (BC) and breast surgery.

METHODS

Cross-sectional study of patients with stage I-II BC undergoing a specific selection of OPS procedures from 04/2012 to 12/2018 by three breast surgeons at a single tertiary referral hospital in Switzerland. PROs were evaluated using the postoperative BREAST-Q questionnaire.

RESULTS

One hundred twenty-seven patients met the inclusion criteria and were surveyed. All OPS techniques achieved comparably elevated scores in satisfaction with breasts, psychosocial, and sexual well-being. Compared to normative data of healthy women, all OPS groups postoperatively achieved significantly better satisfaction with breasts, psychosocial, and sexual well-being.

CONCLUSION

This study shows high PROs across all types of OPS, which were superior to normative data from healthy women. Our findings confirm that OPS is associated with high quality of life and patient satisfaction.

Quality of Life Post Breast Cancer Surgery: Comparison of Breast Conservation Surgery versus Modified Radical Mastectomy in a Developing Country

Introduction  Breast cancer survivors are the largest group of female cancer survivors. Oncologic breast surgery can have a profound impact on a woman's body image and sense of self that can significantly affect their quality of life (QOL). The paucity of data about the effect of type of surgery on QOL of Indian breast cancer survivors has led to this study. Materials and Methods  This prospective study included consecutive female early breast cancer patients who underwent primary surgery, that is, breast conservation surgery (BCS) or modified radical mastectomy (MRM) from January 1, 2015 to December 31, 2015. The primary objective was the comparison of QOL using European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and EORTC QLQ-BR 23 between the two groups at 6 months and 1 year postsurgery with the baseline. Results  One hundred and thirty-eight patients were included of which 62 underwent BCS and 76 underwent MRM. BCS patients fared better with respect to physical functioning, dyspnea, fatigue, appetite loss, and body image at 6 months ( p  < 0.05) as compared with MRM. At 1 year postsurgery, BCS patients fared better with respect to physical functioning, role functioning, global health status, body image, sexual enjoyment, and dyspnea, while MRM patients fared better in emotional functioning and future prospectives ( p  < 0.05). Conclusion  Patients undergoing BCS have a better QOL with respect to various functional and symptom scales at 6 months and 1 year. However, patients undergoing MRM perform better in terms of future perspective and emotional functioning at 1 year.

Sexual Well-Being After Nipple-Sparing Mastectomy: Does Preservation of the Nipple Matter?

INTRODUCTION

The primary aim of this study was to evaluate patient-reported outcome measures in patients undergoing mastectomy with and without breast reconstruction (immediate or delayed) with and without nipple preservation.

METHODS

All female patients undergoing mastectomy between 2011 and 2015 at Mayo Clinic Rochester were identified and were mailed the BREAST-Q survey. Breast satisfaction, psychosocial well-being, and sexual well-being were evaluated and compared by surgery type using Wilcoxon rank-sum tests for univariate analysis and linear regression for multivariable analysis adjusting for potential confounders.

RESULTS

Of 1547 patients, 771 completed the BREAST-Q survey (response rate 50%). Of these 771 respondents, 237 (31%) did not have reconstruction, 198 (26%) had nipple-sparing mastectomy with reconstruction (NSM), and 336 (44%) had skin-sparing mastectomy with reconstruction (SSM) ± nipple-areolar complex (NAC) reconstruction (via surgery ± tattoo). Patients with breast reconstruction had consistently higher BREAST-Q scores versus those without. Comparing NSM with all SSMs, there was no difference in satisfaction with breasts (mean 71.8 vs. 70.2, p = 0.21) or psychosocial well-being (mean 81.9 vs. 81.3, p = 0.47); however, sexual well-being was significantly higher in the NSM group on univariate (mean 64.5 vs. 58.0, p = 0.002) and multivariable (β = -4.69, p = 0.03) analysis. Sexual well-being scores were similar for NSM and the SSM subgroups with any type of NAC reconstruction.

CONCLUSIONS

This study demonstrates that NSM positively impacts patient sexual well-being after breast reconstruction compared with SSM, particularly SSM without nipple reconstruction or tattoo. SSM with any type of NAC reconstruction achieved similar satisfaction and sexual well-being to those undergoing NSM.

Quality of Life in Patients with Breast Cancer following Breast Conservation Surgery: A Systematic Review and Meta-Analysis

To evaluate the health-related quality-of-life (QOL) outcomes in surgical breast cancer survivors who received breast conservation therapy (BCT) compared to mastectomy, we utilized a systematic review to conduct observational studies of QOL in patients with breast cancer following breast conservation therapy from their inception until October 2021. The PubMed, the Cochrane Library, and the Web of Science databases were systematically searched to retrieve the observational studies. The pooled odds ratios (ORs) with 95% confidence intervals (CIs) were applied as an effect estimate and calculated using Stata 15 software. Nine studies comprising 2301 patients were included. The results showed that no significant differences compared to mastectomy were detected for global health status (P=0.971 and P=0.613), physical function (P=0.099), emotional function (P=0.096), cognitive function (P=0.377), social function (P=0.602), sexual functioning (P=0.072), and sexual enjoyment (P=0.142), while role function (P=0.036), body image (P=0.000), and future perspective (P=0.012) showed a significant difference for BCT when compared to mastectomy. When compared to breast reconstruction (BR), the BCT group was inferior at physical function (P=0.002) and cognitive function (P=0.040) but superior at body image (P=0.001). When used the Functional Assessment of Cancer Therapy (FACT) tool, BCT has better results in physical function (P=0.000), emotional function (P=0.000), and social function (P=0.000) than mastectomy. QOL outcomes after BCT were better than mastectomy in body image, future perspective, and role function. BCT may be an acceptable option in the study setting for breast cancer patients who pursue high QOL.

Oncoplastic breast-conserving surgery for women with primary breast cancer

BACKGROUND

Oncoplastic breast-conserving surgery (O-BCS) involves removing the tumour in the breast and using plastic surgery techniques to reconstruct the breast. The adequacy of published evidence on the safety and efficacy of O-BCS for the treatment of breast cancer compared to other surgical options for breast cancer is still debatable. It is estimated that the local recurrence rate is similar to standard breast-conserving surgery (S-BCS) and also mastectomy, but the aesthetic and patient-reported outcomes may be improved with oncoplastic techniques.

OBJECTIVES

Our primary objective was to assess oncological control outcomes following O-BCS compared with other surgical options for women with breast cancer. Our secondary objective was to assess surgical complications, recall rates, need for further surgery to achieve adequate oncological resection, patient satisfaction through patient-reported outcomes, and cosmetic outcomes through objective measures or clinician-reported outcomes.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via OVID), Embase (via OVID), the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov on 7 August 2020. We did not apply any language restrictions.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and non-randomised comparative studies (cohort and case-control studies). Studies evaluated any O-BCS technique, including volume displacement techniques and partial breast volume replacement techniques compared to any other surgical treatment (partial resection or mastectomy) for the treatment of breast cancer.

DATA COLLECTION AND ANALYSIS

Four review authors performed data extraction and resolved disagreements. We used ROBINS-I to assess the risk of bias by outcome. We performed descriptive data analysis and meta-analysis and evaluated the quality of the evidence using GRADE criteria. The outcomes included local recurrence, breast cancer-specific disease-free survival, re-excision rates, complications, recall rates, and patient-reported outcome measures.

