Effect of cosmetic outcome on quality of life after breast cancer surgery

doi:10.1016/j.ejso.2014.12.002

European Journal of Surgical Oncology (EJSO)

Volume 41, Issue 3, March 2015, Pages 426-432

https://doi.org/10.1016/j.ejso.2014.12.002 Get rights and content

Abstract

Purpose

Studies regarding the effects of aesthetic outcomes after breast cancer surgery on quality of life (QoL) have yielded inconsistent results. This study analyzed the aesthetic outcomes and QoL of women who underwent breast conserving surgery (BCS) or total mastectomy with immediate reconstruction (TMIR) using objective and validated methods.

Patients and methods

QoL questionnaires (EORTC QLQ-C30, BR23, and HADs) were administered at least 1 year after surgery and adjuvant therapy to 485 patients who underwent BCS, 46 who underwent TMIR, and 87 who underwent total mastectomy (TM) without reconstruction. Aesthetic results were evaluated using BCCT.core software and by a panel of physicians. Patients' body image perception was assessed using the body image scale (BIS).

Results

QoL outcomes, including for social and role functioning, fatigue, pain, body image, and arm symptoms, were significantly better in the BCS and TMIR groups than in the TM group (p<0.05 each). BIS was significantly better in the BCS than in the TM or TMIR group (p<0.001 each). In the BCS and TMIR groups, general QoL factors were not significantly associated with objective cosmetic outcomes, except for body image in the QLQ-BR23. In contrast, patients with poorer BIS score reported lower QoL in almost all items of the QLQ-C30, BR23, and HADS (p<0.05 each).

Conclusion

In conclusion, BCS and TMIR enhanced QoL compared with TM. Among BCS and TMIR patients, objectively measured cosmetic results did not affect general QoL. Self-perception of body image seems to be more important for QoL after breast cancer surgery.

Introduction

Treatment for breast cancer frequently results in marked changes to the physical appearance of patients. The overall safety of breast conserving surgery (BCS) and reconstruction surgery, as well as improvements in long term outcomes of breast cancer treatment, have enhanced concerns about esthetic results. However, despite efforts to preserve their breasts for cosmetic reasons, a substantial percentage of patients are not satisfied with the esthetic result of surgery. For example, one study reported that 28.3% of patients who underwent BCS were dissatisfied with the cosmetic results.¹ Moreover, unlike oncologic outcomes, there are no standard and objective methods for evaluating esthetic outcomes. An objective measure of assessing breast cosmetic results after BCS or reconstruction is needed to improve surgical strategies and to identify factors that affect esthetic outcomes.

The extent to which cosmetic results affect the quality of life (QoL) of breast cancer patients remains unclear. QoL is an important endpoint of breast cancer treatment, and the effects of various interventions on the QoL of these patients are of major interest. However, studies to date of the effects of esthetic outcomes on postoperative QoL have yielded inconsistent results.2, 3, 4, 5, 6 Evaluation using standardized and validated methods may justify efforts to improve cosmetic outcomes of breast cancer surgery, as well as being essential for patients to make an informed choice of surgical options.

The aim of this study was to investigate patient QoL after breast cancer surgery and to correlate these QoL results with subjectively and objectively measured breast cosmesis. We therefore analyzed and compared esthetic results and patient QoL in women who underwent BCS and those who underwent total mastectomy followed by immediate reconstruction (TMIR).

Section snippets

Patients

This study was approved by the Institutional Review Board (IRB) of Seoul National University Hospital (IRB No. 1206-120-416). We surveyed all women who underwent BCS or TMIR at Seoul University Hospital by a single surgeon (Han W) between January 2007 and September 2011. Women were included if they had: 1) primary, unilateral, histologically proven invasive or in situ breast cancer; 2) clear resection margins at final surgery; 3) no evidence of disease recurrence or metastasis during the

Patient characteristics

The study included 485 women who underwent BCS and 46 who underwent TMIR between January 2007 and September 2011. 86 patients who underwent TM without reconstruction were selected as a control group. Patient characteristics are presented in Table 1. Patients in the TMIR group were significantly younger and had significantly lower BMI than patients in the BCS and TM groups (p = 0.001 each). Cancer stage, however, was similar in the three groups, as were the proportions of patients who received

Discussion

This study attempted to clarify the relationships among esthetic results and patient QoL in women who have undergone breast cancer surgery. The impact of objectively measured breast cosmetic results and patient reported body image on QoL was analyzed a median 2.1 years after BCS or TMIR. We found that breast symmetry, measured objectively by BCCT.core software and panel judgment, did not correlate with patients' general QoL. In contrast, patient self-reported BIS was significantly associated

Acknowledgments

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea Government (MSIP) (No. 2012M3A9B2028834, No. 2013005540).

