The option of delayed reconstructive surgery following mastectomy for invasive breast cancer: Why do so few patients embrace this offer?

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Abstract

Background

Only a minority of patients who had undergone mastectomy for invasive breast cancer (BC) chose the option for delayed breast reconstruction (BR). We hypothesized that this might partly be (a) due to a lack of information, or (b) because many women cope well with their altered body.

Methods

A cross-sectional survey was completed by 101 early-stage BC survivors who had primary mastectomy. Twenty-six patients had delayed BR. The survey included measures to attitudes to BR and experiences/expectations about information related to BR.

Results

The percentage of patients who was informed regarding BR was high (97%). For 39.5% such information was not considered important, neither before mastectomy, nor during follow-up; advanced age was an important factor for the disinterest in information (odds ratio 1.81; 95% CI: 1.04–3.16; p = 0.033). For women without BR, the perception that mastectomy caused a serious damage to their body image changed over time to perceiving the operation as an acceptable alteration of the body (−1.10; 95% CI, −1.52, −0.64; p < 0.001); this process was similar to that in patients who had BR (paired t-test: −2.12; 95% CI, −2.82, −1.41; p > 0.001). From 63 patients who reported no intention to have a BR in the future, 28 (44.4%) responded with answers that showed a high satisfaction with their mastectomies without BR; 30 patients (47.6%) reported reasons, which might potentially be dispelled by information by an experienced reconstructive surgeon.

Conclusions

We did not find any evidence that the low number of patients who chose delayed BR results from a lack of information regarding this procedure. The majority of patients overcome negative attitudes towards their mastectomy quickly and are uninterested in BR. Patients who are ambivalent must be identified; these women require particular attention and should receive intensive counseling.

Introduction

In the current era of breast cancer (BC) surgery, in approximately one third of the patients, mastectomy is required. In these cases, the patients must not only cope with the fears of cancer as a life-threatening disease but also with the anxiety associated with a surgical procedure which results in a considerable alteration of body image. Breast reconstruction (BR), both as an immediate and as a delayed procedure is generally believed to improve psychological, social, emotional and functional wellbeing.1 However, despite the undisputed advantages of BR and the fact that there is universal access to reconstructive breast surgery in the Western world, only a minority of patients (approximately 20% taking geographic variations into consideration) who had undergone mastectomy chose this option.2, 3

The current reviews, which systematically evaluated the literature examining patient-reported outcome measures in terms of quality of life after BR, found that most of the studies had limitations of study design and methodology.4, 5, 6, 7, 8, 9 Therefore, our study does not focus on quality of life issues. Instead, we developed a different approach where we surveyed an unselected cohort of women who received mastectomy for primary invasive BC with the aim to evaluate and explain the fact why so few patients chose BR. We hypothesized that this might partly be due to a lack of information by their doctors. On the other hand, it might be underestimated how well women cope with their altered body image particularly when considering the background of a potentially life-threatening disease. Contrary to the “classical” quality of life issues, we focused our survey on more clinical issues (experience, expectations and attitude). In a study-specific self-report questionnaire, the following issues were highlighted:

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    Were the patients counseled by their doctors regarding BR and what were/are the patient's expectations regarding such a counseling?

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    What were/are the patients' attitudes regarding their altered body after mastectomy?

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    When patients did not opt for BR: what are the reasons to decline BR?

We put particular attention in which way the patients' experiences and attitudes developed over time; therefore, most questions of the survey referred to a) the situation when BC was diagnosed and primary mastectomy was performed as well as to b) the situation of a cancer survivor with a follow-up period of at least two years after mastectomy. Furthermore, we deliberately included older patients in our study and sent the questionnaire to patients who were ≤70 years at the time of the survey and who were healthy enough to be considered for BR.

Section snippets

Study design, Patient population and enrollment

We conducted a cross-sectional 13-item survey of patients who had been treated with mastectomy for stage I–III invasive BC at the University Women's Hospital Basel, Switzerland between 1998 and 2009. Eligible patients were identified through the prospective relational Basel Breast Cancer Database (BBCD), which includes all newly diagnosed primary invasive BC cases treated at the institution since 1990. In this study, we included BC survivors who were ≤70 years at the time of the survey (n

Results

From our entire study cohort (n = 101), seventy-five patients had mastectomy only at the time of the survey and 26 patients had BR (Table 1). Patients who had BR were significantly younger at the time of BC diagnosis/mastectomy (44.6 years vs. 51.3 years, p < 0.001).

Potential reason for low BR rates-the coping process after mastectomy

Given the potential advantages of BR, all women who have to undergo mastectomy should be given the opportunity of deciding whether or not to have BR. This well-intentioned proposal is possibly related to the general perception that the loss of a breast results in psychological distress for every woman in all cases and that reconstructive surgery is a pivotal factor during the coping process of BC. However, the general assumption that the removal of a breast must inevitably mean a severe

Conflict of interest statement

The authors declare that there are no financial or personal relationships with other people or organizations that could inappropriately influence the work reported or the conclusions, implications, or opinions stated.

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