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5
omen identified with a
BRCA1/2 muta48 to 64 percent.
At this moment,
bilateral or
tion have a cumulative lifetime risk of
contralateral prophylactic mastectomy is the
39 to 85 percent for breast cancer and
most effective, although radical, strategy to re11 to 63 percent for ovarian cancer at age 70
duce the risk of breast cancer in high-risk
6 , 7 Family Cancer Clinic of the
years. 1 4 Furthermore, the lifetime risk of conwomen.
At the
tralateral breast cancer for genetically predisErasmus Medical CentreDaniel den Hoed Canposed women after a history of breast cancer is
cer Centre in Rotterdam, between 35 and 51
percent of the identified mutation carriers opt
From the Departments of Medical Psychology and Psychotherapy,
for prophylactic mastectomy with breast
Medical Oncology, Surgical Oncology, Psychiatry, and Clinical reconstruction.
6, 8
Satisfaction
with prophylactic
Genetics, the Daniel den Hoed Cancer Center, and the Family
mastectomy
has
reported
tomastectomy
vary
between
www.plasreconsurg.org
1675
present
construction
reconstruction
were
the
ever,
longer
study,
that
major
70satisfaction
not
investigated
percent
term
awe
limitations
after
primary
after
assessed
inbeen
prophylactic
114
prophylactic
infocus
with
awomen
and
of
satisfaction
small
the
immediate
of
nearly
published
the
subsample.In
mastectomy
at
increased
study
100
with
breast
or
percent.
studies
breast
itHowwas
risk
the
rein
Cancer
Human
Received
21,
Presented
Aspects
2003,
sium,
Copyright
DOI:
2005.
10.1097/01.prs.0000217383.99038.f5
in
and
Clinic,
and
of
San
for
at
the
2006
Hereditary
Clinical
Antonio,
the
publication
26th
Erasmus
Eighth
by
Annual
Genetics,
the
Texas,
Cancer,
International
Medical
American
January
San
December
in
Leiden
Antonio
Barcelona,
Center;
26,
Society
2005;
Meeting
University
5,
Breast
and
2003.
ofrevised
Spain,
Plastic
the
on
Cancer
Medical
Psycho-Social
Department
November
March
Surgeons
SympoCenter.
of
14,
9,10
12 ,113
1
0,,115
16
6
tomy/breast reconstruction; (3) history of breast As is shown in Table 2, 68 women (60 percent)
cancer; (4) bilateral salpingo-oophorectomy; andwere satisfied with the result of prophylactic mas(5) hormone replacement therapy. Each predic- tectomy and breast reconstruction. One hundred
tor variable was tested on the outcome variable six women (95 percent) would opt for prophylacseparately, including the variables that were ad- tic mastectomy again, should they have to choose
justed for. A value of
p
0.05 (two-tailed) wasagain; 89 women (80 percent) would choose to
considered statistically significant.
undergo the same type of breast reconstruction
again; and 95 women (85 percent) felt sufficiently
RESULTS
informed.
Sample Characteristics
Forty-eight women (43 percent) reported periOf the 136 women who received the question- operative and/or postoperative complications
naire, 114 participated in this study (84 percent). and 35 women (32 percent) mentioned that they
Two-thirds of these women (
n
77) were unafexperienced ongoing physical complaints in one
fected BRCA1/2 mutation carriers ( n
63) or 50 or both reconstructed breasts. Twenty-eight
percent risk carriers (
n
14); 22 women had women (25 percent) reported limitations in acpreviously been treated for breast cancer by either
tivities of daily life attributable to the aftermath of
breast-conserving therapy ( n
13) or unilateralprophylactic mastectomy/breast reconstruction.
mastectomy ( n
9). Fifteen women elected to
The sensation of the breasts was altered in
undergo bilateral mastectomy with reconstruction
nearly all women (97 percent), 58 women (51
when breast cancer was diagnosed. None of these
percent) rated their breasts as
feeling like
not
women experienced a recurrence of breast cancer
in the years after surgery until time of assessment. their own, and 32 (29 percent) women reported
altered feelings of femininity after prophylactic
Thirteen of 37 women with a history of breast
cancer were proven BRCA1/2 mutation carriers.mastectomy/breast reconstruction, whereas only
eight women (8 percent) thought their partners
Some women did not answer all questions,
resulting in different totals. Median follow-up af- found them less feminine. Ten women (13 perter surgery for the complete sample was 3 years cent) experienced positive changes in their sexual
relationship resulting from prophylactic mastec(range, 2 months to 8 years). Respondents and
tomy/breast reconstruction. Forty women (44 pernonrespondents ( n
22) did not differ demographically. Characteristics of the participants are cent) reported an adverse change in their sexual
presented in Table 1.