MAIN RESULTS

We included 78 non-randomised cohort studies evaluating 178,813 women. Overall, we assessed the risk of bias per outcome as being at serious risk of bias due to confounding; where studies adjusted for confounding, we deemed these at moderate risk. Comparison 1: oncoplastic breast-conserving surgery (O-BCS) versus standard-BCS (S-BCS) The evidence in the review found that O-BCS when compared to S-BCS, may make little or no difference to local recurrence; either when measured as local recurrence-free survival (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.61 to 1.34; 4 studies, 7600 participants; very low-certainty evidence) or local recurrence rate (HR 1.33, 95% CI 0.96 to 1.83; 4 studies, 2433 participants; low-certainty evidence), but the evidence is very uncertain due to most studies not controlling for confounding clinicopathological factors. O-BCS compared to S-BCS may make little to no difference to disease-free survival (HR 1.06, 95% CI 0.89 to 1.26; 7 studies, 5532 participants; low-certainty evidence). O-BCS may reduce the rate of re-excisions needed for oncological resection (risk ratio (RR) 0.76, 95% CI 0.69 to 0.85; 38 studies, 13,341 participants; very low-certainty evidence), but the evidence is very uncertain. O-BCS may increase the number of women who have at least one complication (RR 1.19, 95% CI 1.10 to 1.27; 20 studies, 118,005 participants; very low-certainty evidence) and increase the recall to biopsy rate (RR 2.39, 95% CI 1.67 to 3.42; 6 studies, 715 participants; low-certainty evidence). Meta-analysis was not possible when assessing patient-reported outcomes or cosmetic evaluation; in general, O-BCS reported a similar or more favourable result, however, the evidence is very uncertain due to risk of bias in the measurement methods. Comparison 2: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy alone O-BCS may increase local recurrence-free survival compared to mastectomy but the evidence is very uncertain (HR 0.55, 95% CI 0.34 to 0.91; 2 studies, 4713 participants; very low-certainty evidence). The evidence is very uncertain about the effect of O-BCS on disease-free survival as there were only data from one study. O-BCS may reduce complications compared to mastectomy, but the evidence is very uncertain due to high risk of bias mainly resulting from confounding (RR 0.75, 95% CI 0.67 to 0.83; 4 studies, 4839 participants; very low-certainty evidence). Data on patient-reported outcome measures came from single studies; it was not possible to meta-analyse the data. Comparison 3: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy with reconstruction O-BCS may make little or no difference to local recurrence-free survival (HR 1.37, 95% CI 0.72 to 2.62; 1 study, 3785 participants; very low-certainty evidence) or disease-free survival (HR 0.45, 95% CI 0.09 to 2.22; 1 study, 317 participants; very low-certainty evidence) when compared to mastectomy with reconstruction, but the evidence is very uncertain. O-BCS may reduce the complication rate compared to mastectomy with reconstruction (RR 0.49, 95% CI 0.45 to 0.54; 5 studies, 4973 participants; very low-certainty evidence) but the evidence is very uncertain due to high risk of bias from confounding and inconsistency of results. The evidence is very uncertain for patient-reported outcome measures and cosmetic evaluation.

AUTHORS' CONCLUSIONS

The evidence is very uncertain regarding oncological outcomes following O-BCS compared to S-BCS, though O-BCS has not been shown to be inferior. O-BCS may result in less need for a second re-excision surgery but may result in more complications and a greater recall rate than S-BCS. It seems that O-BCS may give better patient satisfaction and surgeon rating for the look of the breast, but the evidence for this is of poor quality, and due to lack of numerical data, it was not possible to pool the results of different studies. It seems O-BCS results in fewer complications compared with surgeries involving mastectomy. Based on this review, no certain conclusions can be made to help inform policymakers. The surgical decision for what operation to proceed with should be made jointly between clinician and patient after an appropriate discussion about the risks and benefits of O-BCS personalised to the patient, taking into account clinicopathological factors. This review highlighted the deficiency of well-conducted studies to evaluate efficacy, safety and patient-reported outcomes following O-BCS.

Comparing Hypofractionated With Conventional Fractionated Radiotherapy After Breast-Conserving Surgery for Early Breast Cancer: A Meta-Analysis of Randomized Controlled Trials

Background

The purpose of this meta-analysis was to compare the safety and efficacy between hypofractionated and conventional fractionation radiotherapy in patients with early-stage breast cancer after breast-conserving surgery.

Methods

We conducted a comprehensive search of PubMed, Embase, Web of Science, and the Cochrane Library to identify relevant randomized controlled trials (RCTs) published before February 2021. At the same time, the hazard ratio (HR), risk ratio (RR), and 95% confidence interval (CI) were calculated to evaluate local recurrence (LR), relapse-free survival (RFS), overall survival (OS), adverse events, and cosmetic outcomes.

Results

A total of 14 articles were included in this meta-analysis. Four thousand eight hundred and sixty-nine patients were randomly assigned to the control group to receive conventional radiotherapy (CFRT); 6,072 patients were randomly assigned to the experimental group and treated with hypofractionated radiotherapy (HFRT). The results showed that there was no statistical difference between HFRT and CFRT in LR (HR = 0.99, 95%CI = 0.97-1.02, p = 0.476), RFS (HR = 0.99, 95%CI = 0.97-1.02, p = 0.485), OS (HR = 1.00, 95%CI = 0.97-1.03, p = 0.879), and cosmetic outcomes (RR = 1.03, 95%CI = 0.95-1.12, p = 0.53). In addition, HFRT showed fewer severe adverse reactions such as acute skin toxicity, induration, breast atrophy, and pain.

Conclusion

Our results suggest that there is no statistical difference between HFRT and CFRT in terms of LR, RFS, OS, and cosmetic outcomes. HFRT reduces the risk of developing toxicity reactions compared to CFRT. HFRT may be a better option for patients with early breast cancer after breast-conserving surgery.

Prediction of quality of life in early breast cancer upon completion of adjuvant chemotherapy

Quality of life (QoL) is a complex, ordinal endpoint with multiple conditioning factors. A predictive model of QoL after adjuvant chemotherapy can support decision making or the communication of information about the range of treatment options available. Patients with localized breast cancer (n = 219) were prospectively recruited at 17 centers. Participants completed the EORTC QLQ-C30 questionnaire. The primary aim was to predict health status upon completion of adjuvant chemotherapy adjusted for multiple covariates. We developed a Bayesian model with six covariates (chemotherapy regimen, TNM stage, axillary lymph node dissection, perceived risk of recurrence, age, type of surgery, and baseline EORTC scores). This model allows both prediction and causal inference. The patients with mastectomy reported a discrete decline on all QoL scores. The effect of surgery depended on the interaction with age. Women with ages on either end of the range displayed worse scores, especially with mastectomy. The perceived risk of recurrence had a striking effect on health status. In conclusion, we have developed a predictive model of health status in patients with early breast cancer based on the individual's profile.

