For centuries, descriptions have been offered of the influence that women’s breasts have on their self-identity, interpersonal relationships (including sexual ones), and other important aspects of their lives. Not surprisingly, the impact of breast cancer has been extensively discussed. For example, Moyer and Salovey (4) state that the disfigurement associated with breast cancer treatment forces a woman to address the cultural connection of the breast to her femininity, sexuality, and physical intactness (3,6).

Some women may grieve or mourn the loss of her preoperative breast(s) (7). The grieving process may be pronounced and lengthy, particularly when treatment involves radical surgery such as mastectomy (8, 9). It can include a wide range of thoughts, feelings, and behaviors. For example, a breast cancer survivor may purchase loose fitting clothes to hide the appearance of her breasts, thereby reflecting her physical self-consciousness (10). She may be less comfortable engaging in sexual behavior because of her body changes, which in turn can result in less frequent or less satisfying sexual experiences. Whereas such behaviors may diminish with time, they may also be the circumstances that eventually motivate women toward breast reconstruction.

A woman’s adaptation to breast reconstruction may be hindered if the surgery is immediate rather than delayed. In these circumstances, the mourning of the loss of the breast may be short-circuited. Interestingly, some urge women to “complete” the grieving process prior to reconstruction surgery (7). Winder and Winder (11) comment that when ample time is given, a woman will be more able to integrate the reconstructed breast into her new body image. However, it is important to note that these are clinical perspectives only, and they remain to be examined empirically.

We view women’s responses to changes to the breast following cancer surgery as being similar to those of persons who experience traumatic life stressors (3). The Breast Impact of Treatment Scale (BITS) (see Questionnaire 11-1) is a 15-item questionnaire designed specifically for use with breast cancer patients to assess their level of body image distress attributed to the breast cancer surgery. Within the measure, body image distress is conceptualized as a breast cancer survivor’s thoughts and behaviors (that tend to reflect anxiety like symptoms) toward her new altered body image following the stressor (i.e., surgery for breast cancer).

The BITS format is similar to that of the Impact of Events Scale (IES) (12, 13). The IES is a self-report measure that subjectively assesses anxiety symptoms such as avoidance and intrusion responses to a significant life event (e.g., cancer). Similarly the BITS items are scored on a scale of 0 = not at all, 1 = rarely, 3 = sometimes, and 5 = often. The BITS consists of 15 items where four items are characterized as Avoidance (scores ranging from 0 to 20) and the remaining 11 items are Intrusion (scores ranging from 0 to 55). The Avoidance and Intrusion items reflect the two factors of this measure. Intrusive responses are worded to evaluate pervasive thoughts (e.g., “Things I see or hear remind me that my body is different”), troubling images (e.g., “How my body changed pops into my mind”), and troubled dreams and strong feelings (“I think about how my treatments may affect my sex life”). Avoidant responses include thoughts (e.g., “I think about how my body looked before I was treated”), denial surrounding the event (e.g., “I avoid looking at and or touching my scar”), and behaviors (e.g., “I turn away when I have to undress in front of my partner”).

The BITS has satisfactory reliability and validity (14) as demonstrated in studies of breast cancer samples. For example, women receiving mastectomy report higher body change stress on the BITS than do women receiving breast-conserving treatment following surgery (4) as well as 12 months later (14). The BITS appears to be a clinically useful and relevant measure for a breast cancer team.

As discussed in Chapter 4, body image is a multidimensional concept that refers to how persons perceive their physical appearance, with all associated thoughts, feelings, and behaviors (15). In the breast cancer literature, Hopwood (16) has commented on the similarities between body image and related topics, such as self-concept, attractiveness, self-confidence, sexuality, and self-esteem. Unfortunately in this literature, some researchers have used the term body image, when in fact they were measuring sexual functioning, self-esteem, or body integrity (17). With this confusion, integrating findings and arriving at definitive conclusions regarding the role of body image in breast reconstruction is difficult (6,16, 17, 18, 19). Further complicating the issue is the fact that many different “body image” measures have been used
in past research. These include the Body Image Scale from the Derogatis Sexual Functioning Inventory (20); Body Satisfaction Scale short version (21); Body Image Visual Analogue Scale (6); Tennessee Self Concept Scale (22); Body Cathexis Scale (23); Homonyms Test (24); and the Body Esteem Scale (25), among others. Some of these measures, unfortunately, have relatively undocumented reliability and validity, thus limiting their utility (8,26). Both clinicians and researchers need to be mindful of these issues when selecting measures. Chapter 4 provides a more detailed discussion of body image assessment tools.

