A Comparison of Psychological Response, Body Image, Sexuality, and Quality of Life between Immediate and Delayed Autologous Tissue Breast Reconstruction: A Prospective Long-Term Outcome Study.
BACKGROUND
This is the first study to use generic distress, cancer-specific, and procedure-specific measures to prospectively evaluate psychological responses, body image, sexuality, and health-related quality of life in immediate compared with delayed breast reconstruction.


METHODS
Consecutive patients undergoing autologous immediate and delayed breast reconstruction (June of 2009 to December of 2010) completed the Hospital Anxiety and Depression Scale, Body Image Scale, Sexuality Scale, and BREAST-Q preoperatively and postoperatively (6, 12, and 18 months). Linear mixed-effects analyses between each outcome and time point were performed.


RESULTS
One hundred six women underwent mastectomy with immediate (n = 30) and delayed breast reconstruction (n = 76). Before reconstruction, 26 percent of patients had abnormal anxiety scores and 9 percent had abnormal depression scores, with no significant differences between groups. Patients awaiting delayed breast reconstruction had significantly impaired prereconstruction body image (p = 0.01) and sexuality (p = 0.01) and worse satisfaction with breast (p < 0.01), psychological (p < 0.01), and sexual well-being (p < 0.01). At 18 months after immediate and delayed breast reconstruction, there was significant improvement in anxiety, depression, body image, sexuality, and health-related quality of life.


CONCLUSIONS
This single-center study shows that mastectomy with immediate breast reconstruction may protect breast cancer patients from a period of psychosocial distress, poor body image, and diminished sexual well-being compared with those waiting for delayed breast reconstruction. In patients who are oncologically eligible and strongly interested in breast reconstruction, efforts should be made to provide immediate breast reconstruction to decrease the interval of psychosocial distress, poor body image, and impaired sexuality.
Toronto, Ontario, Canada.|From the Division of Plastic and Reconstructive Surgery, Breast Reconstruction Program, the Department of Surgery, and Department of Surgical Oncology, University Health Network; and the Division of Plastic and Reconstructive Surgery and the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.
Toni
T
Zhong
Toronto, Ontario, Canada.|From the Division of Plastic and Reconstructive Surgery, Breast Reconstruction Program, the Department of Surgery, and Department of Surgical Oncology, University Health Network; and the Division of Plastic and Reconstructive Surgery and the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.
Jiayi
J
Hu
Toronto, Ontario, Canada.|From the Division of Plastic and Reconstructive Surgery, Breast Reconstruction Program, the Department of Surgery, and Department of Surgical Oncology, University Health Network; and the Division of Plastic and Reconstructive Surgery and the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.
Shaghayegh
S
Bagher
Toronto, Ontario, Canada.|From the Division of Plastic and Reconstructive Surgery, Breast Reconstruction Program, the Department of Surgery, and Department of Surgical Oncology, University Health Network; and the Division of Plastic and Reconstructive Surgery and the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.
Anthony
A
Vo
Toronto, Ontario, Canada.|From the Division of Plastic and Reconstructive Surgery, Breast Reconstruction Program, the Department of Surgery, and Department of Surgical Oncology, University Health Network; and the Division of Plastic and Reconstructive Surgery and the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.
Anne C
AC
O'Neill
Toronto, Ontario, Canada.|From the Division of Plastic and Reconstructive Surgery, Breast Reconstruction Program, the Department of Surgery, and Department of Surgical Oncology, University Health Network; and the Division of Plastic and Reconstructive Surgery and the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.
Kate
K
Butler
Toronto, Ontario, Canada.|From the Division of Plastic and Reconstructive Surgery, Breast Reconstruction Program, the Department of Surgery, and Department of Surgical Oncology, University Health Network; and the Division of Plastic and Reconstructive Surgery and the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.
Christine B
CB
Novak
Toronto, Ontario, Canada.|From the Division of Plastic and Reconstructive Surgery, Breast Reconstruction Program, the Department of Surgery, and Department of Surgical Oncology, University Health Network; and the Division of Plastic and Reconstructive Surgery and the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.
Stefan O P
SOP
Hofer
Toronto, Ontario, Canada.|From the Division of Plastic and Reconstructive Surgery, Breast Reconstruction Program, the Department of Surgery, and Department of Surgical Oncology, University Health Network; and the Division of Plastic and Reconstructive Surgery and the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.
Kelly A
KA
Metcalfe
D000328:Adult; D000368:Aged; D001007:Anxiety / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D001828:Body Image; D003863:Depression / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016014:Linear Models; D016462:Mammaplasty / Q000379:methods* / Q000523:psychology; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology; D011446:Prospective Studies; D011569:Psychiatric Status Rating Scales; D011788:Quality of Life; D020018:Sexual Dysfunctions, Psychological / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D013997:Time Factors; D014182:Transplantation, Autologous
Derogatis LR, Morrow GR, Fetting J, et al. The prevalence of psychiatric disorders among cancer patients. JAMA 1983;249:751757.
