Contralateral prophylactic mastectomy in breast cancer patients with a family history: A prospective 2-years follow-up study of health related quality of life, sexuality and body image

doi:10.1016/j.ejca.2012.04.023

European Journal of Cancer

Volume 48, Issue 17, November 2012, Pages 3150-3156

https://doi.org/10.1016/j.ejca.2012.04.023 Get rights and content

Abstract

Introduction

Contralateral prophylactic mastectomy (CPM) is the most effective option to prevent the occurrence of a second breast cancer in hereditary breast cancer patients. This study aimed to prospectively evaluate health-related quality of life (HRQoL), anxiety and depression, sexuality and body image in breast cancer patients with a family history undergoing CPM with immediate breast reconstruction.

Patients and methods

In total, 60 of 69 eligible patients agreed to participate in the study. Four validated questionnaires were used: the SF-36, the Hospital Anxiety and Depression Scale (HAD), the Body Image Scale (BIS), and the Sexual Activity Questionnaire (SAQ). Forty-five patients (75%) responded before CPM, 49 (82%) at 6 months, and 45 (75%) at 2 years after CPM.

Results

Overall, the patients showed a satisfactory HRQoL 2 years after CPM, similar to women in the general population. There were no differences in HRQoL, anxiety, depression or sexuality before and after CPM. However, more than half of the women reported at least one body image problem 2 years postoperatively.

Conclusion

No adverse effects on HRQoL, anxiety, depression or sexuality were observed. However, some aspects of body image were negatively affected after CPM. These findings could be used in preoperative counselling of breast cancer patients opting for CPM.

Introduction

About 10% of breast cancer patients have a hereditary predisposition and are considered to be at high risk for a contralateral breast malignancy.1, 2For a patient with a hereditary non-BRCA1/2 breast cancer, the cumulative probability of developing contralateral breast cancer is about 27% at 20 years after the primary diagnosis.³ For a patient with an identified BRCA1 or BRCA2 mutation the estimated risk after 10 years is 43% and 35%, respectively.⁴

The risk reducing effect of bilateral and contralateral prophylactic mastectomy (CPM) against developing a primary breast cancer amounts to 90%.5, 6, 7 Nevertheless, CPM is not likely to greatly affect survival.8, 9 In recent years, a substantial increase of CPM rates from 0.4% in 1998 to 4.7% in 2007 has been reported among breast cancer patients.⁸ BRCA mutation screening, magnetic resonance imaging, primary tumour characteristics, and prophylactic oophorectomy are independently associated with increased rates of CPM.10, 11

Retrospective studies conclude that, after CPM, about 85% of the patients are satisfied with their decision to undergo CPM. Patients report levels of health related quality of life (HRQoL) comparable with the levels found among breast cancer patients who have not undergone CPM.12, 13, 14 We have not found any prospective study assessing HRQoL, sexuality and body image before and after CPM. Such information may be important for women in the decision making process.

This study aimed to prospectively (before CPM, 6 months and 2 years after CPM) evaluate HRQoL, anxiety and depression, sexuality and body image in breast cancer patients with a family history, undergoing CPM with immediate breast reconstruction.

Section snippets

Study population

Consecutive patients with a confirmed family history who underwent CPM at Karolinska University Hospital, Department of Reconstructive Plastic Surgery, from January 1998 to June 2008 were eligible for the study. Women diagnosed with bilateral breast cancer were excluded.

Surgical procedure

Skin-sparing mastectomies with tailor-made incisions was the method of choice for CPM. The axilla on the prophylactic side was not explored. All breast reconstructions were implant-based, i.e. adjustable expander-implants or

Results

Ninety-one consecutive breast cancer patients underwent CPM with immediate breast reconstruction at the Karolinska University Hospital during the study period. Twenty-two patients did not have a consultation with the medical psychologist before CPM and were not eligible for the study: 12 women because they underwent CPM in conjunction with breast cancer surgery and 10 women due to administrative failure. Of the remaining 69 women invited to participate, nine did not return any questionnaire.

Discussion

This study prospectively evaluates breast cancer patients with an increased risk of contralateral breast cancer due to family history operated on with CPM. No statistically significant changes in HRQoL, sexuality, body image, anxiety or depression were found after CPM over time.

The patients showed a satisfactory HRQoL 2 years after CPM, similar to women in the general population. Six months after CPM, however, patients scored clinically lower than preoperatively on three SF-36 domains. This

Conflict of interest statement

The authors Dmytro Unukovych, Kerstin Sandelin, Annelie Liljegren, Brita Arver, Marie Wickman, Hemming Johansson, and Yvonne Brandberg disclose no actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within that could inappropriately influence the work.

