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Choice of Surgical Procedure Has Lasting Impact on Quality of Life

Bennett, Christina, MS

doi: 10.1097/01.COT.0000553545.07124.be
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SAN ANTONIO—Young women with breast cancer who had breast-conserving surgery scored better on quality-of-life measures than women who had bilateral or unilateral mastectomy, yet still had long-term quality-of-life problems, an observational, multicenter prospective study showed. The findings were presented at the 2018 San Antonio Breast Cancer Symposium (Abstract GS6-06).

“Despite equivalent local regional control and survival with breast conservation and mastectomy, rates of mastectomy, and particularly bilateral mastectomy, are increasing in young women,” said study presenter Laura Dominici, MD, FACS, a surgeon at Dana-Farber/Brigham and Women's Cancer Center, Assistant Professor of Surgery at Harvard Medical School, and Division Chief of Breast Surgery at Brigham and Women's Faulkner Hospital. A ten-fold increase in mastectomy rates was seen from 1998 to 2011.

“We know that young women are at increased risk for poor psychosocial outcomes following a breast cancer diagnosis and in survivorship,” Dominici continued. “However, little is known about the impact of surgery, particularly in the era of increasing bilateral mastectomy, on quality of life in young survivors.”

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Study Details

Between October 2006 and June 2016, women who were 40 years of age or younger at diagnosis of breast cancer (stage 0, I, II, or III) were enrolled on study. Patients who did not provide consent were not included. The study used a cross-sectional design and was conducted at 12 academic and community hospital sites. Demographics and treatment information were obtained from serial surveys and chart review.

Patients were sent the BREAST-Q, an instrument to gather patient-reported outcomes specific to breast surgery. The instrument generates a BREAST-Q score on a scale of 0 to 100, and higher scores correspond with better quality of life. Four BREAST-Q domains were included: satisfaction with breasts, psychosocial well-being, physical well-being, and sexual well-being. The BREAST-Q was administered either as a standalone survey or as part of patients' 10-year follow-up. The median time from diagnosis to BREAST-Q completion was 5.8 years, and the response rate was 79 percent.

A total of 560 patients were included in the analysis. Patients had a median age at diagnosis of 37 years (range, 17-40 years). Most patients (90%) were Caucasian, married (77%), financially comfortable (79%), and had a college education or higher (86%). One-third of patients had a body mass index of 25 or greater. Most patients were stage I (38%) or II (39%); 10 percent were stage 0 and 14 percent were stage III. Most patients underwent chemotherapy (72%), and 66 percent underwent endocrine therapy.

As for surgery characteristics, 52 percent of patients had bilateral mastectomy, 28 percent had breast-conserving surgery, and 20 percent had unilateral mastectomy. Most patients had reconstruction (71%), 69 percent of which had implant-based reconstruction, 12 percent had flap reconstruction, 8 percent had unknown or other reconstruction, and 11 percent had no reconstruction. Nearly all patients who had breast-conserving surgery had radiation (99%), and 45 percent of patients who had mastectomy received radiation. At 1 year after surgery, 29 percent of patients reported lymphedema.

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Quality-of-Life Findings

The average BREAST-Q scores for breast satisfaction were highest for breast-conserving surgery (65.5) and lowest for bilateral mastectomy (60.4) and unilateral mastectomy (59.3). The average BREAST-Q score for physical well-being was similar for breast-conserving surgery (78.9), bilateral mastectomy (78.7), and unilateral mastectomy (78.9). The average BREAST-Q score for psychosocial well-being was highest for breast-conserving surgery (75.9) and lowest for bilateral mastectomy (68.4) and unilateral mastectomy (70.6). The average BREAST-Q score for sexual well-being was highest for breast-conserving surgery (57.4), followed by unilateral mastectomy (53.4), and bilateral mastectomy (49).

A multivariate analysis revealed a significantly lower breast satisfaction among women who had unilateral (p<0.001) or bilateral mastectomy (p<0.001) compared with women who had breast-conserving surgery. Women who had radiation or reported an uncomfortable financial status also had a lower breast satisfaction score.

No significant difference in physical well-being score was seen on the basis of surgical procedure, but women who reported lymphedema or an uncomfortable financial status had significantly lower physical well-being quality-of-life scores than women who did not. Women who were greater than 5 years out from surgery had significantly higher scores for physical well-being than those who were between 1 and 5 years from surgery.

For psychosocial well-being, women who had a unilateral (p=0.001) or bilateral mastectomy (p<0.0001) had lower psychosocial well-being than women who had breast-conserving surgery. Again, women who received radiation or reported an uncomfortable financial status had lower psychosocial well-being. In addition, women who had a body mass index of 25 or higher had a lower psychosocial well-being.

Lastly, for sexual well-being, women who had unilateral (p=0.15) or bilateral mastectomy (p<0.001) had lower sexual well-being than women who had breast-conserving surgery. Again, women who reported an uncomfortable financial status, lymphedema, or a body mass index of 25 or higher had lower sexual well-being.

“Local therapy decisions are associated with a persistent impact on quality of life in young breast cancer survivors,” Dominici concluded. “Compared to breast-conserving surgery, unilateral or bilateral mastectomy, even with the majority of these patients having reconstruction, is associated with significant decrease in quality-of-life domains for satisfaction with breasts, psychosocial well-being, and sexual well-being. Financial distress was associated with lower scores across all four BREAST-Q domains and socioeconomic stressors likely contribute to poorer quality of life.”

The study has limitations, such as being a one-time survey and observational study. In addition, the study may lack generalizability to more diverse populations because most of the participants were white and of a high socioeconomic status.

“What surprised me a little bit is just how long-term and sustained the impact on, not just the satisfaction, but also their physical, psychosocial, sexual well-being are,” Alastair Thompson, MD, the Section Chief of Breast Surgery, Division of Surgical Oncology, at Baylor College of Medicine, told Oncology Times. “We always tend to emphasize the way things look, and clearly as surgeons or breast plastic surgeons, we tend to want to give people the best look we can, but their psychosocial well-being and sexual well-being can really be impacted.

“Almost everything we do, whether it's surgically or surgically plus radiation, does have consequences for women who go through the necessary treatments,” Thompson noted.

Christina Bennett is a contributing writer.

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
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