Preoperative psychosocial characteristics may predict body image and sexuality two years after risk-reducing mastectomy: a prospective study

The impact of prophylactic mastectomy on sexual well-being: a systematic review

INTRODUCTION

Considering the increasing women's awareness of health promotion and disease prevention programs, mutation carriers are inevitably asked to face important decisions concerning the possibility of undergoing prophylactic mastectomy. Risk-reducing mastectomy (RRM) has become increasingly more common, although it has a significant impact on women's quality of life and sexual well-being.

OBJECTIVES

The systematic review aims to evaluate the impact of RRM on the sexuality of women with breast cancer.

METHODS

According to Cochrane Collaboration guidelines and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, the study quantified the effects of frontline work on the mental health of healthcare workers. This review followed the PRISMA guidelines. Three databases were systematically searched from inception to December 2022. The expression ("sexuality" OR "sexual" OR "sex") AND ("prophylactic mastectomy" OR "risk-reducing mastectomy") was searched in PubMed, Ovid Medline, and Embase. Twenty-two articles published in English until 2022 were selected.

RESULTS

Two studies investigated sexual experience after risk-reducing surgeries as a single outcome, while other studies analyzed the relationship between sexuality and psychosocial outcomes, risk perception, and satisfaction. In all of the included studies, significant findings in sexual dysfunction were found. The most reported problems were related to sexual satisfaction and attractiveness, body image, and loss of femininity. Last, women reported changes in the relationship with their partners.

CONCLUSION

RRM has a major impact on body image that affects sexual functioning and quality of life. These implications must be considered during treatment selection.

Prospective examination of psychological risk and maintenance factors for body image distress after mastectomy with immediate breast reconstruction

Reconstructive breast surgery aims to improve body image following mastectomy, yet many women experience ongoing body image distress (BID). The relationship between the esthetic outcome of reconstructive surgery with BID has been underexplored in mastectomy. This study aimed to assess whether reconstruction outcome following mastectomy is associated with post-surgery BID, and to examine potential psychological risk and maintenance factors for BID above reconstruction outcome. In 49 women undergoing mastectomy with immediate breast reconstruction, we prospectively assessed hypothesized pre-surgery psychological risk factors and post-surgery maintenance factors for post-surgery BID. Reconstruction outcome was assessed via blind surgeon ratings of post-surgery photographs. Surgeon-rated reconstruction outcome was uncorrelated with BID, or with patients' ratings of surgical outcome. Higher pre-surgery depressive symptoms and lower pre-surgery patient expectations for reconstruction predicted greater post-surgery BID, above reconstruction outcome. Post-surgery body checking also predicted greater BID, above reconstruction outcome. Results suggest that the medical team cannot assume their perception of reconstruction outcome matches the patient's view or degree of BID. If replicated, results point to potential psychological risk and maintenance factors that are stronger predictors of post-reconstruction BID, highlighting opportunities for light-touch prevention and intervention to reduce BID after mastectomy with breast reconstruction.

Breast cancer genetic mutation: Synthesis of women's experience

AIMS AND OBJECTIVES

To systematically identify and synthesise the experiences reported by women with a breast cancer mutation who do not have cancer as reported in qualitative research published between 2013 and 2020.

BACKGROUND

Women carrying a BReast CAncer (BRC) genetic mutation have an increased risk for breast and ovarian cancer. They must engage in emotional decision-making regarding risk management strategies to prevent cancer, including risk-reducing bilateral mastectomy and bilateral salpingo-oophorectomy.

DESIGN AND METHODS

The ENTREQ statement guided this review. Eight databases were systematically searched (CINAHL, Pubmed, Embase, Psychinfo [Ovid], Web of Science, Scopus, Proquest and Lenus). Synthesis was guided by "best fit" framework. The Critical Appraisal Skills Programme guided assessment of methodological limitations and confidence in the review findings was informed by GRADE-CERQual.

RESULTS

Twenty studies met the inclusion criteria for synthesis. Six themes were synthesised from the included studies (anxiety; family planning; it's a family affair; empowerment; actions; pragmatic adjustments).

CONCLUSIONS

The multidimensional experiences of women living with a BRCA1/2 mutation require an individualised response based on women's needs at their life stages. A decision coaching model adopted during consultations could support women to guide decision-making regarding cancer risk-reducing strategies.

Preoperative Body Image Factors Are Associated with Complications after Breast Reconstruction

BACKGROUND

Psychological factors are broadly understood to contribute to overall health, but their contribution to wound healing is less well defined. Limited data exist on the association of preoperative psychological factors such as body image and postoperative complications. The present study analyzed the association between preoperative body image factors and postoperative complications following breast reconstruction.

