What Effect Do Surgical Choices Have on Quality of Life in Young Breast Cancer Survivors?

Unilateral or bilateral mastectomy can have a significant negative effect on quality of life when compared with breast-conserving surgery (BCS) in young breast cancer survivors, according to a new study.

“Despite the fact there is equivalent locoregional control and survival with breast conservation and mastectomy, rates of bilateral mastectomy are increasing in young women,” said Laura Dominici, MD, of the Dana-Farber Cancer Institute and Brigham and Women’s Hospital in Boston. She said the rate of mastectomy has jumped almost tenfold in recent years, from 3.6% in 1998 to 33% in 2011. “Young women are at an increased risk for poorer psychosocial outcomes following a breast cancer diagnosis and in survivorship; however, little is known about the impact of surgery, particularly in the era of increasing bilateral mastectomy, on quality of life in young survivors.”

Dominici presented results of a prospective study using the BREAST-Q questionnaire at the San Antonio Breast Cancer Symposium (SABCS), held December 4–8 (Abstract GS5-06). Researchers sent the survey to 743 breast cancer survivors aged 40 and younger who were included in the Young Women’s Breast Cancer Study; there was a response rate of 79% (584 participants). The median time from diagnosis to completion of the BREAST-Q questionnaire was 5.8 years.

Most of the patients included were Caucasian (90%), 32% had a BMI of 25 or higher, and 77% were married. Most patients reported their financial status was comfortable (77%), and 61% worked full-time.

Just over half the participants (52%) underwent bilateral mastectomy, with 20% undergoing unilateral mastectomy and 28% undergoing BCS. Among 400 patients who underwent mastectomy, 11% did not have any reconstruction, 69% had implant-based reconstruction, 12% had flap reconstruction, and 8% had unknown or other types of reconstruction. Of the 160 patients who underwent BCS, 99% received radiation; 45% of eligible patients received post-mastectomy radiation.

The BREAST-Q had four domains, and BCS patients had better scores on three of the four. With regard to satisfaction with breasts, the mean score was 65.5 among BCS patients compared with 60.4 and 59.3 among bilateral and unilateral mastectomy patients (P = .008). For psychosocial well-being, the mean scores for BCS, bilateral mastectomy, and unilateral mastectomy patients were 75.9, 68.4, and 70.6, respectively (P < .001). For sexual well-being, those scores were 57.4, 49, and 53.4, respectively (P < .001). Scores for physical well-being were similar, at 78.9, 78.7, and 78.9, respectively (P = .8).

On a multivariate analysis, mastectomy, radiation, and uncomfortable financial status were all significantly associated with decreased satisfaction with breasts. An uncomfortable financial situation was associated with poorer physical well-being, as was the presence of lymphedema. Compared with BCS, both forms of mastectomy were associated with significantly poorer psychosocial well-being, as well as with poorer sexual well-being.

“Knowledge of the potential long-term impact of surgery on quality of life is of critical importance for counseling young women about surgical decisions,” Dominici said.

C. Kent Osborne, MD, of the Dan L. Duncan Cancer Center at Baylor College of Medicine and co-director of SABCS, who was not involved with the research, said the data are particularly disconcerting given the high rate of mastectomy in the United States when compared with elsewhere. “This urge to have bilateral mastectomy… is ridiculous in some cases, because it doesn’t improve your outcome, and it does have deleterious effects that can last for years,” he said.