What Does CATS Have to Do With Cancer? The Cognitive Activation Theory of Stress (CATS) Forms the SURGE Model of Chronic Post-surgical Pain in Women With Breast Cancer

Chronic post-surgical pain (CPSP) represents a highly prevalent and significant clinical problem. Both major and minor surgeries entail risks of developing CPSP, and cancer-related surgery is no exception. As an example, more than 40% of women undergoing breast cancer surgery struggle with CPSP years after surgery. While we do not fully understand the pathophysiology of CPSP, we know it is multifaceted with biological, social, and psychological factors contributing. The aim of this review is to advocate for the role of response outcome expectancies in the development of CPSP following breast cancer surgery. We propose the Cognitive Activation Theory of Stress (CATS) as an applicable theoretical framework detailing the potential role of cortisol regulation, inflammation, and inflammatory-induced sickness behavior in CPSP. Drawing on learning theory and activation theory, CATS offers psychobiological explanations for the relationship between stress and health, where acquired expectancies are crucial in determining the stress response and health outcomes. Based on existing knowledge about risk factors for CPSP, and in line with the CATS position, we propose the SURGEry outcome expectancy (SURGE) model of CPSP. According to SURGE, expectancies impact stress physiology, inflammation, and fear-based learning influencing the development and persistence of CPSP. SURGE further proposes that generalized response outcome expectancies drive adaptive or maladaptive stress responses in the time around surgery, where coping dampens the stress response, while helplessness and hopelessness sustains it. A sustained stress response may contribute to central sensitization, alterations in functional brain networks and excessive fear-based learning. This sets the stage for a prolonged state of inflammatory-induced sickness behavior - potentially driving and maintaining CPSP. Finally, as psychological factors are modifiable, robust and potent predictors of CPSP, we suggest hypnosis as an effective intervention strategy targeting response outcome expectancies. We here argue that presurgical clinical hypnosis has the potential of preventing CPSP in women with breast cancer.

The impact of mastectomy on body image and sexuality in women with breast cancer: a systematic review

Objective: The study aims to evaluate the impact of mastectomy on body image and sexuality of women with breast cancer, as well as to provide a general understanding of their quality of life. Method: This review followed the PRISMA guidelines. The expression “Mastectomy AND (sexuality OR “body image”)” was searched in Lilacs, Scielo, Pubmed and Scopus databases. Articles published in English, Portuguese and Spanish between 2010 and 2020 were selected. The text analysis was carried out by peers. Results: 69.3% (43) of the studies presented mastectomy as a technique that worsens body image, sexual functioning and quality of life of women. Less radical procedures, such as breast-conserving surgery, showed lower impact on these indicators. Breast reconstruction is an alternative to mitigate breast surgery impacts. Conclusion: Mastectomy caused the major impacts on body image, sexual functioning and quality of life. These implications need to be considered during therapeutic choice.

The impact of age on patient-reported outcomes after oncoplastic versus conventional breast cancer surgery

Purpose

Some studies have indicated age-specific differences in quality of life (QoL) among breast cancer (BC) patients. The aim of this study was to compare patient-reported outcomes after conventional and oncoplastic breast surgery in two distinct age groups.

Methods

Patients who underwent oncoplastic and conventional breast surgery for stage I-III BC, between 6/2011–3/2019, were identified from a prospectively maintained database. QoL was prospectively evaluated using the Breast-Q questionnaire. Comparisons were made between women < 60 and ≥ 60 years.

Results

One hundred thirty-three patients were included. Seventy-three of them were ≥ 60 years old. 15 (20.5%) of them received a round-block technique (RB) / oncoplastic breast-conserving surgeries (OBCS), 10 (13.7%) underwent nipple-sparing mastectomies (NSM) with deep inferior epigastric perforator flap (DIEP) reconstruction, 23 (31.5%) underwent conventional breast-conserving surgeries (CBCS), and 25 (34.2%) received total mastectomy (TM). Sixty patients were younger than 60 years, 15 (25%) thereof received RB/OBCS, 22 (36.7%) NSM/DIEP, 17 (28.3%) CBCS, and 6 (10%) TM. Physical well-being chest and psychosocial well-being scores were significantly higher in older women compared to younger patients (88.05 vs 75.10; p < 0.001 and 90.46 vs 80.71; p = 0.002, respectively). In multivariate linear regression, longer time intervals had a significantly positive effect on the scales Physical Well-being Chest (p = 0.014) and Satisfaction with Breasts (p = 0.004). No significant results were found concerning different types of surgery.

Conclusion

Our findings indicate that age does have a relevant impact on postoperative QoL. Patient counseling should include age-related considerations, however, age itself cannot be regarded as a contraindication for oncoplastic surgery.

Contrast of Mastoscopic and Conventional Axillary Lymph Node Dissection of Patients With Breast Cancer: Meta-Analysis

Mastoscopic axillary lymph node dissection (MALND) is a currently used and safe surgical treatment option for breast cancer. However, the extensive application of MALND is still debatable because of the use of conventional axillary lymph node dissection (CALND). Therefore, in the current study, we aimed to compare the efficacy and safety of MALND and CALND for obtaining evidence-based conclusions about the short-term and long-term outcomes of MALND for patients with breast cancer. PubMed, Web of Science, Cochrane Library, and CNKI were comprehensively searched for articles published between January 1998 and January 2019. Then Newcastle-Ottawa scale was used for quality assessment. The Review Manager software version 5.0 was utilized for generating forest maps and funnel plots. Twelve studies including 2157 patients were selected for the meta-analysis. There were no significant differences in the number of lymph node dissections, tumor recurrence rate, axillary drainage, postoperative hospitalization time, and tumor size between the MALND and CALND groups (P > .05). In the MALND group, the surgery time was longer, while the incidence of intraoperative bleeding was lesser and the duration of drainage was shorter than those in the CALND group (P < .01). The complications in the MALND group were also fewer than those in the CALND group (P < .05). The results of the current study showed that MALND is reliable and feasible for breast cancer owing to the lesser incidence of intraoperative bleeding, shorter drainage duration, and lower incidence of complications compared to CALND.

Assessment of the quality of life in breast cancer depending on the surgical treatment

PURPOSE

The objective of the study is to describe QoL in women who have undergone surgical treatment for breast cancer (BC). The focus of the description is the differences in QoL between women treated by modified radical mastectomy (MRM) and women who underwent breast-conserving surgery (BCS) at the Breast and Endocrine Surgery Department of the Clinical Center of Niš, Serbia.

METHOD

From January 1, 2014, until December 31, 2017, 300 patients were treated with BCS and 300 patients with MRM. To assess the QOL, a total of 600 BC patients completed the WHOQOL-BREF questionnaires. The results were analyzed using the t test and chi-square test. WHOQOL produces a quality of life profile. It derives four domain scores: physical health, psychological, social relationships, and environment. Social and demographic factors (age, education, marital status) were collected in both groups.

RESULT

In all four domains, patients treated with conserving surgeries scored higher than patients treated with radical mastectomy. This result was controlled for a set of demographic variables. The differences in QoL scores are present on all levels of controlling variables.

CONCLUSION

According to the results of this study, the QoL in women after an MRM is significantly lower than the QoL in women after BCS. It is especially true for the environment domain. Conserving surgery should be recommended and specific, and patient-centered interventions for increasing QoL of the patients who opted for radical mastectomy should be designed. The intervention should focus on social and environmental domains.