METHODS

This was a prospective cohort study of 302 breast cancer patients undergoing breast reconstruction from 2011 to 2015. All patients completed the BREAST-Q; demographics, surgical details, and postoperative complications were recorded. The association of body image factors by means of the BREAST-Q and postoperative complications was analyzed.

RESULTS

On univariate analysis, patients who reported lower preoperative satisfaction with how they appeared in the mirror unclothed, or felt less self-confident or attractive, were significantly more likely to develop an infection postoperatively. Preoperative satisfaction scores were not associated with complications when analyzed in a multivariate fashion. On binomial logistic regression analysis, after controlling for age, body mass index, reconstruction technique, and use of radiotherapy, patients who reported less preoperative satisfaction with how comfortably bras fit or how they appeared in a mirror unclothed were at an increased risk for delayed wound healing.

CONCLUSIONS

Patients with lower preoperative body satisfaction were found to have an increased incidence of infections and delayed wound healing. Although postoperative outcomes are multifactorial, the data suggest that baseline psychological factors such as body image may play a role in postoperative outcomes. Broader use of prehabilitative therapies, targeted at psychosocial factors, may warrant further investigation to optimize postoperative outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Implant-based immediate reconstruction in prophylactic mastectomy: is the caudal dermis flap a reliable alternative to synthetic mesh or acellular dermal matrix?

Introduction

The demand for prophylactic mastectomy has increased significantly over the last 10 years. This can be explained by a substantial gain of knowledge about the clinical risk and outcome of patients with high risk mutations such as BRCA1 and 2, the improved diagnostic possibilities for detecting the genetic predisposition for the development of breast cancer and the awareness for those mutations by health care professionals as well as patients. In addition to expander-to-implant reconstruction and microsurgical flap surgery, definitive immediate reconstruction with subpectoral insertion of breast implants is often preferred. The prosthesis is covered at its inferior pole by a synthetic mesh or acellular dermal matrix. In these cases, in addition to the silicone prosthesis, a further foreign body must be implanted. This can be exposed in the event of wound healing disorder or necrosis of the usually thin soft tissue covering after subcutaneous mastectomy, thus calling into question the reconstructive result. In this study, the coverage of the lower pole by a caudal deepithelialized dermis flap, which allows the implant to be completely covered with well vascularized tissue, is compared to coverage by a synthetic mesh or acellular dermal matrix.

Patients and methods

From January 2014 to June 2020, 74 patients (106 breasts) underwent breast reconstruction following uni or bilateral prophylactic mastectomy. Reconstruction was performed with autologous tissue (15 breasts), with tissue expander or implant without implant support (15 breasts), with implant and use of an acellular dermal matrix or synthetic mesh (39 breasts) and with implant and caudal dermis flap (37 breasts).

In this study, we compared the patients with implant and dermal matrix/mesh to the group reconstructed with implant and dermal flap.

Results

In the group with the caudal dermis flap, 4 patients developed skin necrosis, which all healed conservatively due to the sufficient blood supply through the dermis flap. In the group with the use of a synthetic mesh or acellular dermal matrix, skin necrosis was found in three cases. In one of these patients the implant was exposed and had to be removed.

Discussion

For patients with excess skin or macromastia, the caudal dermis flap is a reliable and less expensive option for complete coverage of an implant after prophylactic mastectomy. In particular, the vascularized dermis flap can protect the implant from the consequences of skin necrosis after prophylactic mastectomy.

Patient-reported Outcomes and 3-dimensional Surface Imaging after Risk-reducing Mastectomy and Immediate Breast Reconstruction

The cosmetic results after risk-reducing mastectomy (RRM) and immediate breast reconstruction (IBR) are intended to be long-lasting. Long-term follow-up of the cosmetic outcome can be evaluated subjectively by the women themselves through patient-reported outcome measures such as questionnaires, or by using data from three-dimensional surface imaging (3D-SI) to calculate the volume, shape, and symmetry of the reconstructed breasts as a more objective cosmetic evaluation. The study aim was to evaluate the correspondence between patient-reported measures and 3D-SI measurements.

Protocol for a multicentre, prospective, cohort study to investigate patient satisfaction and quality of life after immediate breast reconstruction in Japan: the SAQLA study

INTRODUCTION

The aim of breast reconstruction (BR) is to improve patients' health-related quality of life (HRQOL). Therefore, measuring patient-reported outcomes (PROs) would clarify the value and impact of BR on a patient's life and thus would provide evidence-based information to help decision-making. The Satisfaction and Quality of Life After Immediate Breast Reconstruction study aimed to investigate satisfaction and HRQOL in Japanese patients with breast cancer who undergo immediate breast reconstruction (IBR).

