title: The impact of mastectomy type on the Female Sexual Function Index (FSFI), satisfaction with appearance, and the reconstructed breast's role in intimacy.
abstract: BACKGROUND
  As mastectomy rates increase and overall survival for early breast cancer improves, a better understanding of the long-term consequences of mastectomy is needed. We sought to explore the correlation of specific mastectomy type with the Female Sexual Function Index (FSFI), body image satisfaction, and the reconstructed breast's role in intimacy.
  
  
  METHODS
  This study is a secondary analysis of a cross-sectional survey including a retrospective chart review. Patients at least one year from primary surgery were invited to complete the survey between 2012 and 2014. Baseline characteristics and survey responses were compared between three mastectomy groups: total/modified radical (TMRM), skin-sparing (SSM), and nipple-sparing (NSM). All patients underwent reconstruction.
  
  
  RESULTS
  Of 453 invited, 268 (59%) completed the survey. Sixty underwent mastectomy with reconstruction: 16 (27%) TMRM, 36 (60%) SSM, and 8 (13%) NSM. There were no significant differences in median total FSFI scores between groups, yet median FSFI scores for the NSM group indicated sexual dysfunction. After adjusting for receipt of chemotherapy and/or radiation, NSM had the lowest median desire score. There was a trend for the NSM group to be the least satisfied with postoperative appearance, but also more likely to report that the chest was "often" caressed during intimacy. However, nearly 40% of the NSM group reported that caress of the reconstructed breast was unpleasant.
  
  
  CONCLUSIONS
  NSM offers patients the greatest opportunity for preservation of their native skin envelope and potentially enhanced cosmetic outcome, but our results did not demonstrate superior sexual function or body image outcomes in this group. By highlighting surgical consequences of mastectomy preoperatively, surgeons may better set realistic patient expectations regarding both aesthetic and functional outcomes after breast cancer surgery. With clearer expectations, patients will have a better opportunity for improved surgical decision-making.
authors.affiliation: The Program in Women's Oncology, Women & Infants Hospital Breast Health Center, Warren Alpert School of Medicine/Brown University, Providence, RI, USA. krojas@wihri.org.
authors.forename: K
authors.identifier: http://orcid.org/0000-0001-7826-176X
authors.initials: K
authors.lastname: Rojas
authors.affiliation: Department of Gynecologic Oncology, MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: M
authors.initials: M
authors.lastname: Onstad
authors.affiliation: Division of Research, Women and Infants' Hospital of Rhode Island, Providence, RI, USA.
authors.forename: C
authors.initials: C
authors.lastname: Raker
authors.affiliation: Center for Health Policy and Research, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
authors.forename: M A
authors.initials: MA
authors.lastname: Clark
authors.affiliation: The Program in Women's Oncology, Women & Infants Hospital Breast Health Center, Warren Alpert School of Medicine/Brown University, Providence, RI, USA.
authors.forename: A
authors.initials: A
authors.lastname: Stuckey
authors.affiliation: The Program in Women's Oncology, Women & Infants Hospital Breast Health Center, Warren Alpert School of Medicine/Brown University, Providence, RI, USA.
authors.forename: J
authors.initials: J
authors.lastname: Gass
mesh_terms: D000328:Adult; D000368:Aged; D001828:Body Image; D001943:Breast Neoplasms / Q000523:psychology / Q000601:surgery*; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008408:Mastectomy / Q000009:adverse effects*; D008875:Middle Aged; D059351:Organ Sparing Treatments; D009948:Orgasm; D017060:Patient Satisfaction; D012649:Self Concept; D020018:Sexual Dysfunctions, Psychological / Q000209:etiology*
keywords: Breast cancer; Intimacy; Mastectomy; Nipple sparing; Sexuality; Survivorship