14 Psychosocial Aspects of Oncoplastic Breast Conservation

10.1055/b-0037-144859

14 Psychosocial Aspects of Oncoplastic Breast Conservation

Diana Harcourt

The psychosocial consequences of breast cancer surgery can be profound, including a negative impact on a woman’s sense of self and body image, as well as an impact on those people close to her. These effects have been documented in numerous research reports and moving, personal accounts. Recent developments in breast conservation and oncoplastic surgery have been driven, in part, by a desire to minimize these negative experiences and they have offered considerable benefits to many women who have lost one or both breasts. ¹

This chapter considers the possible psychosocial implications of breast reconstruction after a full or partial mastectomy and reflects on the need to provide appropriate support for women who are faced with often complex and overwhelming decisions about oncoplastic and reconstructive surgery. Examples of recently developed interventions to support patient decision-making and areas for future research in this field are also discussed.

The Psychological Impact of Breast Reconstruction

A large body of research in this field suggests that a breast cancer patient’s psychosocial functioning (in terms of anxiety, depression, and quality of life) typically returns to presurgical levels approximately 1 year after diagnosis. Researchers have also explored the effect of treatment on patients’ body image (defined here as their thoughts, feelings, and behaviors in relation to their physical appearance), sexuality, and self-esteem. Less-invasive surgical procedures typically have a more favorable impact on a patient’s body image than radical operations ² but any form of surgery may have lasting effects that can remain problematic when other psychosocial aspects have improved. ³ – ⁵

Although reconstruction has proved beneficial for many women ⁶ it is not a universal remedy for the challenges and distress associated with a mastectomy. ⁷ Women often report being satisfied with their decision to undergo reconstruction, ⁶ – ⁹ even though they may still have difficulty adjusting to their postsurgical appearance and body image because of scarring, the loss of sensation, and breast asymmetry. ⁸ , ¹⁰

The number of women who choose either a conservative surgical procedure or a mastectomy with reconstruction, instead of a mastectomy alone, illustrates the importance they place on their appearance and on preserving their body image and body integrity throughout their breast cancer treatment. ⁹ Women often seek treatment that will make them feel “intact,” and developments in partial reconstruction are likely to appeal to many who undergo cancer surgery. However, although breast conservation and partial reconstructive techniques are less radical, there may still be a poor cosmetic result, causing patients to feel “less whole.”

To date, there has been limited research into the psychosocial impact of partial breast reconstruction. That which has been conducted has found that anxiety about residual cancer and concerns around breast self-examination were similar among women who had either a skin-sparing surgery or partial mastectomy with flap reconstruction. ¹¹ Anxiety and depression were similar in the two surgical groups.

On the basis of the small amount of research in this area to date, it would be shortsighted to assume that partial breast reconstruction is a panacea for the body image concerns of patients who do not undergo a full mastectomy; they all face the challenge of assimilating the altered appearance, sensations, and texture of the reconstructed breast into their body image. This can be a difficult and slow process.

Conservative procedures will not suit all women, and it is important to reiterate that women who undergo less-radical procedures can also experience the difficulties and concerns associated with full reconstruction.

Patient Satisfaction and Expectations of Surgery

Several studies have reported a high level of patient satisfaction with the outcome of breast reconstruction and with the decision to undergo the surgery. However, findings about patient satisfaction are inconsistent. In an audit of more than 15,000 women who underwent mastectomy in England, ¹² which included more than 5,000 who chose to undergo breast reconstruction, a third of immediate reconstruction patients and almost a quarter (22%) of delayed reconstruction patients could not describe the outcome as “excellent” or “very good” 18 months after surgery. Forty percent of immediate reconstruction patients were unsatisfied with the appearance of their breast after surgery.

Patient satisfaction is a complex issue, and general reports of ‘overall satisfaction’ do not reveal whether patients are more or less satisfied with some aspects than with others.

Scarring (particularly at the donor site), asymmetry of the breasts, complications, and the need for additional procedures have all been identified as areas of dissatisfaction among patients who have undergone a full reconstruction. ⁸ , ¹⁰ , ¹³ , ¹⁴ These factors are also likely to influence the satisfaction of women who have had partial procedures.