METHODS AND ANALYSIS

This ongoing prospective, observational multicentre study will assess 406 patients who had unilateral breast cancer and underwent mastectomy and IBR, and were recruited from April 2018 to July 2019. All participants were recruited from seven hospitals: Okayama University Hospital, Iwate Medical University Hospital, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Showa University Hospital, University of Tsukuba Hospital, Osaka University Hospital and Yokohama City University Medical Center. The patients will be followed up for 36 months postoperatively. The primary endpoint of this study will be the time-dependent changes in BREAST-Q satisfaction with breast subscale scores for 12 months after reconstructive surgery, which will be collected via an electronic PRO system.

ETHICS AND DISSEMINATION

This study will be performed in accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects published by Japan's Ministry of Education, Science and Technology and the Ministry of Health, Labour and Welfare, the modified Act on the Protection of Personal Information and the Declaration of Helsinki. This study protocol was approved by the institutional ethics committee at the Okayama University Graduate School of Medicine, Dentistry, on 2 February 2018 (1801-039) and all other participating sites. The findings of this trial will be submitted to an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

UMIN000032177.

Shared Decision-Making in Breast Reconstruction for Breast Cancer Patients: A Scoping Review

For most breast cancer (BC) patients who have undergone a mastectomy, the decision whether to proceed with breast reconstruction (BR) is complicated and requires deliberation. Shared decision-making (SDM) helps to address those needs and promote informed value-based decisions. However, little is known about the SDM status for BR in BC patients. This scoping review describes: 1) basic characteristics of studies on BR SDM in BC patients; 2) factors influencing BR SDM in BC patients; 3) experience and perception of BR SDM in BC patients; and 4) outcome measures reported. This review was performed in accordance with the Arksey and O'Malley methodology. A total of 5 English and 4 Chinese databases were searched, as well as different sources from grey literature. The data extraction form was developed by referring to the objectives and the Ottawa Decision Support Framework (ODSF). Data was analyzed using thematic analysis, framework analysis and descriptive statistics, with findings presented in the tables and diagrams. A total of 1481 records were retrieved and 42 of these included after screening. In 21 (21/42, 50%) of the studies, patient decision aids (PDAs) were utilized, and in 17 (17/42, 40.48%) of the studies, the factors influencing the implementation of SDM were explored. Of these 17 studies, the factors influencing the implementation of SDM were categorized into the following: the patient level (17/17, 100%), the healthcare level (2/17, 11.76%) and the organizational and system level (7/17, 41.18%). A total of 8 (19.05%) of the 42 studies focused on patients' experiences and perceptions of SDM, and all studies used qualitative research methods. Of these 8 studies, a total of 7 (7/8, 87.50%) focused on patients' experiences of SDM participation, and 4 (4/8, 50.00%) focused on patients' perceptions of SDM. A total of 24 studies (24/42, 57.14%) involved quantitative outcome measures, where 49 items were divided into three classifications according to the outcomes of ODSF: the quality of the decision (17/24, 70.83%), the quality of the decision-making process (20/24, 83.33%), and impact (13/24, 54.17%). Although researchers have paid less attention to other research points in the field of SDM, compared to the design and application of SDM interventional tools, the research team still presents some equally noteworthy points through scoping review. For instance, the various factors influencing BC patients' participation in SDM for BR (especially at the healthcare provider level and at the organizational system level), patients' experiences and perceptions. Systematic reviews (SRs) should be conducted to quantify the impact of these different factors on BR SDM. Implementation of scientific theories and methods can inform the exploration and integration of these factors.

Predictors of women's sexual outcomes after implant-based breast reconstruction

Objective

Although breast reconstruction has become an important treatment modality following mastectomy, few studies assessed predictors of postoperative sexual outcomes after breast reconstruction. Therefore, we aimed to study three sexual outcomes following implant‐based breast reconstruction (IBBR), and associate multiple biopsychosocial factors with these outcomes.

Methods

Data collection was part of a multicenter prospective study on IBBR. A predictive model was tested including medical, background and psychological predictors, partner relationship factors and physical sexual function. Data collection included clinical and questionnaire data (preoperatively and 1 year following reconstruction) using the BREAST‐Q Sexual well‐being scale (BQ5), and questions regarding sexual dysfunction and sexual satisfaction questions (Female Sexual Function Index).

