Younger women diagnosed with early-stage breast cancer who opted for mastectomy reported lower satisfaction with their breasts and worse sexual and psychosocial well-being than women who chose lumpectomy, according to the results of a survey of 560 women.
The research was presented on Dec. 7, 2018, at the San Antonio Breast Cancer Symposium. Read the abstract of “Local therapy and quality of life outcomes in young women with breast cancer.”
Surgery options for early-stage breast cancer
Women diagnosed with early-stage breast cancer have two main surgery options:
- mastectomy, which is total removal of the breast
- lumpectomy, which removes the cancer, plus a healthy rim of tissue around the cancer, followed by radiation therapy
Some women who’ve been diagnosed with early-stage breast cancer in one breast choose to have that breast and the other healthy breast removed — a double mastectomy. Removing the other healthy breast is called contralateral prophylactic mastectomy.
The healthy breast usually is removed because of an understandable fear that a new, second breast cancer might develop in that breast. More and more women who’ve been diagnosed with early-stage disease are opting for contralateral prophylactic mastectomy. In 2016, a study found that rates of prophylactic mastectomy more than tripled from 2002 to 2012, even though other studies have shown that removing the other healthy breast doesn’t improve survival.
Is surgery giving young women the outcomes they expect?
In this study, the researchers wanted to know if young women who chose either single or double mastectomy were having the outcomes they expected.
“We’ve noticed that over the past several years, rates of mastectomy — and particularly bilateral mastectomy in young women — has gone up almost ten-fold,” said Laura Dominici, M.D., FACS, 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, in an interview with Breastcancer.org. “We recognized that it was really complicated, what the reasons for that were. Now, we didn’t really feel like we had a good way to look at that in a study, as you might imagine, but what we didn’t know was, 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.
“Within Dana-Farber, my colleague, Ann Partridge, has a cohort of young women that she followed from 2006 to 2016,” Dominici continued. “These women…were all women 40 and under who had a diagnosis of breast cancer — and that’s really the population 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 for whom we had an opportunity to have very long-term follow-up. So, we did a one-time survey sent out to all these women using 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.”
The BREAST-Q survey asks about a woman’s satisfaction with her breasts, sexual well-being, and psychosocial well-being issues such as anxiety, depression, and happiness.
The study included 560 women who had been diagnosed with early-stage breast cancer at age 40 or younger. The BREAST-Q survey was sent to the women between October 2016 and November 2017. Half the women completed the survey about 6 years after breast cancer surgery and half completed it a shorter time after surgery.
- 28% had lumpectomy
- 72% had mastectomy; among these women, 72% had double mastectomy
- 89% had reconstruction
- Average age was 37
- 90% were white
- 61% worked full time
- 86% were college graduates or had done postgraduate work
- 32% had a body mass index (BMI) greater than 25
- About 10% had a genetic mutation that made their risk for breast cancer higher than average
Overall, average BREAST-Q survey scores for breast satisfaction and sexual and psychosocial well-being were lower for women who had mastectomy or double mastectomy compared to women who had lumpectomy.
Average breast satisfaction scores were:
- 65.9 for women who had lumpectomy
- 59.5 for women who had single mastectomy
- 60.3 for women who had double mastectomy
Average sexual well-being scores were:
- 57.5 for women who had lumpectomy
- 53.2 for women who had single mastectomy
- 48.6 for women who had double mastectomy
Average psychosocial well-being scores were:
- 76.1 for women who had lumpectomy
- 70.5 for women who had single mastectomy
- 68.1 for women who had double mastectomy
Average physical well-being scores were the same for the three groups of women.
Dominici said that the researchers had not looked specifically at the group of women at high risk for breast cancer because of a genetic mutation to determine their surgery choices and quality of life.
What does this mean for you?
"Knowledge of the potential long-term impact of surgery on quality of life is of critical importance for counseling young women about surgical decisions," Dominici said. “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 she wants to get out of surgery and long-term goals and be able to then walk her through a process where we can predict what’s going to get her 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,” she continued. “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.”
When you’re first diagnosed with breast cancer, fears about the future can affect how you make decisions. This is especially true for women who have a genetic mutation or who have watched a mother or sister be diagnosed with breast cancer. You have to make a number of decisions at a very emotional time when it can be hard to absorb and understand all the new information you’re being given.
At Breastcancer.org, we support every woman’s right to make treatment decisions based on the characteristics of the cancer she’s been diagnosed with, her medical history, her risk of recurrence or a new breast cancer, and her personal preferences. But it’s very important to make sure you understand all the pros and cons of any treatment or procedure you’re considering, including how the treatment or procedure may affect your quality of life and if the treatment is likely to make you live longer.
If you’ve been diagnosed with early-stage breast cancer, ask your doctor about ALL of your treatment and risk reduction options. Contralateral prophylactic mastectomy is only one of these options and is an aggressive step. While it may be the right decision for you, give yourself the time you need to consider the decision carefully. It’s a good idea to talk to your doctor about how the details in your pathology report may affect your future risk. You want to be sure that your decisions are based on your actual risk of recurrence or a new cancer. Make sure you understand the benefits and risks of all your options. Together, you and your doctor can make the choices that are best for you and your unique situation.
For more information, visit the Breastcancer.org pages on Surgery.
To discuss the benefits and drawbacks of lumpectomy or mastectomy with others, join the Breastcancer.org Discussion Board forum Surgery - Before, During, and After.
Written by: Jamie DePolo, senior editor
Reviewed by: Brian Wojciechowski, M.D., medical adviser