Breast-conserving surgery with intraoperative radiotherapy in recurrent breast cancer: the patient's perspective

Purpose

When ipsilateral breast-tumor recurrence (IBTR) following breast-conserving surgery (BCS) occurs, the cure of a potentially life-threatening disease is the main goal. If, however, this is diagnosed early, prognosis is still good and patient-reported outcomes become more important. Despite the fact that many patients would prefer a further BCS, international breast cancer guidelines still recommend mastectomy, mainly because previous radiation implies limited options. Our comparative study evaluates the long-term quality-of-life and outcome in patients with IBTR who received BCS plus intraoperative radiotherapy (IORT) versus mastectomy.

Methods

Patients with IBTR were retrospectively divided into three groups according to the local treatment: group 1 (n = 26) was treated with BCS + IORT; group 2 (n = 35) received a standard mastectomy; group 3 (n = 52) had a mastectomy with subsequent reconstruction. Outcomes were analyzed after a mean follow-up of 5 years after IBTR. Quality-of-life was evaluated by the validated questionnaire BREAST-Q in 50 patients who fulfilled the inclusion criteria.

Results

Quality-of-life scores varied within the groups, ranging from 51.4 to 91.3 (out of 100 points). We observed satisfactory scores in all items, with no statistical difference within the groups. Disease-free survival of all groups did not statistically differ, and overall mortality was very low (0.9%). The postinterventional complication rate was lower after BCS (19.2% versus 34.3% after mastectomy and 30.8% after mastectomy with reconstruction).

Conclusion

For patients with previous surgery and radiation who demand a second BCS in the recurrent situation, this surgical technique can be offered in combination with IORT. Our long-term results imply oncological safety, lower complication rate, and good patient satisfaction.

Skin-Reducing Mastectomy and Direct-to-Implant Breast Reconstruction With Submuscular-Dermal-Mesh Pocket

BACKGROUND

Despite skin-sparing mastectomy techniques have significantly improved reconstructive options and aesthetic outcomes, patients with large and ptotic breasts remain a challenging group to treat satisfactorily. The Wise-pattern skin-reducing mastectomy (SRM) has been designed for this kind of patients but is not without morbidity. To improve safety, the authors reviewed their experience with a modified SRM and immediate 1-stage implant-based breast reconstruction, using a synthetic absorbable mesh combined with a dermal flap.

METHODS

A retrospective review was undertaken to identify women with medium to large ptotic breast and medium minimally ptotic breast who had undergone SRM and direct-to-implant breast reconstruction using definitive anatomical gel implant, de-epithelialized dermal flap, and absorbable synthetic mesh, between October 2014 and December 2016. Patient demographics were queried, and complication rates, aesthetic outcomes, and patients satisfaction were assessed.

RESULTS

Sixty-two procedures of SRM were performed in 56 patients. Forty-five women received contralateral symmetrization. Twenty-one overall complications occurred in 16 patients. Statistical correlation between risk factors and complications onset was assessed. Body mass index resulted the most substantial risk factor (P = 0.0028) for developing complications, whereas preoperative chemotherapy (P = 0.0050) and comorbidities (P = 0.0117) played a decent role. Smoking attitude (P = 0.1122), age (P = 0.9990), and implant weight (P = 0.1583) did not result as significant risk factors. The reconstructive outcomes were good to excellent in 92.8%, with patient satisfaction ranking very to highly satisfied in 84%.

CONCLUSIONS

The authors' series suggests that SRM with direct-to-implant breast reconstruction can be easily performed when an appropriate SRM pattern is designed, providing complete implant coverage with submuscular-dermal-mesh pocket.

Health-related quality of life following breast reconstruction compared to total mastectomy and breast-conserving surgery among breast cancer survivors: a systematic review and meta-analysis

The present review evaluated health-related quality of life (HR-QoL) outcomes in surgical breast cancer survivors who received breast reconstruction (BR), breast-conservation surgery (BCS) or mastectomy (M), and whether HR-QoL domains across generic and disease/surgery-specific questionnaires are compatible. Six electronic databases were searched for appropriate observational studies. Standardized scores for different HR-QoL domains in the BR, BCS, and M treatment groups were extracted from each study for the purpose of a meta-analysis. Using Stata version 14.0, a random-effects meta-analysis model was adopted for each outcome variable to estimate the effect size, 95% CI-confidence intervals, and statistical significance. Sixteen of the 18 eligible studies with BR (n = 1474) and BCS (n = 2612) or M (n = 1458) groups were included in the meta-analysis. The BR group exhibited a better physical health (k = 12; 0.1, 95% CI 0.04, 0.24) and body image (k = 12; 0.50, 95% CI 0.10, 0.89) than the M group. However, the two groups exhibited comparable social health (k = 13; 0.1, 95% CI -0.07, 0.37), emotional health (k = 13; -0.08, 95% CI - 0.41, 0.25), global health (k = 7; 0.1, 95% CI - 0.01, 0.27), and sexual health (k =11; 0.2, 95% CI - 0.02,0.57). There was no clear evidence of the superiority of BR to BCS for all the six domains. These results suggest that HR-QoL outcomes in BR and BCS groups are better than the M group. Therefore, women opting for BR or BCS are likely to report fairly better HR-QoL outcomes than M. However, due to the significant heterogeneity observed in most BR versus BCS outcomes, developing a unified questionnaire incorporating both breast/surgery-specific and generic HR-QoL domains is warranted.

Physical Activity of Women After Radical Unilateral Mastectomy and Its Impact on Overall Quality of Life

Radical unilateral mastectomy is an acknowledged source of traumatic experience for women, adversely affecting their behavioral and emotional paradigm. The present study aimed to assess the quality of life in physically active and inactive postmastectomy women. Population sample involved 100 women, aged 50 to 60 years, having undergone radical unilateral mastectomy, allocated into 2 groups, upon assumption of undertaking physical activity. The abbreviated version of WHOQOL-BREF questionnaire was a research tool of choice. The data were analyzed with the aid of χ² test, Kruskal-Wallis test, and Mann-Whitney U test. Statistically significant dependence was established between physical activity actually pursued and self-assessment of overall quality of life (P = .014) and overall the self-rated perception of health (P < .001). In the group of physically inactive women, physical health was a variable dependent upon individual level of education (P = .031). The highest scores in this domain were noted in the women boasting secondary education, whereas the lowest in the ones with vocational education. Social domain was the highest rated aspect of quality of life in both the physically active and inactive postmastectomy women, while the physical health domain was rated the lowest. Both in the case of physically active and inactive postmastectomy women, the quality of life in the respective domains, as listed in the WHOQOL-BREF questionnaire, was found independent of the living environment.

Influence of socioeconomic status on immediate breast reconstruction rate, patient information and involvement in surgical decision-making

Background

Immediate breast reconstruction (IBR) rates in breast cancer differ between healthcare regions in Sweden. This is not explained by regional differences in patient age distribution or tumour characteristics, but by differences in patient‐reported information and patient involvement in the decision‐making process. As socioeconomic status may play a significant role in surgical decision‐making, its potential associations with IBR rates were analysed.

