Surgery Choice Seems to Affect Quality of Life for Younger Women
Laura Dominici, M.D., FACS
December 7, 2018

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Dr. Laura Dominici, surgeon at the Dana-Farber/Brigham and Women's Cancer Center, assistant professor of surgery at Harvard Medical School, and division chief of breast surgery at Brigham and Women's Faulkner Hospital, discusses the research she presented at the 2018 San Antonio Breast Cancer Symposium looking at how the type of breast cancer surgery affected quality of life in women 40 and younger who had been diagnosed with breast cancer.

Listen to the podcast to hear Dr. Dominici explain:

  • the design of the study
  • what we can and can't infer from the results
  • why she hopes these results will lead to better communication between doctors and patients

Running time: 10:13

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This podcast is made possible by the generous support of Lilly Oncology.

Jamie DePolo: Hello, everyone. I’m Jamie DePolo, senior editor at Breastcancer.org. We’re podcasting on location from the 2018 San Antonio Breast Cancer Symposium. My guest is Dr. Laura Dominici, a surgeon at Dana-Farber/Brigham and Women’s Cancer Center, who is also assistant professor of surgery at Harvard Medical School and division chief of breast surgery at Brigham and Women’s Faulkner Hospital. We’re going to talk about her research on how surgery choice may affect quality of life for young women diagnosed with breast cancer.

Dr. Dominici, welcome to the podcast.

Laura Dominici: Thank you, I’m so glad to be here.

Jamie DePolo: So, research shows that more younger women are choosing mastectomy, or even double mastectomy, over lumpectomy. And in some cases I’ve read, this is because the women are really afraid of a recurrence or a new cancer. Other times, it’s because they’ve been told their reconstruction options would be better with a mastectomy. But now, your research shows that women who had lumpectomy had better quality of life. So, I was wondering if you could talk about the design of your study, and why you wanted to look into this.

Laura Dominici: Sure. So, like you allude to, we’ve noticed that over the past several years, rates of mastectomy — and particularly bilateral mastectomy in young women — has gone up almost tenfold. And so for that reason, we recognized that it was really complicated, what the reasons for that were. Now, that, we didn’t really feel like we had a good way to look at in a study, as you might imagine, but what we didn’t know is: Are these women actually achieving the things that they want? Are they happier? Do they feel better? Are they happy with how their breasts look afterwards? And we have no data on that.

So, within Dana-Farber, my colleague Ann Partridge has a cohort of young women that she’s followed back from 2006 to 2016. These women enrolled. And they were all women 40 and under who had a diagnosis of breast cancer — and that’s really the population in where the rates of bilateral mastectomy have skyrocketed. So, it was really the right population that we wanted to look at. And these women have been wonderful participants in this study in that they fill out a lot of survey data and they follow them longitudinally. So, we thought that was a nice group of women who were agreeable to fill out surveys and also whom we had an opportunity to have very long-term follow-up. So, essentially, we did a one-time survey sent out to all these women of a survey instrument called the BREAST-Q. The BREAST-Q is an internationally used, validated, quality-of-life instrument, meaning that in studies it’s been shown to be valid in different groups of women.

Jamie DePolo: And it’s a survey that they fill out? Is that right?

Laura Dominici: It’s a survey women fill out, and it has a bunch of different parts to it. Now, some of them are related to: how did you feel after your surgery, and was your doctor — did you connect well with your doctor? We didn’t use those because most of these women were well out from their surgery. But what we did use were the four domains that we felt would be pertinent, and that was specifically the satisfaction with breast, psychosocial well-being, physical well-being, and sexual well-being.

And so we sent all these women this survey at one point in time. And the survey was specific to whether or not they had had breast conservation — breast-conserving surgery and radiation, mastectomy without reconstruction, or mastectomy with reconstruction. And so the women filled out the survey that was appropriate for what surgery they had had and sent it back. And so what we did is, we then broke down the demographic and the clinical factors about these women. And then we compared what their quality of life was for all these different surveys and then tried to look at what factors might contribute to better or worse quality of life.

Jamie DePolo: Okay. And I’m curious, in the results — and you’ll probably tell me this — but did women who had mastectomy with no reconstruction, where did they fall? Did they have better quality of life or better satisfaction with the things that you looked at than women who had mastectomy with reconstruction?

Laura Dominici: So that’s a great question. That’s not what we did in this study.

Jamie DePolo: Oh, you didn’t? Okay.

Laura Dominici: In this study, we specifically looked at the lumpectomy, the single mastectomy, and the double mastectomy — just to try to look at the difference there. We do know that there was a breakdown. About 11% of patients didn’t have reconstruction, 89% did — and different kinds of reconstruction. So our next step in analysis, and what we’re working on now, is looking at just that piece.

Jamie DePolo: Okay.

