Methods
Parameters used
Scores
Conclusion
Fibrosis, breast retractions, changes in the skin and the matchline effect
0 = none
1 = slight
2 = moderate
3 = severe
Excellent, good, fair, or poor
Asymmetry, skin color change, and scar visibility
Excellent, good, fair, or poor
Asymmetry
Good, fair, or poor
Garbay et al. [13]
Volume and shape of breasts, symmetry, position of the sulcus, and scar
Ranging from 0 (worst result) to 10 (best result)
Calabrese et al. [14]
Shape, volume, and symmetry
Ranging from 1 (worst result) to 3 (best result)
8–9 = excellent
6–7 = good
4–5 = fair
3 or below = poor
In 1979, Harris et al. [5] evaluated the aesthetic outcomes considering fibrosis, breast retractions, changes in the skin, and the matchline effect. The scoring system was as follows: score 0 for none, 1 for slight, 2 for moderate, and 3 for severe. In addition, other classifications were also used: scar unapparent (0), scar apparent (1), and major tissue loss (2). As a whole, the aesthetic results were classified as 1 for excellent (treated breast nearly identical to untreated breast), 2 for good (treated breast slightly different from untreated breast), 3 for fair (treated breast clearly identical to untreated breast but not seriously distorted), and 4 for poor (treated breast seriously distorted).
Two objective methods were described to assess aesthetic results in breast conservative surgery, Breast Cancer Conservative Treatment. Cosmetic results (BCCT.core) [6] and the Breast Analyzing Tool (BAT) [7]. Both methods evaluate photographic records of the patients. BCCT.core analyzes parameters related to asymmetry, color change, and scar, whereas BAT focuses only on asymmetry.
The BCCT.core program automatically evaluates several indices used for the aesthetic evaluation of breast cancer conservative treatment (asymmetry, skin color change, and scar visibility). BCCT.core then uses artificial intelligence techniques to translate these measures into an overall objective classification of aesthetic results reported to the user as excellent, good, fair, or poor [8, 9]. A former analysis showed that the BCCT.core aesthetic status agreed fairly with the patient perspective, measured by the Breast Conservative Treatment Outcome Scale (BCTOS) aesthetic status [10–12].
The BAT program uses well-defined landmarks (jugulomamillary distance and distances from the nipples to the edge of the breast) and calculates the difference between left and right breasts. This difference in length is multiplied by the difference in surface area and is noted as a percent difference and as a difference factor. The values obtained can be converted to a simplified three-point Harris scale (good, fair, poor) [7, 9].
The BCTOS aesthetic status, constructed by Stanton et al. [12], contains 22 items. It was designed to assess women’s subjective evaluation of both the aesthetic and the functional outcome after breast cancer treatment. Patients are instructed to rate each item of the BCTOS questionnaire on a four-point scale evaluating the differences between the treated and the untreated breast (1 for no difference to 4 for large difference). The English version produced a coherent factor structure on 18 items and three internally consistent scales, which are defined as functional status (e.g., shoulder and arm movement, stiffness or pain), cosmetic status (e.g., breast size and texture, breast shape, scar tissue), and breast-specific pain (e.g., breast pain, breast tenderness, and sensitivity) [12].The value of the score of each scale is the mean of the ratings over all the items belonging to this scale [11].
Another method described to evaluate the aesthetic results and modified by Garbay et al. [13], considers the volume and shape of the breast, symmetry, the position of the inframammary crease, and scars (Table 47.2). This instrument seems to be the most complete one from the objective point of view for the evaluation of aesthetic results by experts.
Subscale | Category 0 | Category 1 | Category 2 |
|---|---|---|---|
Volume of breast | Marked discrepancy relative to contralateral side | Mild discrepancy relative to contralateral side | Symmetrical volume |
Shape of breast | Marked contour deformity or shape asymmetry | Mild contour deformity or shape asymmetry | Natural or symmetrical contour |
Placement of breast | Marked displacement | Mild displacement | Symmetrical and aesthetic placement |
Inframammary fold | Poorly defined/not identified | Defined, but with asymmetry | Defined and symmetrical |
Breast scars | Poor (hypertrophy, contracture) | Fair (wide scars, poor color match, but without hypertrophy, contracture) | Good (thin scars, good color match) |
Another scale reported in the literature, developed by Calabrese et al. [14], uses a scoring system that ranges from 1 to 3, and the values of parameters that can be easily identified and quantified by the researcher: shape, volume, and symmetry of the operated on breasts (Table 47.3). A sum of the scores of the three parameters between 8 and 9 was considered excellent, between 6 and 7 was good, between 4 and 5 was fair, and 3 or below was poor. This scoring was reduced by one point every time the following elements were identified: visible scar, NAC badly placed, and visible cutaneous effects from radiotherapy.
