Using Bionics to Restore Sensation to Reconstructed Breasts

A longitudinal study of sexual activity and influencing factors in breast cancer patients during treatment in the Southwest of China: a trajectory analysis model

PURPOSE

The aim of this study was to describe the longitudinal developmental trajectories and its influencing factors of sexual activity in patients with breast cancer during treatment.

METHODS

A prospective longitudinal study was conducted, including 225 newly diagnosed breast cancer patients in A tumor specialty three-class hospital in Southwest China. We measured sexual activity at the time of admission and diagnosis (T0) and one month (T1), three months (T2), six months (T3), and nine months (T4) after diagnosis. A trajectory analysis model (GBTM) was used to explore the changes in sexual activity in breast cancer patients. Multivariate binary logistic regression analysis was used to analyse the factors that affected the classification of sexual activity trajectories.

RESULTS

The ratio of sexual activity abruptly declined from 100% at baseline to 39.1% at T1. The percentage of sexual activity was improved, from 51.4% at T2 to 63.1% at T4. The optimal model was a 2-group trajectory of sexual activity in breast cancer patients,36.6% in the "low activity group" and 63.4% in the "high activity group." The multivariate binary logistic regression analysis revealed statistically significant and positive correlations between sexual activity and age (β = 0.085, OR = 1.089, 95%CI 1.035 ∼ 1.145, P = 0.001),libido(β = 0.774, OR = 2.168, 95%CI 1.337 ∼ 3.515, P = 0.002), vaginal lubrication(β = 1.254, OR = 33.503, 95%CI 2.000 ∼ 6.137, P<0.001).

CONCLUSIONS

Breast cancer patients exhibited varying levels of sexual activity during treatment; higher age was associated with increased sexual activity, which can contribute to the recovery of sexual function. Therefore, it is crucial to provide appropriate guidance on sexual health for younger patients.

Learning Sensory Nerve Coaptation in Free Flap Breast Reconstruction

BACKGROUND

 The aims of this study were to assess whether sensory nerve coaptation in free flap breast reconstruction is subject to learning, and to elucidate challenges of this technique.

METHODS

 In this single-center retrospective cohort study, we reviewed consecutive free flap breast reconstructions performed between March 2015 and August 2018. Data were extracted from medical records, and missing values were imputed. We assessed learning by exploring associations between case number and probability of successful nerve coaptation using a multivariable mixed-effects model. Sensitivity analysis was performed in a subgroup of cases with evidence of attempted coaptation. Recorded reasons for failed coaptation attempts were grouped into thematic categories. Multivariable mixed-effects models were used to examine associations between case number and postoperative mechanical detection threshold.

RESULTS

 Nerve coaptation was completed in 250 of 564 (44%) included breast reconstructions. Success rates varied considerably between surgeons (range 21-78%). In the total sample, the adjusted odds of successful nerve coaptation increased 1.03-fold for every unit increase in case number (95% confidence interval 1.01-1.05, p < 0.05), but sensitivity analysis refuted this apparent learning effect (adjusted odds ratio 1.00, 95% confidence interval 1.00-1.01, p = 0.34). The most frequently recorded reasons for failed nerve coaptation attempts were inability to locate a donor or recipient nerve. Postoperative mechanical detection thresholds showed a negligible, positive association with case number (estimate 0.00, 95% confidence interval 0.00-0.01, p < 0.05).

CONCLUSION

 This study does not provide evidence in support of a learning process for nerve coaptation in free flap breast reconstruction. Nevertheless, the identified technical challenges suggest that surgeons may benefit from training visual search skills, familiarizing with relevant anatomy, and practicing techniques for achieving tensionless coaptation. This study complements prior studies exploring therapeutic benefit of nerve coaptation by addressing technical feasibility.

Breast sensorisexual function: a novel patient-reported outcome measure of sexual sensory functions of the breast

BACKGROUND

A validated measure assessing sexual sensory functions of the breast is needed to optimize sexual and other health outcomes after breast procedures.

AIM

To describe the development of a patient-reported outcome measure (PROM) to assess breast sensorisexual function (BSF).

METHODS

We applied the PROMIS standards (Patient Reported Outcomes Measurement Information System) for measure development and evaluation of validity. An initial conceptual model of BSF was developed with patients and experts. A literature review yielded a pool of 117 candidate items that underwent cognitive testing and iteration. Forty-eight items were administered to an ethnically diverse, national panel-based sample of sexually active women with breast cancer (n = 350) or without (n = 300). Psychometric analyses were performed.

OUTCOMES

The main outcome was BSF, a measure that assesses affective (satisfaction, pleasure, importance, pain, discomfort) and functional (touch, pressure, thermoreception, nipple erection) sensorisexual domains.

RESULTS

A bifactor model fit to 6 domains-excluding 2 domains with only 2 items each and 2 pain-related domains-revealed a single general factor representing BSF that may be adequately measured by the average of the items. This factor, with higher values denoting better function and with the standard deviation set to 1, was highest among women without breast cancer (mean, 0.24), intermediate among women with breast cancer but not bilateral mastectomy and reconstruction (-0.01), and lowest among those with bilateral mastectomy and reconstruction (-0.56). Between women with and without breast cancer, the BSF general factor accounted for 40%, 49%, and 100% of the difference in arousal, ability to orgasm, and sexual satisfaction, respectively. Items in each of 8 domains demonstrated unidimensionality (ie, they measured 1 underlying BSF trait) and high Cronbach's alphas for the entire sample (0.77-0.93) and the cancer group (0.71-0.95). Correlations with sexual function, health, and quality of life were positive for the BSF general factor and mostly negative for the pain domains.