Kadan-Lottick NS, Vanderwerker LC, Block SD, Zhang B, Prigerson HG. Psychiatric disorders and mental health service use in patients with advanced cancer: A report from the coping with cancer study. Cancer 2005;104:28722881.
Roth RS, Lowery JC, Davis J, Wilkins EG. Psychological factors predict patient satisfaction with postmastectomy breast reconstruction. Plast Reconstr Surg. 2007;119:20082015; discussion 2016.
Al-Ghazal SK, Sully L, Fallowfield L, Blamey RW. The psychological impact of immediate rather than delayed breast reconstruction. Eur J Surg Oncol. 2000;26:1719.
El-Hadidy MA, Elnahas W, Hegazy MA, Hafez MT, Refky B, Wahab KM. Psychiatric morbidity among Egyptian breast cancer patients and their partners and its impact on surgical decision-making. Breast Cancer (Dove Med Press) 2012;4:2532.
Rosenberg SM, Tamimi RM, Gelber S, et al. Body image in recently diagnosed young women with early breast cancer. Psychooncology 2013;22:18491855.
Gilboa D, Borenstein A, Floro S, Shafir R, Falach H, Tsur H. Emotional and psychosocial adjustment of women to breast reconstruction and detection of subgroups at risk for psychological morbidity. Ann Plast Surg. 1990;25:397401.
Holmberg L, Zarén E, Adami HO, Bergström R, Burns T. The patient’s appraisal of the cosmetic result of segmental mastectomy in benign and malignant breast disease. Ann Surg. 1988;207:189194.
Maguire GP, Lee EG, Bevington DJ, Küchemann CS, Crabtree RJ, Cornell CE. Psychiatric problems in the first year after mastectomy. BMJ 1978;1:963965.
Reaby LL. Reasons why women who have mastectomy decide to have or not to have breast reconstruction. Plast Reconstr Surg. 1998;101:18101818.
Al-Ghazal SK, Fallowfield L, Blamey RW. Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur J Cancer 2000;36:19381943.
Eltahir Y, Werners LL, Dreise MM, et al. Quality-of-life outcomes between mastectomy alone and breast reconstruction: Comparison of patient-reported BREAST-Q and other health-related quality-of-life measures. Plast Reconstr Surg. 2013;132:201e209e.
Stevens LA, McGrath MH, Druss RG, Kister SJ, Gump FE, Forde KA. The psychological impact of immediate breast reconstruction for women with early breast cancer. Plast Reconstr Surg. 1984;73:619628.
Wellisch DK, Schain WS, Noone RB, Little JW III. Psychosocial correlates of immediate versus delayed reconstruction of the breast. Plast Reconstr Surg. 1985;76:713718.
Handel N, Silverstein MJ, Waisman E, Waisman JR. Reasons why mastectomy patients do not have breast reconstruction. Plast Reconstr Surg. 1990;86:11181122; discussion 1123.
Harcourt DM, Rumsey NJ, Ambler NR, et al. The psychological effect of mastectomy with or without breast reconstruction: A prospective, multicenter study. Plast Reconstr Surg. 2003;111:10601068.
Hopwood P, Lee A, Shenton A, et al. Clinical follow-up after bilateral risk reducing (‘prophylactic’) mastectomy: Mental health and body image outcomes. Psychooncology 2000;9:462472.
Michopoulos I, Douzenis A, Kalkavoura C, et al. Hospital Anxiety and Depression Scale (HADS): Validation in a Greek general hospital sample. Ann Gen Psychiatry 2008;7:4.
Hopwood P, Fletcher I, Lee A, Al Ghazal S. A body image scale for use with cancer patients. Eur J Cancer 2001;37:189197.
Cull AM. The assessment of sexual function in cancer patients. Eur J Cancer 1992;28:16801686.
Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient-reported outcome measure for breast surgery: The BREAST-Q. Plast Reconstr Surg. 2009;124:345353.
Aaronson N, Alonso J, Burnam A, et al. Assessing health status and quality-of-life instruments: Attributes and review criteria. Qual Life Res. 2002;11:193205.
Klassen AF, Pusic AL, Scott A, Klok J, Cano SJ. Satisfaction and quality of life in women who undergo breast surgery: A qualitative study. BMC Womens Health 2009;9:11.
Cancer Care Ontario. Available at: https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=351577. Accessed March 7, 2016.
Thornton J, Sorokin ES. Optimal timing of breast reconstruction: An algorithm for management based on a review of the literature. Breast Dis. 2002;16:3135.
Bostwick J III, Carlson GW. Reconstruction of the breast. Surg Oncol Clin N Am. 1997;6:7189.
