Nicholson
Nicholson
THE BREAST
www.elsevier.com/locate/breast
ORIGINAL ARTICLE
a
Norfolk and Norwich University Hospital, UK
b
School of Health Policy and Practice, University of East Anglia, UK
Received 6 September 2006; received in revised form 3 January 2007; accepted 24 January 2007
KEYWORDS Summary
Breast surgery; Method: The cosmetic and psychological outcomes of patients who underwent
Cosmetic outcome; reconstructive surgery, conservative surgery or simple mastectomy for breast cancer
Psychosocial between 1995 and 2002 were compared.
adjustment Results: There was a significant correlation between good psychological adjustment
and good cosmetic outcome scores (p ¼ 0.01–0.05). There was no difference in
cosmetic outcome between different reconstruction methods. Reconstruction
patients rated their cosmetic outcome better than conservative surgery patients,
and conservative surgery patients better than mastectomy patients. There were no
differences in psychological outcome between patient groups.
Conclusion: Good perception of cosmetic outcome is associated with good
psychological adjustment. There is no cosmetic advantage of one type of
reconstruction over another. Reconstruction patients have a better body image
compared with other treatment groups but there are no other psychological
advantages of one type of treatment over another.
& 2007 Elsevier Ltd. All rights reserved.
Introduction
!Corresponding author. 42 The Common, Lavenham, Suffolk The mainstay of breast cancer treatment is still
CO10 9RL, UK. Tel.:+44 1787 247146; fax:+44 1603 591175.
surgical tumour resection although adjuvant ther-
E-mail address: [email protected] (R.M. Nichol- apy is now considered to be mandatory. Although
son). conservative surgery is now the approach of choice,
0960-9776/$ - see front matter & 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.breast.2007.01.009
ARTICLE IN PRESS
Risk factors affecting breast reconstruction 397
mastectomy is indicated in a substantial minority of investigate the relationship between cosmetic and
patients. Each year 40% of patients receiving psychological outcomes of patients treated for
surgical treatment for breast cancer undergo breast cancer.
mastectomy. It is now generally accepted that
breast reconstruction offers benefit to these
women.1 The number of patients in the UK Materials and methods
potentially requiring breast reconstruction is in
the region of more than 10,000 women per year.2 All of the patients studied were treated for breast
The timing of surgery may influence the out- cancer at the Norfolk and Norwich University
come. Several studies suggest that immediate Hospital between 1995 and 2002 and were identi-
reconstruction may be more beneficial than de- fied using the theatre records database. All of the
layed.3–7 Other studies have found that timing patients who had undergone breast reconstruction
made no difference8,9 and Tykka et al.10 found that (n ¼ 170) were selected along with two random
delayed reconstruction resulted in an improved groups (conservative surgery and mastectomy),
body image but no difference in psychological each of 100 subjects. The status of the patients in
outcome. The effect of the method of reconstruc- all of the groups was then verified. Live patients
tion on the outcome is complex. A number of were invited to participate in the study using their
studies have reported no difference in outcome currently listed address. Patients who had recon-
between different methods of reconstruction.2,8 structive or conservative surgery were assessed
However, other studies have reported that auto- using self-report questionnaires and photographs.
genous tissue reconstruction gives a better cos- The group who had a mastectomy but no recon-
metic result when compared with expander/ structive surgery was assessed by questionnaire
implant reconstruction,11–13 although this may not only. The self-report questionnaires were com-
be associated with an improved psychological pleted by patients at home, and collected by post.
outcome.13 Cederna et al. found that the auto- Photographs of the standard clinical record type
logous flap scored better in terms of feeling natural were taken by the Department of Clinical Photo-
but despite this the patients had more serious life graphy at the Norfolk and Norwich University
difficulties.14 Hospital.
