Clinical follow-up after bilateral risk reducing ('prophylactic') mastectomy: mental health and body image outcomes.
BACKGROUND
In Manchester, approximately 120 women at > or = 1:4 lifetime risk of breast cancer have considered preventative surgery since 1992. Women treated within the Manchester protocol receive two genetic counselling sessions, a psychological assessment and a surgical consultation pre-operatively and annual follow-up post-operatively. The vast majority of women have breast reconstruction.


METHODS
Since 1996, mental health and body image have been assessed in women attending annual follow-up using self-report questionnaires: the 28-item General Health Questionnaire (GHQ) and 10-item Body Image Scale (BIS). Women with high scores are assessed by clinical interview together with a proportion who have no significant problems.


RESULTS
Between 1995 and 1999, 76 women completed surgery. Ten were awaiting post-operative review and 60 (91%) attended for follow-up of whom 45 (75%) were interviewed. Questionnaire data were available for 52 (79%) women, mean age 40.8 years (range 27-58). Six women were gene mutation carriers and of these three had had breast cancer. One additional patient was affected but had not been genetically tested. Eight (17%) of 47 women with assessments in the first post-operative year scored in the 'caseness' range on the GHQ: the mean GHQ score was 3.8 (S.D. 6.7), range 0-25. Results were comparable with those for women attending the Family History Clinic for risk assessment. The mean score on the BIS was 5.1 (S.D. 5.5), range 0-25, comparable with scores for women undergoing conservative surgery for breast cancer. Twenty-one percent of women reported no negative change in body image following surgery (i.e. zero questionnaire summary scores) and the majority of changes reported were of minor degree (item scores 0 or 1). The most frequently reported changes were in sexual attractiveness (55%), feeling less physically attractive (53%) and self-consciousness about appearance (53%): a third of women felt less feminine to a minimal degree. These results appeared stable over time. A minority of women had more serious psychological or body image concerns, usually in relation to surgical complications: they received further psychiatric intervention.


CONCLUSIONS
For the majority of women there is no evidence of significant mental health or body image problems in the first 3 years following Bilateral Prophylactic Mastectomy (BPM), but women who have complications warrant additional psychological help. Careful pre-operative preparation and long-term monitoring are advocated in this new field of cancer prevention.
Hopwood
P
P
The CRC Psychological Medicine Group, Christie Hospital NHS Trust, Withington, Manchester, UK. penelope.hopwood@man.ac.uk
Lee
A
A
Shenton
A
A
Baildam
A
A
Brain
A
A
Lalloo
F
F
Evans
G
G
Howell
A
A
D000328:Adult; D001828:Body Image; D001943:Breast Neoplasms / Q000517:prevention & control* / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008408:Mastectomy / Q000523:psychology*; D008603:Mental Health; D008875:Middle Aged; D016609:Neoplasms, Second Primary / Q000517:prevention & control*; D011183:Postoperative Complications; D012307:Risk Factors