Methods

Women who had undergone therapeutic mastectomy for primary breast cancer in Sweden in 2013 were included in the analysis. Tumour and treatment data were retrieved from the Swedish National Breast Cancer Register, and socioeconomic background data from the Central Bureau of Statistics Sweden. Postal questionnaires regarding information about reconstruction and perceived involvement in the preoperative decision‐making process had been sent out in a previous survey.

Results

In addition to regional differences, lower tumour and nodal category, independent factors increasing the likelihood of having IBR for the 3131 women in the study were living without a registered partner, having current employment and high income per household. Patient‐reported perceived preoperative information (odds ratio (OR) 12·73, 95 per cent c.i. 6·03 to 26·89) and the feeling of being involved in the decision‐making process (OR 2·56, 1·14 to 5·76) remained strong independent predictors of IBR despite adjustment for socioeconomic factors. Importantly, responders to the survey represented a relatively young and wealthy population with a lower tumour burden.

Conclusion

Several socioeconomic factors independently influence IBR rates; however, patient‐reported information and involvement in the surgical decision‐making process remain independent predictors for the likelihood of having IBR.

Does Quality of Life Among Modified Radical Mastectomy and Breast Conservation Surgery Patients Differ? A 5-Year Comparative Study

Breast cancer is the most common cancer among females worldwide, of whom more than 80% survive for more than 5 years. Hence, ensuring a good quality of life (QOL) is essential to achieve holistic approach in treating patients. A cross-sectional study was conducted to compare the QOL in women who underwent modified radical mastectomy (MRM) and breast conservation surgery (BCS) for breast cancer in the last 5 years. QOL was evaluated based on the long-term quality of life-breast cancer (LTQOL-BC) questionnaire. A greater percentage of women who underwent MRM complained of difficulty in completing their house work compared with the BCS group (50% compared with 31%). Twenty-five percent (6) of the women who had undergone MRM reported feeling of being incomplete as women, along with a lack of femininity. However, more than 80% of the women in both groups said that they felt stronger as survivors and derived strength from their experience. There were significant differences in the quality of life of women from both groups in terms of physical function and body image, with the BCS group appearing to have a better QOL.

Comparing Quality of Life in Breast Cancer Patients Who Underwent Mastectomy Versus Breast-Conserving Surgery: A Meta-Analysis

: The purpose of our study was to carry out a meta-analysis of current literature to determine whether total mastectomy and breast-conserving surgery induce different outcomes in quality of life, based on the breast-cancer-specific module of the European Organizaation for Research and Treatment of Cancer core questionnaire (EORTC QLQ-BR23) used postoperatively. A systematic literature search of PubMed and EMBASE was conducted. Observational clinical studies that compared the quality of life in different surgery groups and presented empirical findings were selected. Six studies met the inclusion criteria. Breast-conserving surgery has statistically significant better outcomes than mastectomy in three of the eight outcomes measured in the EORTC QLQ-BR23, namely body image (standard mean difference, SMD = 1.742, 95% CI 0.579-2.905, p = 0.003), future perspective (SMD = 0.606, 95% CI 0.075-1.138, p = 0.025) and systemic therapy side effects (SMD = -0.641, 95% CI 0.101-1.181, p = 0.020). Our study highlighted that breast-conserving surgery was preferred over mastectomy because breast-conserving surgery leads to better outcomes in body image, future perspectives and less systemic side effects.

Psychosocial Functioning in Women with Early Breast Cancer Treated with Breast Surgery With or Without Immediate Breast Reconstruction

PURPOSE

To compare psychosocial function outcomes in early breast cancer patients treated with breast-conserving surgery (BCS), mastectomy alone (MA), and mastectomy with immediate breast reconstruction (IBR) at 1 year after surgery.

METHODS

Early-stage (stage 0-2) breast cancer patients treated with BCS, MA, and IBR at the University Health Network, Toronto, Ontario, Canada between May 1 2015 and July 31 2016 were prospectively enrolled. Their changes in psychosocial functioning from baseline to 12 months following surgery were compared by using the BREAST-Q, Hospital Anxiety and Depression Scale, and Impact of Event Scale with ANOVA and linear regression.

RESULTS

There were 303 early-stage breast cancer patients: 155 underwent BCS, 78 MA, and 70 IBR. After multivariable regression accounting for age, baseline score, income, education, receipt of chemoradiation or hormonal therapy, ethnicity, cancer stage, and unilateral versus bilateral surgery, breast satisfaction was highest in BCS (72.1, SD 19.6), followed by IBR (60.0, SD 18.0), and MA (49.9, SD 78.0) at 12 months, p < 0.001. Immediate breast reconstruction had similar psychosocial well-being (69.9, SD 20.6) compared with BCS (78.5, SD 20.6), p = 0.07. Sexual and chest physical well-being were similar between IBR, BCS, and MA, p > 0.05.

CONCLUSIONS

Our study found that in a multidisciplinary breast cancer centre where all three breast ablative and reconstruction options are available to early breast cancer patients, either BCS or IBR can be used to provide patients with a higher degree of satisfaction and psychosocial well-being compared with MA in the long-term.

Quality of life after oncoplastic breast-conserving surgery: a systematic review

BACKGROUND

Oncoplastic breast-conserving surgery (OBCS) has gained increasing attention as a treatment option for early breast cancer patients, aiming to achieve the best possible breast symmetry with concomitant oncological safety. This paper aims to systematically review the current literature on patient quality of life (QoL) after OBCS compared with QoL after breast-conserving surgery (BCS) alone.

METHODS

MEDLINE via Ovid, CINAHL via EBSCO and PsycINFO via OvidSP were searched to retrieve all relevant studies. The reference lists of identified eligible studies were manually examined to search for additional eligible studies. The methodological quality of the included studies was assessed using the Critical Appraisal Skills Programme.

RESULTS

A total of six articles met the inclusion criteria. Most of the studies used validated patient-reported outcome measures for assessing QoL with good response rates. However, only one study was of sufficiently good quality to provide good evidence (P < 0.05) in favour of OBCS, while the remainder were of low to moderate quality with differences in outcomes that were not statistically significant.

CONCLUSION

The review found that the current evidence base is limited and not adequate enough to support or to reject the assumption that OBCS is associated with improved QoL when compared with QoL post-BCS. However, the majority of studies show that OBCS is associated with a trend towards better patient QoL. The impact of OBCS on patient QoL needs to be more adequately investigated. Large prospective cohort studies to assess the impact of OBCS on QoL compared with QoL post-BCS are strongly recommended.

Persistent disparities in breast cancer surgical outcomes among hispanic and African American patients

BACKGROUND

Racial disparities among patients who receive breast mastectomy and reconstruction have not been well characterized.

METHODS

Records of patients undergoing breast extirpative and reconstructive surgery at a high-volume university-affiliated hospital over 5 consecutive years were reviewed. Patient demographics, breast cancer profiles, reconstructive modality, and outcomes were compared by race.