An early clinical study suggested that the diagnosis of cancer produces an “existential plight,” meaning that the news brings shock, disbelief, and emotional turmoil (28). For the individual, the manner in which the information regarding the diagnosis is disclosed is important. Physicians who communicate hope have patients who are, in turn, more hopeful and have a more favorable emotional adjustment. Alternatively, communicating “false hope” is unwelcome (29). In a study of gynecologic cancer patients, for example, Roberts et al. (30) found that, although patients expect compassion from their physicians, the majority (89%) also prefers “straight-talk” about their prognosis. This points to the need for physicians and other health professionals to be effective communicators with their patients (31, 32).

Illustrating this point, a study by Rutter et al. (33) evaluated physician communication training as a strategy to reduce patient distress. Physicians received 1 hour and 15 minutes of training and a handbook regarding ways to improve the structure and style of their patient interactions. Based on Ley’s work (34), training included aids to enhance cognitive understanding (e.g., simplification, repetition) and emotional understanding (e.g., conveying warmth, listening, giving feedback). Trained physicians also provided patient information booklets describing adjuvant treatments to encourage patient participation and enhanced feelings of control. All patients were assessed before and after their physician consultation for adjuvant chemotherapy. Three physicians, prior to their communication skills training, saw a consecutive series of 18 patients who served as controls. Then, physician training was completed, and data were gathered from the next 18 patients of the same physicians. All patients reported reductions in anxiety (35) following their physician visit. More importantly, patients seen following physician training reported fewer depressive symptoms (36) and higher levels of satisfaction and personal control. After training, physicians were also evaluated by their patients as more skilled.

The importance of physician communication training is underscored by the clinical context of sadness (depression), fear (anxiety), and anger, which characterized patients’ responses at the time of diagnosis. A patient’s level of distress exists along a continuum from normal feelings to those including profound vulnerability, sadness, fear, anxiety, panic, and social isolation (37). Depressive symptoms are the most common emotional problem. In a recent review of studies (38), as many as 23% of cancer patients met the criteria for major depressive disorder; much higher than the rate of 5% to 6% in the general population (38). When major depression and depressed mood are considered, prevalence rates are comparable—21% in Bodurka-Bevers et al. (39), 16% in Derogatis et al. (40), 17% in Kornblith et al. (41), and 25% in a review by Massie and Holland (42). Lower rates of depression have been found when patients are ambulatory with good physical functioning rather than in the midst of or recovering from treatments (41, 42, 43). For example, in a study of Latina cervix cancer patients undergoing radiotherapy (44), depressive symptoms were predicted by lower levels of support from the family, stress, physical symptoms from the treatment, and practical barriers to receiving treatment (e.g., transportation difficulties). In general, depression is more common for newly diagnosed patients with pain or other disturbing symptoms rather than not, those in active treatment (e.g., chemotherapy), and/or those with a history of affective disorder or substance abuse (41,45, 46).

Anxiety-related problems also can be significant. For some patients, anxiety is severe. Studies report, for example, that diagnostic rates of cancer-related Post Traumatic Stress Disorder (PTSD) are low (3% to 10%) (47, 48, 49), but sub-syndromal PTSD symptoms occur in up to 50% of patients (50,51). PTSD symptoms include cognitive (e.g., images of re-experiencing the traumatic events), behavioral (e.g., avoidance of reminders of the event), emotional (e.g., a “numbing” or blunting of affect), and physiological (e.g., hyperarousal, alertness) responses. Importantly, the BITS assesses the magnitude of women’s posttraumatic stress responses specific to their breast changes.

Psychological variables appear to play a role in the magnitude of emotional distress. Individuals who perceive their illness as severe (52), or who have a sense of pessimism about one’s life (53), tend to have greater mood disturbance. In fact, Carver et al. (53) found that general pessimism (versus optimism) at diagnosis predicted poorer well being (mood and life satisfaction), not only one day before surgery but at 3-month, 6-month, and 12-month follow-ups as well. Miller et al. (54) reported similar results at 2-month and 4-month follow-ups. Alternatively, when patients use positive ways to cope, such as seeking social support and assistance from friends and family, they have less anxiety and depression; when they use avoidance, their moods worsen (55).