Laura Dominici: Yeah.

Jamie DePolo: Okay. That sounds good. Now, was there any hint as to why the women with lumpectomy maybe had better satisfaction in those areas? I mean, obviously, it’s less surgery, so there was probably less recovery time, less pain, things like that — but does the survey look at any of that? I mean, do we have any ideas?

Laura Dominici: Well, we don’t have a great amount of ideas about it. What I will say is, it’s clearly not any of those acute factors — the pain after surgery, the recovery time — because these women were generally about at least 2 years out, and some were even 10 years out.

Jamie DePolo: Oh, okay.

Laura Dominici: The median follow-up was about 5.8 years, so these women were pretty far out from surgery. There shouldn’t be any of those differences that happen right after, in terms of recovery, that were accounting for the difference. I think the biggest thing we can’t tell from this study is there may be something about them that makes them choose a lumpectomy versus a mastectomy or a double mastectomy at baseline. Unfortunately, the way we did this study, we don’t have that information about them — who they are as a person, whether that might have contributed to them feeling more confident in one choice or another. That’s important information to get, and that’s something we are continuing to work on in this young women’s cohort and in a larger group of women at our institution. But I think that is absolutely an important driver, but it’s something... other than being able to say that from prior analysis of this group, there weren’t major demographic differences — education, financial status, age, those sorts of things — that seem to contribute, but I think we need more data about their quality of life pre-op, which we just don’t have.

Jamie DePolo: Okay, that makes sense because... I guess I’m thinking to myself somebody may have — before diagnosis even — just liked themselves better, have a better body image... choose lumpectomy and be okay with that, as opposed to somebody maybe who has a poorer body image, wants to get mastectomy and reconstruction to maybe make herself feel more like she wants to feel. I don’t know. I’m just… conjecture.

Laura Dominici: That may absolutely be the case. We don’t know. But I think that the thing that we did pull out of this data — even with the one time — is that the group of women having mastectomy, unilateral or bilateral, had such lower quality of life. It’s hard to feel like it’s going — if someone’s doing it to improve that quality of life, it’s hard to feel like you’re going to be able to reassure them that they’ll get there.

Jamie DePolo: Right. Right, right, and then I just start spinning off — and like, "Well, are these people just always unhappy with themselves," which is very sad, but there are some people that are like that.

Laura Dominici: There are. I mean, there certainly… There were large differences in our study groups as far as the negative association. So hopefully not such a large group of people feel that way.

Jamie DePolo: Okay.

Laura Dominici: But I think that also makes us realize that if there are people where we might be able to intervene — either before surgery or certainly after surgery — to help with those symptoms or to help people work through that, so they’re making choices really based on what’s going to be the best decision for them and not just from where they are in a scared place, and not necessarily understanding what the long-term implications are.

Jamie DePolo: Okay. And I’m not sure if you looked at this either, but I’ll ask the question anyway. Do you think the type of reconstruction a woman had after either bilateral or single mastectomy played into the satisfaction at all? Because if I’m remembering right, I think it was about 90% had reconstruction?

Laura Dominici: That’s correct. So I think we don’t know the details on that.

Jamie DePolo: Okay.

Laura Dominici: The other part that we want to get details on is post-mastectomy radiation, which may have a big impact. That we’re looking at as well. But what I think we can say is, despite the fact that almost 90% of these women had reconstruction after unilateral or bilateral mastectomy, the quality of life still was lower than that of breast conservation.

Jamie DePolo: Okay. Okay, so with the results of this study, what are you going to tell your patients? What do you want somebody who’s been diagnosed with breast cancer to take away from this? How can this information help them if they’re making a decision?

Laura Dominici: I certainly wouldn’t use this data to tell every woman that breast conservation is better.

Jamie DePolo: Sure.

Laura Dominici: I think that ideally, at some point in time, we’d be able to get to the place where we can go through a woman’s body type and desires for what they want to get out of surgery and long-term goals and be able to then kind of walk them through a process where we can predict what’s going to get them to that outcome. We’re not there yet. What I would say is that we need to begin having the conversation with women, not just about the oncologic or cancer outcomes of their surgery choices — which now we know for the most part are pretty equivalent — but I think we need to at least start having a conversation with patients about the long-term impacts of surgery. And this study may not be able to allow us to pinpoint exactly what those are, but I think it shows the importance of emphasizing those things because they clearly affect women even years after surgery.

The goal of my looking at these sorts of things is because I strongly believe that there should be shared decision-making, meaning the woman and the physician come together to get the outcome that the woman wants, or as close to that as they can. And I think that having this information is another piece of the long-term outcome that women need to be able to understand their options and choose the right one.

Jamie DePolo: That’s great. Thank you so much. I appreciate your time.

Laura Dominici: Thank you for having me.

Jamie DePolo: Thank you.

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