RESULTS

A total of 1045 patients underwent 1678 breast reconstructions during the five-year period. Mean age and standard deviation was 49.8 ± 10.6 years with a BMI of 27.9 ± 6.5. Hispanic and African American patients had significantly higher BMIs (p < 0.001), higher rates of ASA class III or IV (p = 0.025), obesity, diabetes, hypertension (p < 0.001 for these three comparisons), and smoking (p = 0.003), and had more prior abdominal surgeries (p = 0.007). Comparing oncologic characteristics, this population subset had higher rates of neoadjuvant chemotherapy (p = 0.036), history of radiation (p = 0.016), and were more likely to undergo modified radical mastectomy (p = 0.002) over nipple-sparing mastectomy (p = 0.035). Reconstructive complications revealed a higher overall complication rate (p = 0.023), higher rates of partial mastectomy flap necrosis (p = 0.043), as well as arterial (p = 0.009) and venous insufficiency (p = 0.026) during microvascular reconstruction among Hispanic and African American patients.

CONCLUSIONS

Compared to other patients, the present study identifies higher comorbidity burdens, higher rates of prior radiation and neoadjuvant chemotherapy, and higher post-surgical complication rates among Hispanic and African American patients with breast cancer.

Health-related quality of life of breast cancer patients in the Eastern Mediterranean region: a systematic review and meta-analysis

PURPOSE

Breast cancer is the most common type of cancer in women around the world, and this applies to the Middle East as well. The goal of all medical care and treatment is to improve the quality of life (QoL) of patients. Accordingly, the present study aimed at evaluating the QoL of patients with breast cancer in the Middle East region.

METHODS

In this meta-analysis, three electronic databases (PubMed, Web of Science, and Scopus) were searched from inception until August 2018. The hoy et tool was used to evaluate the quality of the articles included in the meta-analysis. The search, screening, quality evaluation, and data extraction were carried out by two of the researchers.

RESULTS

Thirty-six studies conducted on 8347 Middle Eastern women with breast cancer entered the final stage. QoL was assessed by the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire in 20 studies, with 6034 patients. The mean of the reported QoL was between 31.1 and 75.6. Based on the results of the random effect method, the overall mean of the QoL was 60.5 (95% confidence interval 56.0, 65.0; I2 = 99.0%). In six studies performed on 1053 individuals, QoL was classified as good, moderate, or poor. Less than one-third of patients (21%) had a good QoL.

CONCLUSIONS

Since less than one-third of patients had a good QoL, it seems necessary to design and implement an integrated and multidimensional educational program to improve QoL of patients with breast cancer.

Development and psychometric evaluation of a Dutch-translated shorter Breast Cancer Treatment Outcome Scale (Dutch BCTOS-13)

PURPOSE

To create a Dutch translated short version of the Breast Cancer Treatment Outcome Scale (BCTOS) and validate it in patients who have completed both breast conserving surgery and adjuvant radiotherapy.

METHODS

The BCTOS consists of items comparing the treated with the untreated breast. After forward and backward translation, we tested the BCTOS-12 plus 5 additional items. Two-hundred breast cancer patients treated with breast conserving therapy (BCT) between January 2016 and December 2017, were asked to complete the BCTOS items twice with a 2 week interval. The EORTC QLQ-BR23 breast and arm symptoms subscales were completed once in parallel. Feasibility was assessed by missing or non-unique answer rates and content validity with floor and ceiling effect analysis. Construct validity was evaluated with 1) principal component analysis (PCA) 2) convergent validity and 3) known groups comparison (clinical validity differentiating between patients with and without locoregional side effects). From all potential items with good feasibility, content and construct validity, items were selected for the Dutch BCTOS based on clinical validity. The relation to the EORTC QLQ-BR23 subscales and reliability was tested for the new Dutch BCTOS.

RESULTS

Hundred and one of 200 (50.5%) approached patients participated in this study, with follow-up after surgery ranging from 5 to 29 months. Feasibility was high (1.5% missing answers). Content validity testing showed a floor effect > 20% in all 17 items. PCA showed that all items loaded well (> 0.4) into the assigned subscale and revealed two distinct subscales: cosmesis and function. Based on clinical validity, item "breast shape" was replaced by "breast elevation/position" and "overall skin appearance". Very good clinical validity (Cohen's d = 1.38) was found for the new Dutch BCTOS-13. Correlation to the EORTC QLQ-BR23 subscales was high (ICC = 0.65-0.85) for both subscales. Test-retest reliability (Cohen's d = 0.105) and internal consistency (Cronbach's α =0.90) were excellent.

CONCLUSIONS

Psychometric evaluation of a newly developed Dutch BCTOS-13 questionnaire in BCT patients showed excellent results, that were slightly better than the original BCTOS-22 and the shortened BCTOS-12. The good clinical validity makes the BCTOS-13 a useful tool to identify patients with unfavourable cosmetic and functional outcomes, requiring specific attention.

[Assessment of patient satisfaction following nipple-areolar complex tattooing after breast reconstruction.]

INTRODUCTION

Nipple-areolar complex tattooing often completes the breast mound reconstruction process after cancer surgery. However, there have been few studies evaluating patient satisfaction with this technique.

OBJECTIVE

To assess patients' esthetic satisfaction with the results of tattooing performed by nurses.

METHOD

Ninety-eight women participated in the study. Overall satisfaction with reconstruction and satisfaction with the tattoo's color, dimension, position, and form were determined using questionnaires completed by patients and a professional jury.

RESULTS

97% of patients reported overall satisfaction with the results of nipple-areolar reconstruction. The satisfaction rate with the tattoo's color was 67%, with dimension 96%, with form 95%, and with position 94%. The satisfaction rates of the jury were as follows: nipple-areolar reconstruction 79%; color 52%; dimension 77%; form 75%; and position 69%.

DISCUSSION

On the whole, the patients were satisfied with the results one year after tattooing and their satisfaction rate was higher than that of the jury's. Only 6.1% of women required a second tattoo because of discoloration.

CONCLUSION

Nipple-areolar complex tattooing has a high rate of patient esthetic satisfaction and can be performed by a trained nurse without the need for hospital admission.

Distress Among Locally Advanced Breast Cancer Patients from Diagnosis to Follow-Up: A Critical Review of Literature

OBJECTIVE

This critical review used a systematic approach to explore the prevalence of distress among locally advanced breast cancer (LABC) patients along their treatment journey. This review explored the domains of distress (psychosocial, physical and/or practical) that are significant to this patient population and determined indications for psychosocial support throughout the patients' treatment.

METHODS

Electronic databases including CINAHL, EmBase, Medline PsycInfo, and gray literature were searched from the year 2000 to 2016, to produce relevant literature. A critical review was conducted on 73 articles meeting the inclusion and exclusion criteria. A narrative synopsis was used to summarize the findings under key themes.

RESULTS

The results indicate that 16/73 studies assessed for distress in all three domains of distress throughout the treatment course. A meta-analysis was not possible due to the methodological heterogeneity of the articles, the variation of assessment tools used, timing in which the assessments were done, and the different treatment modalities. Distress was prevalent from the time of diagnosis, through treatment, and into survivorship. Sexuality, body image, age, financial difficulty, family/social support, and informational needs were common themes that emerged among the LABC population in these studies.