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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.
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Observational study of patients with breast cancer who underwent GCT consecutively treated. Evaluated retrospectively: indications, clinical characteristics, surgical features and recurrences. Cosmesis were evaluated prospectively by the BCCT.core software, Harris/Harvard and Garbay scales. Descriptive statistics were performed, chi-square test was used to compare aesthetic outcomes; Kappa and Weighted Kappa test was used to assess agreement between the postoperative evaluations; Kaplan-Meier model for follow-up and recurrence. A systematic review was carried out using PRISMA methodology.
Thirty-six patients were evaluated, 26 (72.2%) with medium/large breasts with or without ptosis, seven (19.4%) with small breasts with or without ptosis, a profile undergoing GCT not previously identified in the literature. The mean tumor clinical size was 3.65 ± 1.59 cm. 34 (94.4%) patients underwent GCT. Mean follow-up time was 36.6 ± 16.8 months, with no local recurrences. According to BCCT.core, the postoperative aesthetic was good in 17 (51.5%) patients and 11 (33.3%) was reasonable. In the systematic review, 3.584 articles were evaluated, 20 articles were selected, 243 patients undergoing GCT were found, with several indications for BCS instead of mastectomy, with high rates of free margins, low recurrence and good aesthetic outcomes.
GCT, an oncologically safe and aesthetically satisfactory option, has been extended to patients with small and medium breasts with ptosis, large tumors to breast volume or in unfavorable resection sites, initially candidates for mastectomy.
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Breast surgery has become less invasive without compromising survival and aimed at improving quality of life (QoL) in terms of satisfaction with cosmesis. Despite that, short-term patient-perceived aesthetic results after breast-conserving surgery (BCS) can still be displeasing. Long-term analysis regarding contentment with cosmesis are lacking and could be different, considering that over time, patients’ priorities might change and a different thought-out judgment could be given. The goal of this study is to describe long-term results in QoL after BCS and to identify possible predictors for disappointing aesthetic results.
In this retrospective cohort study, the long-term outcomes of QoL, patient-reported outcome measurements and aesthetic outcomes were investigated 4.5–10.8 years after BCS. In total, 104 patients received standardized questionnaires from the European Organisation of Research and Treatment of Cancer. The aesthetic results after BCS were evaluated subjectively through a diverse panel of healthcare observers. Objective assessment of the aesthetic results was done using the BCCT.core system of evaluating standardised breast photographs. Factors influencing aesthetic outcome were statistically analysed.
QoL was high in around 75% of the patients. Correlation between QoL and aesthetic outcomes was found according to Spearman's correlation (r = 0.262, p = 0.007). Significant factors negatively influencing patient reported aesthetic outcomes were sentinel node procedure (p = 0.016), axillary lymph node dissection (p = 0.004), chemotherapy (p = 0.001), and hormonal therapy (p = 0.001).
The majority of the patients have acceptable QoL after BCS during long-term follow-up. Unacceptable aesthetic outcomes after BCS are associated with lower QoL and are influenced by sentinel node procedure, axillary lymph node dissection, chemotherapy, and hormonal therapy.
Special Considerations in Patients with Early-Stage Breast Cancer and Survivors
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Citation Excerpt :
While further research is required to fully elucidate these subgroups and different trajectories, collectively, these studies indicate QoL and impairment in body image among women with breast cancer are complex and likely to be dependent on a number of factors, such as age, treatment type and time since diagnosis. The association between body image and QoL has been found among various subgroups of women living with breast cancer, including survivors, younger women, those with advanced disease and among different treatment groups (Kim et al., 2015; McClelland et al., 2015; Paterson et al., 2016; Turk & Yilmaz, 2018). For example, Arraras and collegues (2016) found among 243 premenopausal breast cancer survivors (received breast conserving surgery or mastectomy 5–20 years previously), those with better body image had lower odds of low QoL (Arraras et al., 2016).
Women with breast cancer often experience major physical changes, which can impact their body image and Quality of Life (QoL). Traditional assessments of body image implemented within breast cancer research focus solely on body dissatisfaction. This study explored the association between both positive and negative body image and QoL. Australian women (N = 123) within 5-years of a breast cancer diagnosis were invited to complete a web-based questionnaire including measures of body appreciation and functionality appreciation, cancer-specific measures of body dissatisfaction and QoL, and demographic, health and treatment/illness questions. All body image measures were significantly associated with QoL (p < .01). However, when body image variables were entered simultaneously as predictors of QoL (adjusting for comorbidity, treatment and employment), only body dissatisfaction was significantly associated with QoL (p < .001). Further analyses indicated this was due to shared variance in QoL between body and functionality appreciation, suggesting they assess highly related constructs within this population. Results indicate positive and negative components of body image are relevant to QoL within breast cancer populations; though, body dissatisfaction remained the strongest predictor of QoL indicating its pervasiveness. Future research should explore the development and use of breast cancer-specific measures of positive body image.

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^h: Both authors contributed equally.

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Effect of cosmetic outcome on quality of life after breast cancer surgery

Abstract

Purpose

Patients and methods

Results

Conclusion

Introduction

Section snippets

Patients

Patient characteristics

Discussion

Acknowledgments

Aesthet Surg J

Eur J Surg Oncol

Radiother Oncol

Radiother Oncol

Eur J Cancer

J Psychosom Res

Artif Intell Med

Neural Netw

Int J Radiat Oncol Biol Phys

Eur J Cancer

Am J Surg

Eur J Surg Oncol

Eur J Surg Oncol

Eur J Oncol Nurs