Table 47.3
Scale for evaluation of aesthetic results
Parameters | Score |
|---|---|
Shape | 1 2 3 |
Volume | 1 2 3 |
Symmetry | 1 2 3 |
Rough and visible scar | −1 |
NAC badly placed | −1 |
Cutaneous effects from radiotherapy | −1 |
Cano et al. [15] recently published a study evaluating results using BREAST-Q with only 66 % adherence, which makes it questionable because the ideal rate would be above 75 % [16]. BREAST-Q, a patient-reported outcome instrument, was developed with strict adherence to recommended international guidelines to address the lack of instruments for breast surgery patients [17]. There are currently four modules (breast reduction, augmentation, reconstruction, and mastectomy without reconstruction), each of which includes a core of independent scales assessing six domains (satisfaction with breasts, satisfaction with overall outcome, psychosocial well-being, sexual well-being, physical well-being, and satisfaction with care). For each item, the use of response categories scored with successive integer scores (e.g., 1 for very dissatisfied to 4 for very satisfied) implies a continuum of increasing satisfaction, from less (very dissatisfied) to more (very satisfied).
47.3 Quality of Life
In 1947, the World Health Organization defined quality of life for the first time as “a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity.”
Quality of life is the result of a combination of subjective factors, such as the overall level of satisfaction of an individual with his/her own life, and objective factors, such as material well-being, good family relations, promptness to undergo cancer treatment, and reliability on the medical care; to sum up, various items that provide one with peace, reliability, confidence, and well-being. Quality of life needs to cover all human needs, concerning their physical, psychological, social, and spiritual aspects.
Quality of life must be considered throughout all phases of the treatment of a cancer patient. In fact, all symptoms and problems intrinsically related to cancer and its treatment may affect the patient, and they include limitations in daily activities and toxicity resulting from chemotherapy. Many patients still experience changes concerning their jobs, social relations, physical capability, and role within the family.
As a whole, the findings demonstrate that physicians tend to underestimate functioning incapability, the severity of symptoms, psychological afflictions, and psychiatric morbidity among their patients [18, 19]. So, the use of questionnaires that evaluate quality of life has been a way to discover the functioning, psychological, and social needs of patients.
In the past decade, the psychosocial impact of cancer has become a central aspect concerning both the care of patients and the research on this disease. Much research focuses on specific aspects of quality of life that were formerly neglected, such as body image and sexuality [20, 21]. However, there are still few data taking into consideration the period of the end of the primary treatment and extended life [21]. Some researches suggest that problems involving sexuality are usual [20, 22–24], but there is also a decline in the quality of life, body image, humor, and family relations [24, 25].
Several instruments have been used to evaluate quality of life, but we have noticed that they are general questionnaires that do not assess the specific changes realized and experienced by patients undergoing breast cancer treatment (Table 47.4). We have realized that there are changes concerning the self-esteem, sexuality, and femininity that are not properly and satisfactorily assessed in the questionnaires already described and validated. These general instruments aim to evaluate, in a global way, important aspects related to quality of life (physical, social, psychological, spiritual), for instance, the Medical Outcomes Study 36—Item Short Form Health Survey (SF-36) [26], the World Health Organization Quality of Life (WHOQOL) [27], the European Organization for Research and Treatment of Cancer Breast Cancer-Specific Quality of Life Questionnaire (EORTC QLQ-BR23) [28], and Functional Assessment of Cancer Therapy—Breast (FACT-B) [29], and during the climacteric the most relevant ones are the Menopause Specific Quality of Life Questionnaire (MENQOL) [30], the Menopause Rating Scale (MRS) [31], and the Women’s Health Questionnaire (WHQ) [32]. These questionnaires have proven reliable.