CLINICAL IMPLICATIONS

The BSF PROM can be used to assess the impact of breast surgery or other procedures on the sexual sensory functions of the breast in women with and without breast cancer.

STRENGTHS AND LIMITATIONS

The BSF PROM was developed by using evidence-based standards, and it applies to sexually active women with and without breast cancer. Generalizability to sexually inactive women and other women warrants further study.

CONCLUSION

The BSF PROM is a measure of women's breast sensorisexual function with evidence of validity among women affected and unaffected by breast cancer.

Sexual Health after a Breast Cancer Diagnosis: Addressing a Forgotten Aspect of Survivorship

Breast cancer is the most common cancer in women. The life expectancy after a breast cancer diagnosis is improving steadily, leaving many more persons with the long-term consequences of treatment. Sexual problems are a common concern for breast cancer survivors yet remain overlooked in both the clinical setting and the research literature. Factors that contribute to sexual health concerns in breast cancer survivors are biopsychosocial, as are the barriers to addressing and treating these health concerns. Sexual health needs and treatment may vary by anatomy and gender. Multidisciplinary management may comprise lifestyle modifications, medications, sexual health aids such as vibrators, counseling, and referrals to pelvic health physical therapy and specialty care. In this article, we review the contributing factors, screening, and management of sexual difficulties in cisgender female breast cancer survivors. More information is needed to better address the sexual health of breast cancer survivors whose sexual/gender identity differs from that of cisgender women.

Patient-Reported Outcome Measures Used for Assessing Breast Sensation after Mastectomy: Not Fit for Purpose

AIMS

The aims of this review were (i) to evaluate whether patient-reported outcome measures used in clinical studies for assessing sensation after mastectomy and breast reconstruction are suitable for this purpose, and (ii) to explore whether any measures used for assessing sensation after non-oncologic breast surgery are worth modifying for use in post-mastectomy patients.

Methods

PRISMA guidelines were followed (PROSPERO number CRD42020178066). We searched six databases for studies of oncologic (i.e., therapeutic, prophylactic, and reconstructive) and non-oncologic breast surgery (e.g., breast reduction) in which sensation was assessed with a patient-reported outcome measure. From the selected studies, we extracted eligible measures, evaluated their fitness for purpose, and summarized the content of sensation-specific items.

Results

Of 6728 articles identified, we selected 135 studies that used 124 eligible patient-reported outcome measures. For 97% of these measures, details regarding development and measurement properties were unavailable. Four (3%) validated measures—the Sensory Disturbances subscale of the Breast Cancer Sequelae Cause Scales, the Discomfort subscale of the Breast Sensation Assessment Scale (BSAS), Didier et al.’s questionnaire for “Assessment of the patients’ satisfaction with cosmetic results, physical and emotional impact of mastectomy”, and the Breast Specific Pain subscale of the Breast Cancer Treatment Outcomes Scale (BCTOS)—each contain at least one item pertaining to breast sensation, but target different concepts of interest. In total, the measures feature 215 sensation-specific items, most of which concern symptom severity (97%) as opposed to impact on daily functioning (3%).

Conclusion

Patient-reported outcome measures used in clinical studies for assessing sensation after mastectomy and breast reconstruction are unsuitable for this purpose: they are either non-validated or non-specific. We failed to identify any measures for use in non-oncologic breast surgery populations worth modifying. To collect meaningful, patient-relevant data regarding sensation after mastectomy, it is pertinent that future clinical trials adopt psychometrically robust, specific patient-reported outcome measures.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-021-00565-5.

"Innervation of the Female Breast and Nipple: A Systematic Review and Meta-Analysis of Anatomical Dissection Studies"

BACKGROUND

Primary cadaveric studies were reviewed to give a contemporary overview of what is known about innervation of the female breast and nipple/nipple-areola complex (NAC).

METHODS

We performed a PRISMA-compliant systematic review and meta-analysis (PROSPERO number CRD42020150250). We searched four electronic databases for studies investigating which nerve branches supply the female breast and nipple/NAC or describing the trajectory and other anatomical features of these nerves. Inclusion criteria for meta-analysis were at least five studies of known sample size and with numerical observed values. Pooled prevalence (PP) estimates of nerve branches supplying the nipple/NAC were calculated using random-effects meta-analyses; the remaining results were structured using qualitative synthesis. Risk of bias within individual studies was assessed with the Anatomical Quality Assurance (AQUA) checklist.

RESULTS

Of 3653 studies identified, 19 were eligible for qualitative synthesis and 7 for meta-analysis. The breast skin is innervated by anterior cutaneous branches (ACBs) and lateral cutaneous branches (LCBs) of the 2nd - 6th and the nipple/NAC primarily by ACBs and LCBs of the 3rd - 5th intercostal nerves. The ACB and LCB of the 4th intercostal nerve supply the largest surface area of the breast skin and nipple/NAC. The LCB of the 4th intercostal nerve is the most consistent contributory nerve to the nipple/NAC (PP 89.0%; 95% CI 0.80-0.94).

CONCLUSIONS

The ACB and LCB of the 4th intercostal nerve are the most important nerves to spare or repair during reconstructive and cosmetic breast surgery. Future studies are required to elicit the course of dominant nerves through the breast tissue.