CONCLUSIONS

Comprehensive assessments incorporating all three domains of distress with the appropriate tools will assist health care professionals throughout the complicated treatment trajectory of LABC patients in taking a more proactive approach in assisting patients' concerns and preventing undue or increase in psychological distress during or after active treatment. This will encourage effective patient-centered communication and supportive care referrals for a better patient experience.

Health-related quality of life in Asian patients with breast cancer: a systematic review

OBJECTIVE

To summarise the evidence on determinants of health-related quality of life (HRQL) in Asian patients with breast cancer.

DESIGN

Systematic review conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations and registered with PROSPERO (CRD42015032468).

METHODS

According to the PRISMA guidelines, databases of MEDLINE (PubMed), Embase and PsycINFO were systematically searched using the following terms and synonyms: breast cancer, quality of life and Asia. Articles reporting on HRQL using EORTC-QLQ-C30, EORTC-QLQ-BR23, FACT-G and FACT-B questionnaires in Asian patients with breast cancer were eligible for inclusion. The methodological quality of each article was assessed using the quality assessment scale for cross-sectional studies or the Newcastle-Ottawa Quality Assessment Scale for cohort studies.

RESULTS

Fifty-seven articles were selected for this qualitative synthesis, of which 43 (75%) were cross-sectional and 14 (25%) were longitudinal studies. Over 75 different determinants of HRQL were studied with either the EORTC or FACT questionnaires. Patients with comorbidities, treated with chemotherapy, with less social support and with more unmet needs have poorer HRQL. HRQL improves over time. Discordant results in studies were found in the association of age, marital status, household income, type of surgery, radiotherapy and hormone therapy and unmet sexuality needs with poor global health status or overall well-being.

CONCLUSIONS

In Asia, patients with breast cancer, in particular those with other comorbidities and those treated with chemotherapy, with less social support and with more unmet needs, have poorer HRQL. Appropriate social support and meeting the needs of patients may improve patients' HRQL.

Effect of resveratrol on doxorubicin resistance in breast neoplasm cells by modulating PI3K/Akt signaling pathway

In the study, we probed into the effect of Resveratrol (RES) on Doxorubicin (DOX)-resistant breast neoplasm cell line MCF-7/DOX as well as the mechanism of RES underlying the DOX-resistant breast cancer. CCK-8 assay was utilized to assess the survival rates and sensitivity of breast neoplasm cell lines MCF-7 or MDA-MB-231 to DOX and RES. DOX-resistant MCF-7 cell line was successfully cultivated with DOX dose increasing and was named MCF-7/DOX. Afterwards, wound healing and Transwell assays were performed to measure the migration and invasion capabilities of MCF-7/DOX cells, while cell propagation and apoptosis were determined by colony formation assay and flow cytometry analysis. Both western blotting and immunohistochemistry were conducted to examine the expression of proteins involved in PI3K/Akt signaling pathway. Nude mice xenograft model was constructed to further verify the effects of DOX and RES on breast neoplasm in vivo. RES restored DOX sensitivity in MCF-7/DOX cells, inhibiting biological functions of MCF-7/DOX cells and promoting cell apoptosis in vitro and impeding tumor growth in vivo. It was revealed by the mechanistic studies that MCF-7/DOX cells could regain the drug sensibility with RES treatment through inactivating the PI3K/Akt signal transduction pathway. RES could reverse DOX resistance in breast neoplasm cells and inhibited DOX-resistant breast cancer cell propagation and metastasis and facilitated cell apoptosis by modulating PI3K/Akt signaling pathway. © 2018 IUBMB Life, 70(6):491-500, 2018.

TEMPO SENTADO, IMAGEM CORPORAL E QUALIDADE DE VIDA EM MULHERES APÓS A CIRURGIA DO CÂNCER DE MAMA

RESUMO Introdução: A cirurgia é uma das modalidades de tratamento do câncer de mama e pode ser conservadora ou radical. Esse tipo de tratamento pode trazer alterações físicas e psicológicas para a vida das pacientes. Objetivo: Analisar a influência da cirurgia radical e conservadora sobre o tempo sentado, a imagem corporal e a qualidade de vida de mulheres após diagnóstico do câncer de mama. Métodos: Participaram 172 mulheres que foram submetidas à cirurgia radical ou conservadora do câncer de mama. Aplicou-se um questionário contemplando características pessoais, medidas antropométricas, nível econômico (IBGE), características da doença, tempo sentado (IPAQ - versão curta), imagem corporal (BIBCQ) e qualidade de vida (EORTC QLQ-C30 + QLQ BR - 23). Para a análise estatística, utilizou-se o teste do Qui-quadrado ou o teste exato de Fisher e o teste t de Student para amostras independentes e o teste U de Mann-Whitney. Resultados: As mulheres que foram submetidas à cirurgia radical apresentaram maior tempo sentado nos finais de semana, mais relatos de linfedema, piores escores de qualidade de vida (função física, dor, escala funcional, imagem corporal e sintomas no braço) e pior imagem corporal (vulnerabilidade, estigma, limitações, transparência e preocupações com o braço). Conclusão: O tipo de cirurgia pode influenciar o tempo sentado e aspectos da imagem corporal e da qualidade de vida, com piores escores para as mulheres submetidas à cirurgia radical.

Quality of life in patients with recurrent breast cancer after second breast-conserving therapy in comparison with mastectomy: the German experience

BACKGROUND

Although some studies suggest that breast-conserving therapy (BCT) shows better psychosocial outcomes than mastectomy in patients with primary breast cancer, little is known about the outcomes of these surgical options in recurrent breast cancer. We investigated differences in overall survival and re-recurrence rates as well as psychosocial outcomes among patients who underwent BCT or mastectomy after the diagnosis of recurrent breast cancer in a single-center setting.

METHODS

124 of 186 eligible patients who underwent surgical treatment for breast cancer recurrence completed the questionnaires on quality of life (EORTC QLQ-C30 and -BR23), fear of progression (PA-F-KF), anxiety and depression (HADS), and body image (BIS).

RESULTS

Women after breast-conserving surgery (n = 46) showed significantly better outcomes than women after mastectomy (n = 61) with respect to body image (P < 0.001 in BIS and p < 0.001 in BR23), social functioning (p = 0.016), emotional functioning (p = 0.028), and role functioning (p = 0.043). There were no significant group differences regarding anxiety, depression, and fear of progression as well as re-recurrence and survival rates. Predictors of good quality of life were partnership (OR 2.46), higher monthly family income (OR 3.54), and higher professional qualification (OR 4.3) in our group of patients.

DISCUSSION

Our results indicate that patients treated with breast-conserving therapy after recurrent breast cancer perceive lower impairments in body image and several aspects of quality of life than patients treated with mastectomy.

Sexuality after breast cancer: cultural specificities of Tunisian population

INTRODUCTION

Women's sexuality may be particularly affected after breast cancer. The objectives of this study were to evaluate the changes in sexual life after treatment of breast cancer in Tunisian women and to identify the influence of demographic and clinical factors on sexuality.

METHODS

We recruited 50 patients who were in remission for at least 3 months after initial treatment of breast cancer. Sexuality and body image were evaluated using the Arabic version of the specific scale of breast cancer QLQ-BR23. Screening for emotional disorders has been done with the Arabic version of HAD scale (Hospital anxiety and depression scale).