Kronowitz SJ, Kuerer HM. Advances and surgical decision-making for breast reconstruction. Cancer 2006;107:893907.
Zhong T, McCarthy C, Min S, et al. Patient satisfaction and health-related quality of life after autologous tissue breast reconstruction: A prospective analysis of early postoperative outcomes. Cancer 2012;118:17011709.
Kronowitz SJ. State of the art and science in postmastectomy breast reconstruction. Plast Reconstr Surg. 2015;135:755e771e.
Kronowitz SJ. Delayed-immediate breast reconstruction: Technical and timing considerations. Plast Reconstr Surg. 2010;125:463474.
Bates DM, Maechler M, Bolker B. lme4: Linear mixed effects models using S4 classes. R Package Version 0.999999-0 2012.
McCarthy CM, Klassen AF, Cano SJ, et al. Patient satisfaction with postmastectomy breast reconstruction: A comparison of saline and silicone implants. Cancer 2010;116:55845591.
Elder EE, Brandberg Y, Björklund T, et al. Quality of life and patient satisfaction in breast cancer patients after immediate breast reconstruction: A prospective study. Breast 2005;14:201208.
Murphy RX Jr, Wahhab S, Rovito PF, et al. Impact of immediate reconstruction on the local recurrence of breast cancer after mastectomy. Ann Plast Surg. 2003;50:333338.
Vandeweyer E, Hertens D, Nogaret JM, Deraemaecker R. Immediate breast reconstruction with saline-filled implants: No interference with the oncologic outcome? Plast Reconstr Surg. 2001;107:14091412.
Howard MA, Polo K, Pusic AL, et al. Breast cancer local recurrence after mastectomy and TRAM flap reconstruction: Incidence and treatment options. Plast Reconstr Surg. 2006;117:13811386.
Winters ZE, Benson JR, Pusic AL. A systematic review of the clinical evidence to guide treatment recommendations in breast reconstruction based on patient- reported outcome measures and health-related quality of life. Ann Surg. 2010;252:929942.
Lee CN, Ko CY. Beyond outcomes: The appropriateness of surgical care. JAMA 2009;302:15801581.
Fernández-Delgado J, López-Pedraza MJ, Blasco JA, et al. Satisfaction with and psychological impact of immediate and deferred breast reconstruction. Ann Oncol. 2008;19:14301434.
Metcalfe DB, Duggal CS, Gabriel A, Nahabedian MY, Carlson GW, Losken A. Prevalence of body dysmorphic disorder among patients seeking breast reconstruction. Aesthet Surg J. 2014;34:733737.
Alderman AK, Wilkins EG, Kim HM, Lowery JC. Complications in postmastectomy breast reconstruction: Two-year results of the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. 2002;109:22652274.
Atisha D, Alderman AK, Lowery JC, Kuhn LE, Davis J, Wilkins EG. Prospective analysis of long-term psychosocial outcomes in breast reconstruction: Two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study. Ann Surg. 2008;247:10191028.
Eberlein TJ, Crespo LD, Smith BL, Hergrueter CA, Douville L, Eriksson E. Prospective evaluation of immediate reconstruction after mastectomy. Ann Surg. 1993;218:2936.
Alderman AK, Hawley ST, Waljee J, Morrow M, Katz SJ. Correlates of referral practices of general surgeons to plastic surgeons for mastectomy reconstruction. Cancer 2007;109:17151720.
Roth RS, Lowery JC, Davis J, Wilkins EG. Quality of life and affective distress in women seeking immediate versus delayed breast reconstruction after mastectomy for breast cancer. Plast Reconstr Surg. 2005;116:9931002; discussion 1003.
Anderson SG, Rodin J, Ariyan S. Treatment considerations in postmastectomy reconstruction: Their relative importance and relationship to patient satisfaction. Ann Plast Surg. 1994;33:263270; discussion 270.
Yueh JH, Slavin SA, Adesiyun T, et al. Patient satisfaction in postmastectomy breast reconstruction: A comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg. 2010;125:15851595.
Parker PA, Youssef A, Walker S, et al. Short-term and long-term psychosocial adjustment and quality of life in women undergoing different surgical procedures for breast cancer. Ann Surg Oncol. 2007;14:30783089.
Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of psychosocial outcomes in breast reconstruction: One-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. 2000;106:10141025; discussion 1026.
Alderman AK, Wilkins EG, Lowery JC, Kim M, Davis JA. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg. 2000;106:769776.
Zhong T, Fernandes KA, Saskin R, et al. Barriers to immediate breast reconstruction in the Canadian universal health care system. J Clin Oncol. 2014;32:21332141.
Sisco M, Du H, Warner JP, Howard MA, Winchester DP, Yao K. Have we expanded the equitable delivery of postmastectomy breast reconstruction in the new millennium? Evidence from the national cancer data base. J Am Coll Surg. 2012;215:658666; discussion 666.