NEWS

Emotional Outcome After Breast Surgery Is Highly Individual

Barbara Boughton

The final straw for Addie Gilbert, 51, came when she tried on her favorite red dress, one with stylish criss-cross straps in the front, and realized she could probably never wear it again. The heavy prosthesis she used after her mastectomy was clearly apparent underneath. "I was so depressed that I sat on the floor of my bedroom and cut the dress up into little pieces with scissors," she said. As well as not being able to wear the clothes she loved after her mastectomy, Gilbert was constantly reminded of the trauma of her breast cancer diagnosis every time she looked at herself in the mirror and saw the scar on her chest, she said.



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Addie Gilbert had breast reconstruction surgery after her mastectomy. "All I could say was ‘Oh my God,’" Gilbert recalled. "Suddenly, I felt whole again."

 
That’s when Gilbert decided to have a breast reconstruction, in which skin and tissue was taken from her abdomen to mold a new breast. Three months later, Carolyn Kerrigan, M.D., added an areola and nipple in an office procedure, then held up a mirror for Gilbert to observe the results. "All I could say was ‘Oh my God.’ Suddenly, I felt whole again," Gilbert said.

For women like Gilbert, mastectomy can be a bitter pill to swallow. But for others, it is an acceptable alternative—a welcome reprieve from a diagnosis of breast cancer. Researchers find that a woman’s psychological response to breast cancer surgery is highly individual and often depends on her age, her attitudes about body image and sexuality, and whether her surgery will be accompanied by adjuvant therapy, such as radiation and chemotherapy.

The medical community once theorized that lumpectomy would leave women less psychologically scarred than mastectomy, but scientific studies have failed to support this belief. Most studies since the 1980s have shown that women with lumpectomy and mastectomy are comparable in overall self-image and psychological health, though some have contradicted this view.

Only when it comes to personal body image and sense of attractiveness to their partners do women who have had mastectomies clearly suffer more self-doubt. As a result, some scientists are emphasizing the need for health professionals to give women complete explanations of what breast cancer surgery may mean in their physical and emotional lives.

Study Limitations

Early studies on the psychosocial effects of breast cancer surgery were often compromised by problems such as small sample size and variability in methods. So in 1997, researcher Anne Moyer, Ph.D., performed a meta-analysis of 40 investigations on the psychological impact of breast cancer surgery, using weighted effect sizes (ES) to take into account study sample size. Her analysis, published in Health Psychology in May 1997, showed benefits for women with lumpectomies versus those with mastectomies. Women who had lumpectomies had better psychological adjustment, body image, marital and sexual functioning, and social adjustment and fewer cancer-related fears and concerns.

"It’s important for people to understand that though the effect may be small, there are some potential benefits to breast conserving surgery," said Moyer, researcher at the Center for Health Care Evaluation in Palo Alto, Calif.

A large 1999 study bolsters this view but reveals some of the widely varying influences on women’s emotional health after surgery. The study assessed the psychological and physical health of 267 Baltimore and Montreal breast cancer patients—women with lumpectomies, mastectomies plus reconstruction, and mastectomies alone. Researchers found that women with lumpectomies had better physical and psychological health and fewer problems with body image than did women in the other two groups.

Influence of Age

Yet, the women’s quality of life tended to vary depending on age. Among women less than 55 years old, mastectomy patients reported more physical illness and mental health difficulties. Among women older than 55 years, the effect was just the opposite. Women with lumpectomies had the poorest quality of life. The researchers theorized that for women over age 55, body image may not be as critical, and they may find the radiation that accompanies lumpectomy more onerous.

Other researchers, however, explain that there may be additional reasons for the different emotional reactions of older and younger women to their surgeries. "Some older women who have lumpectomies may be getting these surgeries because they have other comorbid illnesses, and may be more prone to physical and psychological symptoms," said Julia Rowland, Ph.D., director of the Office of Cancer Survivorship at the National Cancer Institute. "Likewise, some younger women with mastecomies may also have more advanced cancer, or may not be candidates for breast sparing surgery, and so are more at risk for physical and emotional difficulties," she added.



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Dr. Julia Rowland

 
Carolyn Kerrigan, M.D., one of the lead researchers for the study, also cautioned that the results should be considered in light of the fact that the scientists did not study the women before their surgeries, so those who reported a better quality of life may have been more healthy and emotionally adjusted beforehand.

"For some women, not having a breast is a non-issue," said Kerrigan, professor of surgery at Dartmouth Medical School, Hanover, N.H. "Others would rather die than live without a breast. Often it depends on the type of women they are."

Highly Individual Responses

The most comprehensive research to date—a series of studies on the physical and emotional well-being of almost 2,000 breast cancer patients—supports Kerrigan’s view that a woman’s reaction to her breast cancer surgery is a highly individual issue. But the newest in this series of studies also provides the most conclusive evidence yet that the type of surgery is not the most important factor affecting a breast cancer patient’s emotional health.

In the studies, women who had undergone breast cancer surgery from 1989 to 1996 were asked to fill out a variety of self-report questionnaires that assessed their physical and emotional well-being. "We’ve generally found that age, co-morbidity, and exposure to adjuvant therapy are the most important predictors of a woman’s psychological health—not type of surgery," Rowland said.

In the newest study in the series, which compared women with lumpectomies, those with mastectomies and reconstruction, and those with mastectomies alone, the researchers controlled for age, time since diagnosis, ethnicity, partnership status, education, tamoxifen use, and chemotherapy treatment. "The three groups looked almost identical in terms of psychological health, although the women with lumpectomies clearly had a stronger benefit in terms of personal sense of attractiveness and their feelings about their attractiveness to their partners," Rowland said. The study is on p. 1422 of this issue of the Journal.

As a result of her research, Rowland believes that thorough counseling about breast cancer surgery is especially important. "As much as possible, the choice of surgery should feel right to a woman and fit with her values," she said.



             
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