Motivations, satisfaction, and information of immediate breast reconstruction following mastectomy

Abstract

This study evaluated patients’ motivations for, and satisfaction with, the treatment and information of immediate breast reconstruction (IBR) with a silicone prosthesis. It studied satisfaction more deeply by relating it to the quality of life, body-image and sexual functioning. Seventy-three patients who received mastectomy, followed by IBR with a subpectoral silicone prosthesis, completed a self-report questionnaire concerning their motivations for, perceived advantages of and satisfaction with IBR, the information received, quality of life, body image, and sexual functioning. Despite the fact that 50% of the reconstructions resulted in complications or complaints, 70% of the women were satisfied with the reconstruction and only 12% would never choose IBR again. Satisfaction was strongly correlated with the need for information. The higher the patient’s expectations, the higher their need for information. The most common perceived advantage of IBR was the avoidance of an external prosthesis. A majority of patients were satisfied with the breast reconstruction. However, a sizeable proportion needed more information about breast reconstruction and the use of the silicone prosthesis. To avoid too high expectations more attention should be given to possible complications and the moderate cosmetic results.

Introduction

In recent years, the surgical treatment of breast cancer has made significant advances: from Halsted’s ‘radical’ mastectomy, in which both pectoral muscles are removed en bloc with the breast and axillary lymph nodes; to the Patey or Madden modified radical mastectomy; to breast conserving therapy (BCT), which combines lumpectomy and axillary lymph node dissection, followed by radiation of the breast. Studies comparing the psychological impact of mastectomy and BCT show advantages for BCT on body-image [1], [2], [3], [4], [5], [6], [7] and sexual satisfaction [3], [5], [6], [8], [9]. However, other psychological advantages, such as fewer feelings of depression or loneliness, or a better quality of life, have not been consistently reported in these studies.

BCT is not recommended for all patients. Depending on the size, location or pathological features of the tumour, mastectomy may be preferable. In these cases, breast reconstruction may be the means to improve cosmesis. Studies looking at mastectomy with and without breast reconstruction show the same psychological advantages when comparing mastectomy and BCT: greater satisfaction with the body-image [10], [11], [12], [13], [14] and with sexual functioning [15]. The most common reasons given by women for their choice of breast reconstruction are a reluctance to have an external prosthesis, the chance to wear a greater variety of clothing and a desire to restore their feelings of wholeness and body-integrity [10], [13], [14], [16], [17], [18], [19].

There are various methods of breast reconstruction, the choice of which is dependent on the preference of the surgeon, in consultation with the patient. The women studied by Stevens et al. [14] and Schain et al. [13] showed more psychological benefit from immediate breast reconstruction (IBR) than from a delayed operation: this included less depression, less time to mourn the complete loss of a breast, and not having to endure mutilation while waiting for reconstruction. An additional advantage is that immediate breast reconstruction alleviates the need for a second operation. Later reconstruction is more difficult because of skin restriction.

For the reconstruction of the breast, surgeons can use patients’ own body tissue, such as the latissimus dorsi myocutaneous flap or the transverse rectus abdominous myocutaneous (TRAM) flap. Such procedures involve major operations, with additional scars on the back or abdomen and morbidity; for instance weakness of the abdominal wall after the TRAM flap. Silicone or saline-filled breast implants do not have these disadvantages. The prosthesis can be implanted through one incision in a relatively simple operation. Silicone implants have the advantage over saline-filled implants of being less permeable and thereby having a higher chance of remaining the same volume. Furthermore, silicone implants are better at mimicing natural breast movements.

Because of these advantages, the Department of Surgical Oncology of the Dr. Daniel den Hoed Cancer Center in 1990 adopted IBR with the use of a subpectoral placed silicone-gel prosthesis as its preferred procedure. Subsequently, however, silicone implants became a topic of concern in the medical literature, as well as in the media, reporting both systemic and local complications [18], [20], [21], [22]. Since 1994 several cohort studies have described the introduction of an atypical connective tissue disease or of rheumatic complaints with silicone breast prosthesis [23], [24], [25], [26].

Winer et al. [22] concluded that a significant proportion of patients are worried about possible medical complications as a consequence of silicone breast implants. As implications of their research they suggested that: “the true risks associated with silicone implants will ultimately be known. In the meantime, health care providers need to address patients’ concerns about these implants. Information and guidance regarding the potential benefits and risks of breast implant devices should be provided to women with breast cancer who are considering treatment options.”

Because of these concerns and the controversy, we decided to carry out our own study of patients’ motivation and satisfaction with silicone-implant IBR; and, more particularly, with the psychological aspects related to it.

In this study, we were interested in patients’ motivations for, and satisfaction with IBR. Furthermore, we wanted to look at satisfaction in more detail, since quality of life, body-image and sexual functioning were mentioned in the literature as variables of importance.

For motivation, we looked at the reasons patients mentioned for their choice of IBR, as well as their construed advantages of IBR. Satisfaction was looked at from two points of view: the treatment as such, and the information provided for the treatment. As far as satisfaction with the treatment was concerned, satisfaction was operationalised in terms of questions such as: would the patients recommend IBR to other patients? Would they recommend IBR with silicone prosthesis to other patients? Would they choose the same treatment again? Were they satisfied with the reconstruction? And, did they have complaints about the reconstruction? Satisfaction with the received information looked at items measuring the need for more information about: the use of silicone prosthesis; the advantages and disadvantages of IBR; the results of breast reconstruction; breast cancer as such and its treatment; and, how to cope with specific problems and where to find help. In order to find out how important the information was for the satisfaction of the treatment, the relations between the two were studied. Quality of life, body image and sexual functioning were also looked at in relation to satisfaction.