relationship resulting from prophylactic mastectomy/breast reconstruction. Finally, 10 of the
Overall Evaluation
partners (13 percent) were thought to have experienced a positive change in the sexual relaWomen with and without a history of breast
cancer did not differ significantly in responses on tionship, whereas 27 partners (35 percent) were
the questionnaire. Therefore, we performed the thought to have experienced an adverse change in
analyses on the total sample.
the sexual relationship.
Table 1. General Characteristics of 114 Participants Who Underwent
Reconstruction
from 1994 and
to 2002
Prophylactic Mastectomy
Breast
Unaffected Women*
(n
77)
Median age, years (range) 41 (2559) 46 (3065) 44 (2565)
Median age at time of PM/BR, years (range) 38 (2355) 43 (2659) 40 (2359)
PM,
prophylactic
mastectomy;
BR, breast
reconstruction;
PBSO, prophylactic bilateral salpingoMedian
follow-up,
years (range)
3 (08)
4 (08) 3 (08)
Living
Risk
Additional
BRCA1/2
Women
PBSO,
HRT,
status,
with
%a%at
%
a48
partner,
mutation
risk
17
(46)
14
68breast
(18)
(90)
65
63
(57)
24
32(82)
(65)
(86)
38
100
(35)
(33)
(88)
76 (67)
oophorectomy;
*Women
therapy.
Women
Based
on
with
without
family
a50%
HRT,
history
a(62)
history
history
hormone
of%carriers
breast
of
suggestive
replacement
cancer.
cancer.
for
a 13
breast/ovarian
cancer syndrome.30 (39) 1 (2) 31 (27)
Affected Women
Total Group
(n
37)
114)
n(
1677
Satisfaction
tients and Methods. Significant differences were
found
between satisfied patients and nonsatisfied
We dichotomized the total group into satisfied
patients, as shown in Table 3.
patients ( n
68) and nonsatisfied patients (
n
Nonsatisfied
patients felt significantly less in45) based on the following question: Are you
formed than satisfied patients0.02).
( Nonp
satisfied with the result of breast reconstruction?
The answers were analyzed taking into account satisfied patients reported significantly more comvarious confounders as described above under Paplications ( p0.01) and more physical
Table 3. Relationship between Satisfaction and Womens Experience with
Breast
Reconstruction*
Prophylactic
Mastectomy and
Nonsatisfied Patients
(n
45)
Reported Experience No. No. (%) No. No. (%)
Feeling insufficiently informed 43 10 (23) 68 6 (9) 0.02
Surgery did not meet expectations 45 17 (38) 67 18 (27) 0.08
Complications 44 23 (52) 68 24 (35) 0.01
Complaints 42 26 (62) 68 9 (13) 0.001
Limitations in daily life 43 13 (30) 68 15 (22) 0.33
Change in feeling of the breasts 45 45 (100) 68 65 (96) 0.75
Breasts do not feel like your own 44 28 (64) 68 30 (44) 0.02
Change in feelings of femininity 44 14 (32) 66 17 (26) 0.53
Partners perception of decrease in his wifes
femininity 37 4 (11) 62 4 (7) 0.94
PM,
*Logistic
prophylactic
regression
mastectomy;
analysis,
adjusted
BR,
breast
for reconstruction;
age 26
at the
time 50
of
PBSO,
PM/BR;
prophylactic
years since
bilateral
PM/BR;
salpingohistory of breast
Positive
effects
on
the sexual
relationship
5 (19)
5 (10)
0.70
1678
Adverse
Partners
Would
relationship
not
effects
perception
opt
for
28
26
on
6BR
13
PM
the
(21)
of
(50)
again
again
sexual
positive
adverse
50504replacement
43
44
14
(8)
relationship
10
effect
1effect
(28)
0.07
(2)
(23)
0.06
67
on
on
0sexual
sexual
(0)
32
1 (2)
18
0.28
0.01
(56)
57item.
22significant.
(39) 0.31
oophorectomy;
therapy.
cancer;
Sample
A
valuePBSO;
size;
of
pnumber
and
HRT,
0.05
HRT.
hormone
of
(two-tailed)
women
who
was
had
considered
a68
response
statistically
on
this
Satisfied Patients
(n 68)
p
complaints ( p
0.001) than satisfied patients.
sexual relationship
0.001).