Interestingly, Roth et al ¹⁵ examined the influence of presurgical psychological variables on patient satisfaction with outcome. Affect, depressive symptoms, and somatization (bodily complaints) all related to general and aesthetic satisfaction 1 year after surgery, raising the possibility that presurgical psychosocial support and interventions might influence post-surgical satisfaction.

A surgeon might think that postsurgical scarring could be improved through further intervention, yet the patient is happy with the aesthetic outcome as it stands.

When considering patient satisfaction, surgeons must recognize that this can vary over time and that a woman’s subjective experience and report of satisfaction with the outcome of surgery may not agree with the objective ratings given by another person, such as her partner, or by the breast care team. Indeed, research and personal accounts have repeatedly shown that objective measures of an individual’s appearance (for example, the extent of scarring) fail to predict psychosocial adjustment. ¹⁶ Surgery can still affect a woman’s body image and prove distressing, even if someone else would consider the results to be satisfactory or unnoticeable.

Very little research has focused on the psychological impact of complications after breast reconstruction and their affect on patient satisfaction. A study by Gopie et al ¹⁷ found a discrepancy between patients’ and surgeons’ reports of complications after reconstructive surgery, with women reporting more complications than surgeons did. Women who thought they had had a complication reported higher levels of anxiety and depressive symptoms than those who did not. The psychosocial impact of complications after partial breast reconstruction warrants consideration, as does a more detailed understanding of women’s experiences of complications of any sort and how this relates to patient satisfaction.

Expectations may be particularly high—possibly unrealistically so—if patients view partial reconstruction as a less radical and therefore simpler procedure that will have little impact on their body image and appearance.

Body image and appearance may be particularly salient issues for women who elect to have breast-conserving surgery rather than mastectomy alone. This may lead them to be particularly aware and critical of the aesthetic outcome of their surgery and is one of the reasons that establishing each woman’s motivations and presurgical expectations is so important. Because a reconstruction is not a true replacement, women who expect a reconstructed breast to look and feel the same as their natural breast are likely to be dissatisfied with the outcome of surgery.

Decision-Making

Deciding whether to undergo breast reconstruction after a full mastectomy can be difficult and daunting. ⁸ The numerous options regarding the type and timing of surgery are complex, and each option requires thoughtful consideration. Decision-making can be particularly difficult if the choices are presented soon after the cancer diagnosis. Furthermore, the patient may be influenced—consciously or unconsciously—by other people, including partners ¹⁸ , ¹⁹ and health care professionals. Women’s experiences of decision-making about partial breast reconstruction have yet to be researched, but such a decision is not likely to be any easier than choosing whether to undergo a full reconstruction. A challenge for any oncoplastic breast care team is how to help each woman to make the decision that is best for her as an individual, and to ensure that each patient has the information, support, and time she needs to make that choice.

The reasons for choosing either a full or partial breast reconstruction are likely to be very similar. Women who select either option may want to feel “normal”; to preserve their body’s integrity, symmetry, and wholeness; and to maintain their self-confidence, self-esteem, and a sense of femininity. They might also hope to avoid any restrictions on clothing choices and lifestyle that they believe will be inevitable if they opt to have a full or partial external prosthesis. They will want to minimize any constant reminder of the disease and avoid the effects of a mastectomy on intimacy and relationships. ⁸ , ¹⁸ , ²⁰ – ²³ Their choices may also be influenced by the need for any adjuvant treatment. One of the few studies to explore the psychosexual impact of partial or total reconstruction ²⁴ found that expectations about improved body image and sexual well-being after surgery were not met. Nevertheless, women who underwent partial reconstruction reported greater improvement in body image satisfaction 1 year after surgery than those who underwent full mastectomy and reconstruction. This study supports others that have highlighted the importance of examining patients’ presurgical expectations. However, sample size was small, and a study-specific questionnaire was used rather than a standardized patient reported outcome measure such as the Breast-Q, ²⁵ which would have allowed direct comparison with other studies.

Clarifying each woman’s individual motivations, expectations, preferences, and values is essential if health care professionals are to support them through decision-making and surgery.

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