RESULTS

Patients had poor sexual functioning and sexual satisfaction and the mean scores were respectively 45.3% and 43.9%. Only menopausal status and sexual difficulties in the partner was significantly related to poorer sexual satisfaction (p respectively 0.018 and 0.014). According to the HAD scale, 42% of patients had anxiety and 44% had depression. The sexual satisfaction was statistically associated with the presence of anxiety symptoms (p=0.0003).

CONCLUSION

Results suggest that the psychological side and the sexual difficulties in partner are the most important factors that appear to be involved in sexual satisfaction of Tunisian women after breast cancer. So, those factors need to be taken into account in therapeutic process and psychological counseling to maintain and enhance patient's psychological well-being.

Breast reconstruction after mastectomy: does it decrease depression at the long-term?

BACKGROUND

Depression is associated with breast cancer survivors in 22%. Although breast reconstruction (BR) is intended to provide psychological improvements such as reducing depression, literature is inconclusive and without long-term follow-up. The objective is to evaluate the impact of BR after breast cancer related mastectomy on the long-term depression risk and assess predictive factors for depression.

METHODS

Women who underwent a curative mastectomy between 1999 and 2009 were included. After a mean follow-up of more than 6 years after operation, the Beck Depression Inventory-13 (BDI-13) evaluated depressive symptoms. Multivariable regression analysis provided predictors for depression.

RESULTS

A total of 139 patients, 34 (24.5%) with and 105 (75.5%) without BR, were analyzed. Seventy-seven patients (48.2%) were at high risk for mild (n=58), moderate (n=5) or severe (n=4) depression. There was a trend for slightly better BDI-13 outcomes for women who underwent BR (2 vs. 4; P=0.06). Living alone [odds ratio (OR): 2.16; P=0.04], low educational level (OR: 3.70; P<0.01) and adjuvant hormonal/endocrine-therapy (OR: 2.36; P=0.02) were associated with an increased depression risk.

CONCLUSIONS

BR has no clear influence on depressive symptoms on the long-term. Predictive factors should alert clinicians to assess depressive symptoms in specific breast cancer patients during follow-up.

National study of the impact of patient information and involvement in decision-making on immediate breast reconstruction rates

Background

Reconstructive alternatives should be discussed with women facing mastectomy for breast cancer. These include immediate and delayed reconstruction, which both have inherent advantages and disadvantages. Immediate reconstruction rates vary considerably in Swedish healthcare regions, and the aim of the study was to analyse reasons for this disparity.

Methods

All women who underwent mastectomy for primary breast cancer in Sweden in 2013 were included. Tumour data were retrieved from the Swedish National Breast Cancer Registry and from questionnaires regarding patient information and involvement in preoperative decision‐making sent to women who were still alive in 2015.

Results

Of 2929 women who had undergone 2996 mastectomies, 2906 were still alive. The questionnaire response rate was 76·3 per cent. Immediate reconstruction rates varied regionally, between 3·0 and 26·4 per cent. Tumour characteristics impacted on reconstruction rates but did not explain regional differences. Patient participation in decision‐making, availability of plastic surgery services and patient information, however, were independent predictors of immediate breast reconstruction, and varied significantly between regions. Even in younger patients with low‐risk tumours, rates of patient information ranged between 34·3 and 83·3 per cent.

Conclusion

Significant regional differences in immediate reconstruction rates were not explained by differences in tumour characteristics, but by disparities in patient information, availability of plastic surgery services and involvement in decision‐making.

Information is key

Geographical Inequalities in Surgical Treatment for Localized Female Breast Cancer, Queensland, Australia 1997-2011: Improvements over Time but Inequalities Remain

The uptake of breast conserving surgery (BCS) for early stage breast cancer varies by where women live. We investigate whether these geographical patterns have changed over time using population-based data linkage between cancer registry records and hospital inpatient episodes. The study cohort consisted of 11,631 women aged 20 years and over diagnosed with a single primary invasive localised breast cancer between 1997 and 2011 in Queensland, Australia who underwent either BCS (n = 9223, 79%) or mastectomy (n = 2408, 21%). After adjustment for socio-demographic and clinical factors, compared to women living in very high accessibility areas, women in high (Odds Ratio (OR) 0.58 (95% confidence intervals (CI) 0.49, 0.69)), low (OR 0.47 (0.41, 0.54)) and very low (OR 0.44 (0.34, 0.56)) accessibility areas had lower odds of having BCS, while  the odds for women from middle (OR 0.81 (0.69, 0.94)) and most disadvantaged (OR 0.87 (0.71, 0.98)) areas was significantly lower than women living in affluent areas. The association between accessibility and the type of surgery reduced over time (interaction p = 0.028) but not for area disadvantage (interaction p = 0.209). In making informed decisions about surgical treatment, it is crucial that any geographical-related barriers to implementing their preferred treatment are minimised.

Using Multilevel Models to Explain Variation in Clinical Practice: Surgeon Volume and the Surgical Treatment of Breast Cancer

PURPOSE

To investigate the relationship between surgeon caseload and surgery type, and variation in the surgical treatment of early stage breast cancer patients in Alberta, Canada.

METHODS

All women diagnosed with stage I to III breast cancer in Alberta from 2002 to 2010 were identified from the Alberta Cancer Registry. Type of surgery, surgeon (anonymized), and hospital were obtained from provincial physician claims data. Multilevel logistic regression with surgeons and hospitals as crossed random effects was used to estimate adjusted odds ratios (OR) of receiving mastectomy by surgeon volume. Empirical Bayes estimation was used to estimate adjusted OR for individual surgeons and hospitals.

RESULTS

Mastectomy was found to be inversely related to surgeon volume among stage I and II patients. Patients whose surgery was conducted by a low-volume surgeon had twice the odds of receiving mastectomy as those that had surgery performed by a very high-volume surgeon (stage I OR 2.36, 95 % confidence interval 1.40, 3.97; stage II OR 1.96, 95 % confidence interval 1.13, 3.42). OR of mastectomy varied widely by individual surgeon beyond the variation explained by the factors investigated.

CONCLUSIONS

Surgeon characteristics, including surgeon volume, are associated with surgery type received by breast cancer patients in Alberta. Significant variation in the likelihood of breast-conserving surgery (BCS) by surgeon is concerning given the potential benefits of BCS for those who are eligible.

Accelerated partial breast irradiation: a review and evaluation of indications for treatment

Accelerated partial breast irradiation (APBI) represents a well-studied treatment modality for the delivery of adjuvant radiation therapy following breast-conserving surgery. Interstitial APBI represents the APBI technique with the longest follow-up to date; data from randomized trials and matched pair analyses demonstrate equivalent local control to traditional whole-breast irradiation with comparable rates of toxicity and improved cosmesis. While less mature, prospective data support the efficacy and safety of applicator-based brachytherapy with new multilumen applicators offering the potential for improved outcomes. External beam APBI represents a noninvasive technique; however, concerns regarding toxicity with this technique have emerged though newer techniques may mitigate these concerns. Multiple guidelines have been published based on traditional clinical and pathologic criteria to help physicians offer APBI to appropriately selected patients.