Results

The study sample consisted of 88 women who underwent mastectomy and IBBR. Mean postoperative BQ5 scores were lower than before surgery (M = 58 [SD = 18] vs 65 [SD = 20]; P = .01, Wilks' Lamdba = .88). Sexual dysfunctions were related strongest to orgasm inability and vaginal lubrication issues. The tested models predicted 37%‐46% of the sexual outcomes: sexual outcomes were mostly predicted by psychosocial well‐being, physical sexual function and partner support. Preoperative sexual and psychosocial well‐being were positively associated with postoperative sexual well‐being (r = 0.45 and r = 0.47).

Conclusions

Although moderately positive sexual outcomes were reported after IBBR, some women reported issues with vaginal lubrication, breast sensation and orgasm. Sexual dysfunctions were predicted by vaginal lubrication and medical treatments, while sexual well‐being and satisfaction were more predicted by psychosocial well‐being and partner support. We advocate supportive care that includes partners and psychosocial functioning to optimize sexual outcomes after IBBR.

Presurgical Psychological Evaluation: Risk Factor Identification and Mitigation

Presurgical psychological evaluations (PPEs) are becoming an established component of the surgical process, though methods of conducting PPEs are variable. There is a lack of clarity about the goals of PPEs, the types of information that should be included, and the process for integrating information and making recommendations to the referring physicians/surgeons. This review proposes an empirically supported model for PPEs that is systematic, but flexible enough to be utilized across the broad range of surgical evaluations. This five-step method is termed the Risk Identification and Mitigation (RIM) model and is discussed in detail. The RIM model presented in this review can both serve as a structure to be utilized in under-researched PPE areas and as a stimulus for future empirical investigations.

Influences on Satisfaction with Reconstructed Breasts and Intimacy in Younger Women Following Bilateral Prophylactic Mastectomy: a Qualitative Analysis

PURPOSE

The aim of this study was to explore the influences on satisfaction with reconstructed breasts and intimacy following bilateral prophylactic mastectomy (BPM) in younger women (< 35) with a strong family history of breast cancer.

METHODS

Twenty-six women who had undergone BPM between 1 and6 years ago were recruited from New Zealand and Australia through a genetics clinic, registry, research cohort, and online (M_age = 31). Twenty-three were BRCA mutation carriers. Qualitative interviews guided by interpretative phenomenological analysis were conducted.

RESULTS

Four themes were identified: satisfaction with breasts before surgery, outcome expectations, type of mastectomy, and open communication. Women who liked their breasts pre-BPM appeared less satisfied with their reconstructed breasts post-surgery, and women who disliked their breasts before BPM were more satisfied with their reconstructed breasts. Women with unrealistic expectations concerning the look and feel of reconstructed breasts were often unhappy with their reconstructed breasts and felt they did not meet their expectations. Unrealistic photos of breast reconstruction and satisfactory communication of realistic outcome expectations by surgeons or psychologists also appeared to influence satisfaction. Communication with partners prior to BPM appeared to improve satisfaction with intimacy post-BPM.

CONCLUSIONS

The findings suggest that satisfaction with reconstructed breasts for younger women post-BPM appeared to be influenced by realistic outcome expectations and communication with others concerning reconstructed breast appearance and intimacy post-BPM. Implications for practice include discussion of realistic reconstructed breast appearance, referral to a psychologist to discuss sensitive issues, and accurate communication of surgical risks and consequences.

The sex life of women surviving breast cancer

The diagnosis of breast cancer elicits diverse emotional responses in patients and partners. Surviving cancer has raised new needs and caretakers must understand the medical and psychological latent effects of oncology therapy. Improving patients' well-being is crucial as 19 million survivors are expected in the next decade in the United States alone. In general, sexuality contributes to one's well-being but when it is disrupted by the occurrence of cancer, women withdraw emotionally, no longer feel desirable due to esthetic damage, and become overwhelmed by the thought of sex. Alopecia and mastectomy elicit feelings of unattractiveness affecting even some women with nipple sparing mastectomy. Couples who share the psychological distress of experiencing cancer should be logically included in survivorship interventions. Hence, any support offered to the couple improves their ability to cope significantly. Treatments causing premature ovarian failure as well as adjuvant endocrine treatments deepen the effects of hypo-estrogenism on the genital modifications of arousal. Sexual rehabilitation with vaginal dilators and sensate focus exercises help to lessen pain, and reduce the couple's anxiety toward sex. In conclusion, caregivers must realize that surviving women are often reluctant to voice their needs, thus, efficient interventions must be available to everyone.