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Cited by (47)

EBCC-13 manifesto: Balancing pros and cons for contralateral prophylactic mastectomy
2023, European Journal of Cancer
After a diagnosis of unilateral breast cancer, increasing numbers of patients are requesting contralateral prophylactic mastectomy (CPM), the surgical removal of the healthy breast after diagnosis of unilateral breast cancer. It is important for the community of breast cancer specialists to provide meaningful guidance to women considering CPM. This manifesto discusses the issues and challenges of CPM and provides recommendations to improve oncological, surgical, physical and psychological outcomes for women presenting with unilateral breast cancer: (1) Communicate best available risks in manageable timeframes to prioritise actions; better risk stratification and implementation of risk-assessment tools combining family history, genetic and genomic information, and treatment and prognosis of the first breast cancer are required; (2) Reserve CPM for specific situations; in women not at high risk of contralateral breast cancer (CBC), ipsilateral breast-conserving surgery is the recommended option; (3) Encourage patients at low or intermediate risk of CBC to delay decisions on CPM until treatment for the primary cancer is complete, to focus on treating the existing disease first; (4) Provide patients with personalised information about the risk:benefit balance of CPM in manageable timeframes; (5) Ensure patients have an informed understanding of the competing risks for CBC and that there is a realistic plan for the patient; (6) Ensure patients understand the short- and long-term physical effects of CPM; (7) In patients considering CPM, offer psychological and surgical counselling before surgery; anxiety alone is not an indication for CPM; (8) Eliminate inequality between countries in reimbursement strategies; CPM should be reimbursed if it is considered a reasonable option resulting from multidisciplinary tumour board assessment; (9) Treat breast cancer patients at specialist breast units providing the entire patient-centred pathway.
Body image, physical activity and psychological health in older female cancer survivors
2021, Journal of Geriatric Oncology
To determine the association of physical activity and body image with psychological health outcomes and whether body image mediates the association of physical activity with psychological health among older female cancer survivors.
Data from the Women's Health Initiative (WHI) Life and Longevity after Cancer (LILAC) Study were used. Surveys assessed body image (appearance, attractiveness, scars), moderate-strenuous physical activity (min/week), and psychological health (depression, anxiety, distress). A mediation analysis was conducted to estimate the percentage of the total effect of physical activity on psychological health mediated by body image concerns.
Among 4567 female cancer survivors aged 66–98 years, the average time since cancer diagnosis was 9.2 years. Approximately 50% reported no moderate-strenuous physical activity; 15% reported depressive symptoms, 6% reported anxiety, and 5% reported psychological distress; 3% had concerns with appearance, 20% had concerns with attractiveness, and 21% had concerns with scars. When unadjusted for body image concerns, every 30 min/week increase in physical activity was associated with lower risk of depressive symptoms (RR = 0.93, 95%CI: 0.90–0.96), anxiety (RR = 0.92, 95%CI: 0.87–0.97), and distress (RR = 0.92, 95%CI: 0.87–0.98). Body image concerns with appearance mediated 7%, 8.8%, and 14.5% of the association between physical activity and depressive symptoms, anxiety, and distress, respectively.
Older female cancer survivors reported body image concerns, which were associated with both physical activity and psychological health. Our findings suggest that interventions designed to address body image concerns in older female cancer survivors could serve to improve the benefit of physical activity on psychological health.
Breast reconstruction patterns from a Swedish nation-wide survey
2020, European Journal of Surgical Oncology
The overall aim of the Swedish Breast Reconstruction Outcome Study was to investigate national long-term outcomes after mastectomy with or without breast reconstruction. The current report evaluates breast reconstruction (BR) patterns in Sweden over time.
This is a cross-sectional, registry-based study where all women operated with mastectomy 2000, 2005, 2010 were identified (N = 5853). Geographical differences in type of BR were investigated using heatmaps. Distribution of continuous variables were compared using the Mann-Whitney U test, categorical variables were compared using the chi-square test.
Mean age at survey was 69 years (SD=±11.4) and response rate was 50%, responders were on average six years younger than the non-responders and had a more favourable tumor stage (both p < 0.01). Of the 2904 responders, 31% (895/2904) had received a BR: implant-based in 58% (516/895)autologous in 31% (281/895). BR was immediate in 20% (176/895) and delayed in 80% (719/895) women.
Women with BR were on average one year older, more often had a normal BMI, reported to be married or had a partner, had a higher educational level and a higher annual income when compared to those without BR (all p < 0.001). The independent factors of not receiving BR were older age and given radiotherapy.
To our knowledge, this is the first national long-term follow-up study on women undergoing mastectomy with and without BR. Around 30% of the survey responders have had a BR with a significant geographical variation highlighting the importance of information, availability and standardisation of indications for BR.
Women's body image following mastectomy: Snap shots of their daily lives
2019, Applied Nursing Research
Citation Excerpt :
Women have attributed their decision to undergo a breast reconstruction as a means of returning to being themselves and acquiring a sense of identity or to look their “normal self” (Denford, Harcourt, Rubin, & Pusic, 2011). However, most women experience disturbed body image even after undergoing breast reconstruction (Fallbjörk, Rasmussen, Karlsson, & Salander, 2013; Unukovych et al., 2012). A study on the impact of surgical treatments (breast-conserving surgery [BCS], mastectomy alone, mastectomy with reconstruction) and severity of surgical side-effects on body image of women with early stage breast cancer, reported no significant difference in body image scores of women with BCS and those with mastectomy and reconstruction, over time.
Body image problems in women with and without breast cancer 6–20 years after bilateral risk-reducing surgery – A prospective follow-up study
2019, Breast
Citation Excerpt :
Though bilateral RRM shows a risk-reduction of approximately 90% for developing breast cancer in asymptomatic individuals [1–4], the need for reoperations, due to postoperative complications and/or revisions to achieve satisfying cosmetic results after implant-based reconstruction, still exists [5,6]. Previous prospective short-term follow-up studies have shown high overall cosmetic satisfaction six months and one year post-RRM, corresponding to the women's expectations, and no negative impact on anxiety/depressive symptoms, or HRQoL [7,8]. Body image and sexuality were negatively affected the first years after surgery [9–12].
To prospectively follow-up and investigate women's perceptions of the cosmetic outcome of their implant-based breast reconstruction, body image, sexuality, anxiety/depressive symptoms, and health-related quality of life (HRQoL) 6–20 years after bilateral risk-reducing mastectomy (RRM), or complementary RRM after breast cancer diagnosis, due to increased risk of hereditary breast cancer.
Women with and without previous breast cancer diagnosis that underwent RRM between March 1997 and September 2010 were invited (n = 200). We compared 146 (73%) sets of long-term questionnaire responses (e.g., EORTC QLQ-BRR26, Body Image Scale, Sexuality Activity Questionnaire, Hospital Anxiety and Depression Scale, and SF-36) with responses one year after surgery. Women with and without previous breast cancer were compared at the long-term assessment point.
The HRQoL and anxiety/depressive symptoms remained unchanged compared with one year after surgery, and there were no between-group differences. The negative impact on body image persisted in both groups for most of the items. ‘Sexual discomfort’ increased significantly for women with previous breast cancer (p = 0.016). Women with previous breast cancer also reported more problems with ‘Disease treatment/surgery related symptoms’ (p = 0.006) and ‘Sexuality’ (p = 0.031) in the EORTC QLQ-BRR26 questionnaire.
Problems with body image appeared to persist long time post-RRM. No differences in HRQoL were found at the long-term follow-up between women with and without previous breast cancer. The results of this investigation might be of use in improving future counselling before risk-reducing surgery for women in the decision-making process.
Modified radical mastectomy and simple mastectomy
2018, The Breast: Comprehensive Management of Benign and Malignant Diseases
Introduction: The surgical techniques used in mastectomy are in constant evolution because of advancement in knowledge and the needs of patients.
Methodology: Literature review of different types of mastectomy.
Results: Halsted radical mastectomy (RM), the first effective surgery in treating breast cancer, was later modified by Patey, Madden, and others to preserve the pectoralis major muscle. Studies showed comparable survival outcomes between the two types of mastectomy. The modified radical mastectomy (MRM) became the standard treatment for women with stage I and II breast cancer in the 1970s. However, the axillary lymph node dissection (ALND), a part of modified radical mastectomy, was associated with significant side effects. Hence, the simple mastectomy (SM) was developed to spare the ALND and focus on treating the local disease only. Studies showed that survival after SM with or without radiation was comparable to those with RM.
Recently, adjuvant systemic treatment has been shown to significantly improve disease-free and overall survival in patients with node-positive breast cancer, which requires nodal staging to guide therapy. Sentinel lymph node biopsy (SLNB) was invented to provide adequate pathologic nodal status in clinically negative axilla. Today, SM coupled with SLNB has largely replaced the MRM.
Additional modifications to mastectomy by sparing the skin and the nipple areolar complex further increased its popularity.
Discussion: The evolution of surgical treatment of breast cancer is governed by the principles of controlling the local disease and providing adequate pathology with minimal adverse effects. The validity of any new procedure requires confirmation.