The clinical problem of diagnostic and treatment-related distress can be alleviated through psychological interventions (56, 57). Even modest, early efforts can significantly reduce patients’ distress as they approach cancer treatments. For example, McQuellon et al. developed a brief oncology clinic orientation program in the hopes of reducing anxiety, distress, and uncertainty in newly diagnosed cancer patients (58). The same principles shown in this study could be applied when devising a patient orientation for reconstructive surgery. The standardized program was designed to minimize the appraisal of threat in the new and unfamiliar setting. The 20-minute intervention included a tour of the oncology clinic, a verbal description of clinic administrative procedures, a handout of information (telephone numbers, map to the clinic, etc.), and a brief question and answer session. Patients were encouraged to address all medical questions to the medical staff. One hundred fifty patients were randomized into the treatment and control (no orientation) groups. One week after their initial visit, anxiety and mood disturbance decreased significantly for patients who received the intervention, whereas mood disturbance increased for control patients.
Improvements such as these are all the more impressive because they can be achieved with brief, cost-effective interventions delivered by nonphysicians (56).

Of course, a certain component of the emotional distress that occurs at the time of the breast cancer diagnosis is due to the patient’s anticipation of treatments. Consider the multiple “stops” the breast cancer patient makes on the way to surgery. There are radiology studies, biopsy, physical examinations, tumor surveys, laboratory studies, and other requirements. Thus, the process of learning about and selecting the appropriate therapy, and waiting for it to occur, represents multiple medical stressors for patients. And then, there is the reconstruction consultation.

As discussed below, the data are consistent in their portrayal of increased distress (particularly fear and anxiety) among cancer patients. There are slower rates of emotional recovery, and, perhaps, higher rates of other behavioral difficulties (e.g., food aversions, continued fatigue, and malaise) among surgery patients relative to healthy individuals undergoing medical treatment. There have been few psychosocial investigations of cancer surgery, per se, but there are numerous descriptive and intervention studies of the reactions of healthy individuals undergoing surgery for benign conditions. The latter studies are consistent in their portrayal of (i) high levels of self-reported preoperative anxiety predictive of lowered postoperative anxiety and (ii) postoperative anxiety predictive of recovery (e.g., time out of bed, pain reports). What may distinguish cancer surgery patients are higher overall levels of distress and slower rates of emotional recovery. For example, Andersen, Anderson, and DeProsse reported significantly worse negative moods for cancer patients than those with benign disease, as both awaited surgical treatment (59). Also, negative moods for both groups were higher than those for a matched group of healthy women. Following surgery, distress can continue. Gottesman and Lewis found greater and more lasting feelings of crisis and helplessness among cancer patients in comparison to benign surgery patients for as long as 2 months following discharge (60).

As noted above, there has been considerable research on the psychological and behavioral aspects of surgery. Many effective interventions designed to address these issues have been tested (61). Components of these interventions include procedural information (i.e., how the surgery is to be performed as well as preoperative and postoperative events from the perspective of the patient); sensory information on the actual physical sensations of preparatory procedures and the surgery per se (e.g., the specific nature of postsurgical pain); behavioral coping instructions; cognitive coping interventions; relaxation; hypnosis; and emotion focused interventions. In a meta-analysis of this literature, Johnston and Vogele reported that providing procedural information and behavioral instructions showed consistent and strong positive effects on postoperative recovery (61). Effects are significant for a broad band of measures, including ratings of negative affect and pain, amount of pain medication, length of stay, behavioral recovery, and physiological indices (61).

Psychological interventions have focused on a variety of methods to improve patient adjustment. The physician communication training intervention of Rutter, Iconomou, and Quine (33) discussed above and related efforts to provide additional information (e.g., orientation to the reconstruction consultation) can be cost effective. These interventions, as well as relaxation therapy (62), could be implemented with breast cancer patients. Further, with adequate training and supervision, peers or volunteers could be successfully used as “therapists.” With a triage model, intensive (and expensive) efforts, such as psychiatric referral, could be provided selectively to moderate to high risk/high distress patients. Whether delivered to individual patients or to patient groups, these interventions are
multimodal and include components consisting of stress reduction (progressive muscle relaxation training), disease/treatment information, cognitive-behavioral coping strategies, and social support (56).