Cocquyt et al.15 found reconstruction to be Photographs were shown to a panel of judges
significantly superior to conservative surgery in (comprising two breast surgeons and two plastic
terms of cosmetic result. However, other studies surgeons) for scoring. Scores of cosmetic outcome
have demonstrated the opposite,5,16,17 or no were on a visual analogue scale of 0–10.
difference.18 In fact, Schover et al.19 found that All three groups of patients were asked to fill
when comparing breast reconstruction patients in questionnaires (Appendix A). The questions
with conservative surgery patients, the type of covered:
surgery made no difference in terms of overall
adjustment to illness, body image or satisfaction " The patients’ self-score of cosmetic outcome of
with relationships and sexual life. Harcourt et al.20 surgery using a visual analogue scale.
compared patients who underwent mastectomy " Breast satisfaction using a visual analogue
alone, mastectomy and immediate reconstruction, scale.22
and mastectomy with planned delayed reconstruc- " Body satisfaction using a visual analogue scale.22
tion. The level of satisfaction with surgical/ " An evaluation of their appearance, using the
cosmetic outcome was comparable across all three Derriford Appearance Scale (DAS-59).23
patient groups. Nissen et al.21 compared patient " Their quality of life assessment using the Short
groups who had conservative surgery, breast re- Form 36 scale (SF36).24
construction or mastectomy alone at diagnosis, and " Their general level of anxiety/depression, using
post-operatively. The reconstruction patients had the Hospital Anxiety and Depression Scale
the greatest mood disturbance and poorer well- (HADS).25
being than the other groups. " To what extent they had choice in their type of
Many studies have reported either cosmetic treatment by using multiple choice ratings.
outcome or psychological outcome. Where both " How much information did they have, and from
have been reported it has been on a group basis. It what sources, using multiple choice and yes/no
is possible that good psychological outcome is ratings.
associated with a perceived good cosmetic out- " What clothing adjustments, e.g. to brassieres/
come on an individual level whatever treatment swimwear have they made, using yes/no
the patient has had. The aim of this study is to questions.
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398 R.M. Nicholson et al.
" Whether they would recommend their treatment Table 1 Distribution of patients throughout re-
to others, and whether they would choose the construction groups.
same treatment again, using multiple choice
ratings. Number of Patients (%)
patients
Questions that were not already from standar- Pedicled TRAM 3 1.8
dised questionnaires, i.e. not from HADS, SF-36 or Free TRAM 53 31.2
DAS-59, were designed following the relevant DIEP/ SGAP 17 10.0
recommendations for question format as theorised Latissimus dorsi 37 21.8
in ‘Research Methods in Health’, Ann Bowling22. LD+Implant 21 12.4
Psychological outcome was quantified from the TE/Implant 39 22.9
questionnaires. Primary outcome measures include TOTAL 170 100
the overall scores for SF36, DAS-59 and the HADS
subscales.
Between groups comparisons were made for Table 2 Mean satisfaction score by category of
cosmetic and psychological scores. The correlations reconstruction.
between cosmetic score and psychological scores
were made for all of the patients combined. Category of Number of Mean score
The results were analysed using the SPSS v.11 procedure cases
statistical package. Numerical outcome measures A—complex 36 7.3
were compared using parametric methods where B—intermediate 26 7.0
data was normal (ANOVA analysis). Binary outcomes C—expander/implant 17 7.5
were compared using odds ratios and tests of
association (Pearson analysis). Pearson correlation coefficient 0.112 p ¼ 0.324 (2 sided).
ANOVA F ¼ 0.143 p ¼ 0.867.
Results
One hundred and seventy reconstruction cases unable to be contacted. Of the 58 cases remaining
were identified. One hundred and thirty seven 41 (71%) returned completed questionnaires and 17
patients (81%) had delayed reconstructions and 33 (29%) declined participation in the study. Of the 41
patients (19%) underwent a skin-sparing mastect- patients who completed questionnaires, 14 (34%)
omy combined with an immediate breast recon- attended the department of clinical photography
struction. The age range of the reconstruction for photographs.
patients at the time of surgery was from 27 to 71 For the 100 patients who had undergone mas-
years old, with a mean of 49.7 years and standard tectomy without reconstruction the age range was
deviation of 8.5. One hundred and fifty of the 170 from 37 to 78 years with a mean of 58 years and
cases were still alive at the time of the study. standard deviation of 8.8. From this group 81 live
However 47 (31%) were unable to be contacted by patients were identified and invited to participate
either post or by telephone. From the remaining in the study. Of these patients 22 (27%) were unable
103 patients contacted 3 declined to participate in to be contacted, 46 (78%) returned completed
the study, 80 returned completed questionnaires, questionnaires and 13 (22%) declined to participate
of whom 39 attended the Department of Clinical in the study.