View all citing articles on Scopus

^☆: Some preliminary results of the study was presented as a poster at the European Multidisciplinary Cancer Congress, Stockholm 23–27 September 2011.

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Contralateral prophylactic mastectomy in breast cancer patients with a family history: A prospective 2-years follow-up study of health related quality of life, sexuality and body image☆

Abstract

Introduction

Patients and methods

Results

Conclusion

Introduction

Section snippets

Study population

Surgical procedure

Results

Discussion

Conflict of interest statement

Lancet

Eur J Cancer

Soc Sci Med

Int J Radiat Oncol, Biol, Phys

J Plast Reconstr Aesthet Surg

The contribution of inherited predisposition to cancer incidence

Cancer Surv.

Autosomal dominant inheritance of early-onset breast cancer. Implications for risk prediction

Cancer

Contralateral breast cancer in BRCA1 and BRCA2 mutation carriers

J Clin Oncol

Efficacy of contralateral prophylactic mastectomy in women with a personal and family history of breast cancer

J Clin Oncol

Contralateral prophylactic mastectomy. Predictors of significant histologic findings

Cancer

Efficacy of prophylactic mastectomy in women with unilateral breast cancer: a cancer research network project

J Clin Oncol

Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment

J Clin Oncol

Prophylactic mastectomy for the prevention of breast cancer

Cochrane database of systematic reviews

Trends in contralateral prophylactic mastectomy for unilateral cancer: a report from the national cancer data base, 1998–2007

Ann Surg Oncol