( Finally,
p
they were
Moreover, nonsatisfied patients reported signifi- more likely to report that they would not opt for
cantly more than satisfied patients that their
breast reconstruction again (
p 0.01).
breasts did not feel like they belonged to their
body ( p 0.02). Finally, nonsatisfied patients reDISCUSSION
ported significantly more often that they would
This is the first study that addresses the impact
not opt for breast reconstruction again (
p of
0.01).
both prophylactic surgery and breast reconstruction in a large sample of genetically predisposed
Impact on Perception of Sexual Relationship women. Prophylactic mastectomy/breast reconNearly half of the women who filled out the struction was not regretted by the vast majority of
questions about the sexual relationship (
n
90) women, which is in accordance with other
9, 1 11 5
reported that the result of prophylactic mastectostudies.
Nevertheless,
only 60 percent of the
my/breast reconstruction had negatively affectedwomen were satisfied with the results of the breast
their sexual relationship (44 percent). Therefore, reconstruction. This is less than observed in other
, 13, 16
we performed a logistic regression analysis with
studies.
Higher12distress
or cancer-related worry
the impact on the sexual relationship as an out- has been found in women opting for prophylactic
come variable. We adjusted for the same con- mastectomy compared with those who favoured surfounders as described above under Patients andveillance, although the distress had significantly de9, 14 ,1we
8
Methods.
creased 6 months after surgery.
Therefore,
Results are shown in Table 4. Women who speculate that relief from anxiety of developing a
reported adverse changes in their sexual relationnew breast cancer characterizes the short-term outship stated that they felt insufficiently informed come after prophylactic mastectomy. Thereafter,
about the procedure and its possible consethe growing awareness of the profound consequences ( p 0.01), that surgery had not met their
quences of the surgery might have affected the satexpectations ( p
0.001), and that they were exisfaction with the eventual results. Indeed, signifiperiencing more complaints ( p 0.01) and more
cantly more nonsatisfied women would not opt for
limitations in daily life ( p 0.01). They werebreast
also reconstruction again compared with satisfied
more likely to report that the reconstructed
women.
9
breasts did not feel like their own (
p 0.01) and
Frost
found
et in
al.their
study (mean followthat they experienced altered feelings of feminin- up, 14.5 years) that 80 percent of the surveyed
ity ( p
0.01) and a decrease in their partners women were satisfied with prophylactic mastecperception of his wifes femininity (
p
0.04).
tomy. However, they did not explicitly study the
They were more likely to perceive an adverse
satisfaction with breast reconstruction after prochange in the way the partner experienced their phylactic mastectomy. Moreover, the mean age of
Table 4. Relationship between Adverse Effects on the Sexual Relationship and
Prophylactic
Mastectomy
Womens Experience
withand Breast Reconstruction*
No Effect ( n
n 40)
1679
CONCLUSIONS
Although other studies have shown that prophylactic mastectomy/breast reconstruction obviously serves to decrease cancer-related anxiety in
the short term, the long-term impact on quality of
life and especially on the quality of the sexual
relationship should not be underestimated. Because the women in our group show few regrets
and most of them feel sufficiently informed, we
anticipate that the absence of regrets despite the
awareness of adverse consequences reflects that
the urge to reduce anxiety, remain healthy, and
survive supersedes any ambivalence regarding the
possible negative outcomes of prophylactic mastectomy/breast reconstruction in the long term.
Although physicians must inform their patients
extensively about the long-term ramifications of
prophylactic mastectomy/breast reconstruction,
they should be aware that this information is given
at the moment that the urge to survive predominates. Therefore, it is important to pay attention
to the way the information is processed and assimilated.
Careful exploration of the possible impact on
body image and the sexual relationship enables
the women at risk and their partners to recognize
the potential risk factors for inadequate coping. If
there are any such factors, additional professional
attention from a psychologist or social worker may
be of help to anticipate untoward experiences after
treatment.
If
needed,
follow-up
can
offered
construction.
which
maladjustment
jective
the
information
and
long
Finally,
correctly
women
well-being
after
termahas
prophylactic
assimilated.
if
subject
and/or
and
the
been
ofinadequate
presurgical
these
comprehensively
couples
worthy
mastectomy/breast
persons
of
are
coping.
counseling
further
atsupport
may
high
The
offered
study
benefit
risk
and
subrefor
isbe
in
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