Photography for photographs. No differences in
psychological scores or cosmetic outcome were
found between those patients who had delayed Cosmetic outcome
reconstruction and those who had immediate
reconstruction so the two groups were combined The reconstructions were classified into three
for analysis. groups depending on the complexity of the proce-
The number of patients in each type of recon- dure. Group A was the most complex (pedicled
struction is shown in Table 1. TRAM, free TRAM and DIEP/SGAP); Group B was
For the 100 patients who had undergone breast intermediate (latissimus dorsi flap7implant) and
conservative surgery the age range was from 41 to Group C comprised tissue expanders and simple
81 years old with a mean of 52.3 years and a implants. Table 2 gives the mean satisfaction scores
standard deviation of 8.4. Of the 91 patients who for the 3 groups of patients. There was no
were listed as still being alive, 33 (36%) were difference in the mean scores between the groups
ARTICLE IN PRESS
Risk factors affecting breast reconstruction 399
Table 3 Cosmetic scores (mean) for surgical outcome, breast satisfaction, and body satisfaction between the
three groups of surgery.
Table 4 Analysis of scores for psychological subscales between groups (reconstruction, conservation,
mastectomy).
Scale F Sig.
using ANOVA and no correlation between the servative surgery patients (F ¼ 1.527; p ¼ 0.222).
complexity of the procedure and the patients’ However, there is a significant correlation between
perception of cosmetic outcome. the scores given by health professionals and those
Independent scoring by a panel of surgeons did given by patients themselves (Pearson’s
not show a significant difference in cosmetic coefficient ¼ 0.47: po0.001).
outcome between different types of reconstruction
for the 39 patients who underwent photography for
Psychological adjustment
the study (mean score for Group A ¼ 7.3; B ¼ 7;
C ¼ 7.5; F ¼ 0.121; p ¼ 0.73).
The scores on the psychological questionnaires
Patients who had undergone breast reconstruc-
(HADS, SF-36 and DAS-59) were compared between
tion gave themselves significantly higher scores for
groups using ANOVA (Table 4). There is no sig-
cosmetic outcome, overall body satisfaction and
nificant difference between any of the groups for
breast satisfaction scores in comparison with
any of the subscales.
patients who had breast conservative surgery who
in turn gave themselves higher scores than patients
who had undergone mastectomy. The mean scores Relationship between cosmetic score and
are detailed in Table 3. psychological adjustment
In contrast there was no significant difference in
the mean cosmetic scores given by health profes- A number of the psychological subscales were
sionals to either reconstruction patients or con- negatively correlated with the cosmetic score
ARTICLE IN PRESS
400 R.M. Nicholson et al.
The high scores for cosmetic outcome may be the again, (nearly 80% of both reconstruction and
result of this outlook rather than the cause. conservatory surgery patients and 70% of mastect-
Similarly, a high score for depression on the HADS omy patients), only 52% of mastectomy patients
scale may be associated with a negative outlook on were likely to recommend their treatment to a
life and so be the cause rather than the result of friend compared with 72% of each of the other two
the low cosmetic score. groups.
The lack of correlation with the Anxiety subscale The mean scores for cosmetic outcome are very
of the HADS may be explained by the concept of similar for all categories of reconstruction. While
threat and loss in breast cancer.26 Anxiety arises the small size of the groups may be causing a Type 2
from threat which is mainly focussed on the life- statistical error, any statistical difference found
threatening potential of the cancer. This is, in the with increasing group size is unlikely to be clinically
eyes of the patient, independent of any cosmetic important. This may reflect the increase in com-
considerations. Loss, on the other hand, is asso- plications from more complex reconstructions and
ciated with depression and there is an obvious the negative effect of complications on cosmetic
connection between cosmetic outcome and loss of outcome. Alternatively, it may represent the
an intact body image. successful choice of an appropriate type of recon-
While there are clear correlations between struction for each patient in order to give as good a
cosmetic and psychological outcomes the retro- cosmetic result as possible.