Table 47.4
Examples of instruments for the evaluation of quality of life
Instruments | |
|---|---|
Consisting of 11 questions, in a total of 36 items, divided into 8 components: functioning capacity (10 items), physical aspects (4 items), pain (2 items), general health condition (5 items), vitality (4 items), emotional aspects (3 items), mental health (5 items), social aspects (two items) and a question that compares the current health condition with that 1 year before | |
WHOQOL-100 [27] | Comprising 24 facets scored in six domains: physical health, psychological health, levels of independence, social relationships, environment, and spirituality, religion, and personal belief |
EORTC QLQ-C30 [28] | The domains of the functional scale include overall quality of life, physical functioning, role/performance, cognitive functioning, emotional functioning, and social functioning. The three domains of the symptom scale are fatigue, pain, and nausea/vomit. The six simple items are dyspnea, insomnia, loss of appetite, constipation, diarrhea, and financial problems |
EORTC QLQ BR-23 [28] | Consisting of 23 questions, incorporated into multi-items to measure side effects of chemotherapy, symptoms related to the arm and the breast, body image, and sexuality. There are simple items to evaluate sexual satisfaction, disturbance due to hair loss, and future perspectives |
EORTC Trial 10801 [36] | 10 questions related to body image, fear of recurrence, satisfaction concerning the treatment, and the aesthetic results |
FACT-B [29] | Includes physical, social, emotional, and functional subscales plus the Breast Cancer Subscale |
10 questions, with four options for each answer: strongly agree, agree, disagree, or strongly disagree. | |
State–Trait Anxiety Inventory (STAI) [35] | 20-item scale for measuring state anxiety and trait anxiety |
Center for Epidemiologic Studies Depression Scale (CES-D) [35] | 20-item self-report scale designed to measure the presence and degree of depressive symptoms |
Divided into 8 dimensions: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, general mental health, social functioning, vitality (energy/fatigue), and general health perceptions. In addition, it includes a single item providing an indication of perceived changes in health |
SF-36 is a multidimensional questionnaire that consists of 11 questions, with a total number of 36 items, divided into eight components: functioning capacity (ten items), physical aspects (four items), pain (two items), overall health condition (five items), vitality (four items), emotional aspects (three items), mental health (five items), social aspects (two items) and a question that compares the current health condition with that of 1 year before. Each component corresponds to a value that ranges from zero to 100, for which zero represents the worst and 100 the best health condition [33, 34]. Nevertheless, this questionnaire has some limitations, such as not including questions concerning sexuality.
WHOQOL-100 is an instrument that covers 24 facets, assessed by 96 questions, and one general health and overall quality of life facet. Each facet is measured with four items with a five-point Likert scale. Twenty-four facets were initially scored in six domains of overall quality of life: physical health, psychological health, levels of independence, social relationships, environment, and spirituality, religion, and personal beliefs [27]. Nowadays, it is well accepted to convert these 24 facets into four domains as described by the WHOQOL group [33]. High facet scores indicate good quality of life, except for the facets pain and discomfort, negative feelings, and dependence on medication or treatments, which are negatively framed. The timeframe of reference is the previous 2 weeks. The reliability and validity [33] are adequate, and the sensitivity of the instrument is high [35].
EORTC QLQ-C30 and BR-23 is a questionnaire translated and validated in 81 languages and it is used in over 3,000 studies all over the world. QLQ-C30 3.0 is the most recent version and it must be used in all new studies. It consists of 30 questions that define five functioning scales, three symptom scales, an overall quality of life item, and six simple items. The scales comprise a single question. EORTC QLQ-C30 is supplemented by specific disease modules, for instance, breast (QLQ BR-23), lung, head, and neck, esophageal, ovary, gastric, and cervical cancer and multiple myeloma. The domains of the functioning scale are overall quality of life (items 29 and 30), physical functioning (items 1–5), role/performance (items 6 and 7), cognitive functioning (items 20 and 25), emotional functioning (items 21–24), and social functioning (items 26 and 27). The three domains of the symptom scale are fatigue (items 10, 12, and 18), pain (items 9 and 19), and nausea/vomit (items 14 and 15). The six simple items are dyspnea (item 8), insomnia (item 11), loss of appetite (item 13), constipation (item 16), diarrhea (item 17) and financial difficulty (item 28). Module BR-23 consists of 23 questions incorporated in multi-item scales to measure side effects from chemotherapy (items 31–34 and 36–38), symptoms related to the arms (items 47–49) and the breast (items 50–53), body image (item 39–42), and sexuality (items 44 and 45). There are simple items to evaluate sexual satisfaction (item 46), disturbance due to hair loss (item 35), and future perspectives (item 43) [28].
EORTC Trial 10801 is a study that evaluated the quality of life of 278 patients, 127 undergoing radical modified mastectomy and 151 undergoing conservative surgery, using a questionnaire with ten questions concerning body image, fear of recurrence, and satisfaction with both the treatment and the aesthetic results [36]. Although this questionnaire has not been validated yet, it seems to be the most adequate to evaluate the satisfaction level of patients undergoing breast cancer treatment (Table 47.5).
All of the time | Most of the time | Some of the time | Little of the time | None of the time | |
|---|---|---|---|---|---|
1. I feel self-conscious about my appearance | 1 | 2 | 3 | 4 | 5 |
2. I am bothered by thoughts about the recurrence of cancer |