spective nature of the study does not allow any
inferences on causation. The high scores for
cosmesis might be the result rather than the cause
of the psychological well-being of the patient. Conclusions
The finding that there was no difference in
psychological outcomes between the patient The patient’s perception of cosmetic outcome is
groups (mastectomy, conservation and reconstruc- more important in determining psychological re-
tion) is in keeping with other studies.20,21 The sponse than the type of treatment which she has
finding that the self-assessed cosmetic score was experienced. A good perception of cosmetic out-
highest for the reconstruction group is in keeping come was associated with a favourable psychologi-
with Cocquyt et al.15 who also found that the cal outcome although one cannot determine which
reconstruction group had a better outcome than was the cause and which the effect.
the conservation group although in that study the Although there were no significant differences
assessment was carried out by a group of indepen- between the different patient groups’ scores for
dent experts and not by the patients. In contrast, the psychological scales used in this study, recon-
Al-Ghazal et al.5 found patient satisfaction with struction patients gave themselves much higher
cosmetic outcome to be better after conservative cosmetic scores for both breasts and body when
surgery when compared with reconstruction or compared with the other patient groups. There-
mastectomy alone. As in this study, the lowest fore, reconstruction patients seem to have an
assessment of cosmetic outcome was found with advantage of better body image post treatment
the mastectomy alone group. compared with conservative surgery patients, who
There are several possible explanations for these in turn may have a large advantage over mastect-
marked differences in cosmetic outcome between omy patients. Reconstruction patients also felt
the different patient groups. It may be that the they had more control over their treatment than
reconstruction group represent a highly motivated the other two groups. Both reconstruction and
group for whom appearance and cosmetic outcome conservative surgery patients felt positive about
are important, hence the desire for reconstruction their treatment and would recommend it to others.
in the first place and higher scores. Another Mastectomy patients were less positive about their
possible explanation is that cosmetic scores are treatment and much less keen to recommend it.
affected by the level of choice patients feel that Reconstruction appears to have some psychological
they had in determining the nature of their benefit to patients in terms of improved body
treatment.27 Two-thirds of the reconstruction image and a feeling of choice and control in their
group felt that their treatment was predominantly treatment. Therefore, it seems reasonable to
under their control as compared with only one suggest that when discussing treatment for breast
quarter of mastectomy patients and one fifth of cancer, the patient who is required for reasons of
conservatory surgery patients. It is also of note that oncology to have a mastectomy, should be offered
although all three patient groups were predomi- the chance to discuss breast reconstruction and to
nantly positive about choosing their treatment have a reconstruction if desired.
ARTICLE IN PRESS
402 R.M. Nicholson et al.
" Sometimes
" Not at all
9 I get a sort of frightened feeling like ‘butterflies’ in the stomach:
" Not at all
" Occasionally
" Quite often
" Very often
10 I have lost interest in my appearance:
" Definitely
" I don’t take as much care as I should
" I may not take quite as much care
" I take just as much care as ever
11 I feel restless as if I have to be on the move:
" Very much indeed
" Quite a lot
" Not very much
" Not at all
12 I look forward with enjoyment to things
" As much as I ever did
" Rather less than I used to
" Definitely less than I used to
" Hardly at all
13 I get sudden feelings of panic:
" Very often indeed
" Quite often
" Not very often
" Not at all
14 I can enjoy a good book or radio or TV programme:
" Often
" Sometimes
" Not often
" Very seldom
The next section of the questionnaire is designed to find out if you are sensitive or self-conscious about
any aspect of your appearance, (even if this is not usually visible to others.)
15 Is there any aspect of your appearance (however small) that concerns you at all?
Yes/No
If No, go to question 19
If Yes, go to question 16
16 The aspect of my appearance about which I am most sensitive or self-conscious is
y
From now on, we will refer to this as your ‘feature’
17 The thing I don’t like about my feature is
y
18 If you are sensitive or concerned about any other features of your body or your appearance, please say
what they are
y
y
y
ARTICLE IN PRESS
404 R.M. Nicholson et al.
Please read each statement carefully and than circle the appropriate number on the right-hand side. If a
statement does not apply to you, circle N/A. Please be sure to answer the whole scale: do not miss out any
items.
Slightly Greatly
1 2 3 4 5
71 How confident do you feel? 1 2 3 4 5
72 How irritable do you feel? 1 2 3 4 5
73 How secure do you feel? 1 2 3 4 5
74 How cheerful do you feel? 1 2 3 4 5
ARTICLE IN PRESS
406 R.M. Nicholson et al.
The following questions ask for your views about your health, how you feel and how well you are able to
do your usual activities. If you are unsure about how to answer any questions, please give the best answer
you can and make any of your own comments if you like.
79 In general, would you say your health is:
" Excellent
" Very good
" Fair
" Poor
80 Compared to one year ago, how would you rate your health in general now?
" Much better than one year ago
" Somewhat better than one year ago
" About the same
" Somewhat worse now than a year ago
" Much worse than one year ago
Yes Yes No
Limited Limited Not at all
A Lot A Little Limited
1 2 3
81 Vigorous activities such as running lifting heavy objects 1 2 3
82 Participating in strenuous sports 1 2 3
83 Moderate activities, e.g. moving a table 1 2 3
84 Pushing a vacuum cleaner, bowling or playing golf 1 2 3
85 Lifting or carrying groceries 1 2 3
86 Climbing several flights of stairs 1 2 3
87 Climbing one flight of stairs 1 2 3
88 Bending, kneeling or stooping 1 2 3
89 Walking more than a mile 1 2 3
90 Walking half a mile 1 2 3
91 Walking a hundred yards 1 2 3
92 Bathing and dressing yourself 1 2 3
During the past four weeks, have you had any of the following problems with your work or other regular
daily activities as a result of your physical health.
93 Cut down on the amount of time you spent on work or other activities Yes/No
94 Accomplished less than you would like Yes/No
95 Were limited in work or other activities Yes/No
96 Had difficulty performing work or other activities, e.g. it took extra effort Yes/No
During the past four weeks, have you had any of the following problems with your work or other regular
daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
97 Cut down on the amount of time you spent on work or other activities Yes/No
ARTICLE IN PRESS
Risk factors affecting breast reconstruction 407
101 How much bodily pain have you had in the past four weeks?
" None
" Very mild
" Mild
" Moderate
" Severe
" Very severe
102 During the past four weeks, how much did pain interfere with your normal work (including
work both outside the home and housework)?
" Not at all
" A little bit
" Moderately
" Quite a bit
" Extremely
These questions are about how you feel and how things have been with you during the past month. (For
each question, please indicate the one answer that comes closest to the way you have been feeling.) Please
choose one per line.
How much time during the past month
All Most A Good A Little None
The Of Bit Of The Of The
Time The Of The Time Time
Time Time
1 2 3 4 5
103 Did you feel full of life? 1 2 3 4 5
104 Have you been a very 1 2 3 4 5
nervous person?
105 Have you felt so down 1 2 3 4 5
in the dumps that
nothing could cheer
you up?
106 Have you felt calm and 1 2 3 4 5
cheerful?
107 Did you have a lot of 1 2 3 4 5
energy?
108 Have you felt down- 1 2 3 4 5
hearted and low?
109 Did you feel worn out? 1 2 3 4 5
110 Have you been a happy 1 2 3 4 5
person?
111 Did you feel tired? 1 2 3 4 5
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408 R.M. Nicholson et al.
Please choose the answer that best describes how true or false each of the following statements is for
you.
Definitely Mostly Not Mostly Definitely
True True Sure False False
1 2 3 4 5
113 I seem to get ill more easily than other people 1 2 3 4 5
114 I am as healthy as anybody I know 1 2 3 4 5
115 I expect my health to get worse 1 2 3 4 5
116 My health is excellent 1 2 3 4 5
118 What extent do you think you had choice in which treatment you received?
" None at all
" A little choice
" About half my choice, half health professionals’ choice
" Mostly my choice
" Entirely my choice
119 Do you feel that you had sufficient information about different possible treatments before undergoing
surgery?
" I had very little information
" I had some information
" I had quite good information, but would have liked more
" I was sufficiently well informed
" I was fully informed
120 From which sources did you obtain information? You may indicate as many sources as you like.
&General Surgeon &Breast Care Nurse
&Plastic Surgeon &Physiotherapist
&Internet &Books/leaflets
&Friend &Relative
ARTICLE IN PRESS
Risk factors affecting breast reconstruction 409
&Television &Magazine/newspaper
&Other (please specify)
121 Have you had to buy any new clothing as a result of your surgery?
Yes/No
122 If Yes, what have you needed? You may indicate as many options as you like
&Brassieres &Swimming costume
&Sportswear &T-shirts/shirts
&Knitwear &Skirts/Trousers
&Other (please specify)
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