PSYCHO-ONCOLOGY

Psycho-Oncology 13: 132–139 (2004)

Published online 17 December 2003 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.777

BRIEF REPORT

PSYCHOSOCIAL IMPACT OF BREAST CANCER

SURGERIES IN CHINESE PATIENTS
AND THEIR SPOUSES
W. YEOa,*, W.H. KWANa, P.M.L. TEOa, S. NIPa, E. WONGb, L.Y. HINc and P.J. JOHNSONa
a
Departments of Clinical Oncology, Chinese University of Hong Kong, Prince of Wales Hospital,
Shatin, NT, Hong Kong
b
Centre for Clinical Trials and Epidemiological Research, Chinese University of Hong Kong,
Prince of Wales Hospital, Shatin, NT, Hong Kong
c
Obstetrics and Gynecology, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong

SUMMARY

Background and purpose: This pilot study assesses the psychosocial impact of different modalities of breast cancer
surgery in Chinese patients and their husbands.
Methods: Thirty-six patients who underwent conservative breast therapy (BCT) for breast cancer were compared
with 36 women who underwent total mastectomy (TM) on four aspects of psychosocial adjustment. They were
matched in pairs in terms of stage of disease, age and time since surgery. Where available, their husbands were also
consented for similar assessment.
Results: Women who underwent BCT showed a significantly better response to their body and sexual image than
those who underwent TM. This difference did not translate into any significant difference in terms of emotional and
symptomatic aspects, daily activities, or fear of recurrences. The husbands of patients in the TM group showed
significantly more emotional and symptomatic distress and greater change in the perception of their wives’ body and
sexual images.
Conclusion: This is the first of such study conducted in a Chinese population. The lack of differences in certain
psychosocial aspects may indicate a generally good adjustment in the TM patients after their surgery. It may also
relate to the fact that volunteers for the study were themselves representative only of the patient population who
adapted well to the surgery, and those patients who were emotionally distressed tended to decline to participate.
Psychosocial disruption in the patients’ families is reflected in our study where patients’ husbands in the TM group
were significantly more disturbed. However, due to the limited number of patients studied, the findings are not yet
conclusive and require further studies for confirmation. Copyright # 2003 John Wiley & Sons, Ltd.

INTRODUCTION axillary dissection and radiation therapy, has been

The psychosocial impact of different forms of
surgical treatment for early stage breast cancer has
been extensively investigated in the West. Breast
conserving therapy (BCT), by a combination of
lumpectomy, local excision or partial mastectomy,
*Correspondence to: Department of Clinical Oncology, Chi-
nese University of Hong Kong, Prince of Wales Hospital,
Shatin, NT, Hong Kong. E-mail: winnieyeo@cuhk.edu.hk
adopted as an alternative to the more mutilating
total mastectomy (TM) (Fisher et al., 1985;
Veronesi et al., 1993). Although BCT leaves a
woman’s body more ‘intact’, and may therefore be
expected to be more acceptable in terms of
psychological adjustment, not all studies from
the West have found this to be the case (Fallow-
field et al., 1986; Bartelink et al., 1985; Sneew et al.,
1992; Gilbar et al., 1997; Shimozuma et al.,
1999; Carver et al., 1998; Amichetti et al., 2001).
On the other hand, psychological distress in cancer

Received 19 May 2003

Copyright # 2003 John Wiley & Sons, Ltd. Accepted 14 October 2003
PSYCHOLOGICAL IMPACT OF SURGERY IN CHINESE BREAST CANCER PATIENTS AND THEIR SPOUSES
patients has significant repercussions throughout
the family system (Ell et al., 1988; Northouse,
1984), with the spouse of the patient being
potentially one of the most vulnerable, but few
studies have addressed the psychological adapta-
tion of family members simultaneously with the
patients.
The incidence of breast cancer is rising rapidly
in many countries of the developing world. Over
the last two decades, the age-standardized inci-
dence rate of female breast cancer has steadily
increased from 30.9 to 42.4 per 100,000 standard
population. In 2000, breast cancer accounted for
9.3% of all cancer deaths among Hong Kong
women (Hong Kong Hospital Authority, 2003).
However, in oriental societies such as Hong Kong,
relatively little is known about the psychological
effects of Chinese patients undergoing mastectomy
as compared with those undergoing breast-conser-
ving procedure, and even less is known about such
impact on the patient’s family, in particular, that
of the spouse. We have conducted this pilot study
to evaluate the psychosocial impact of BCT and
TM amongst our patient population and their
spouses.
PATIENTS AND METHODS
Breast cancer patients who had completed surgery
and post-op adjuvant therapies according to the
department protocol without evidence of disease
were considered for the study. Thirty-six consecu-
tive patients undergoing breast-conserving therapy
(BCT) agreed to enter the study. Each was paired
with another patient who had undergone total
mastectomy without breast reconstruction (TM).
The individual of each pair were matched in terms
of age, stage of disease and time after surgery. Two
patients in the TM group who were originally
consented for the questionnaire were distressed
after reading the questionnaire and declined to
participate in the study; they were subsequently
replaced by two other matched patients. The
extent to which patients’ choice in the type of
surgery undertaken could not be assessed.
The patients were handed a short questionnaire
in Chinese format, the design of which was based
on those reported in previous studies (Sneew et al.,
1992; Noguchi et al., 1993), which has reported to
have adequate to excellent reliability, with Cron-
bach’s a coefficients ranging from 0.58 to 0.94. The
Copyright # 2003 John Wiley & Sons, Ltd.
133
questionnaire consisted of five categories of ques-
tions, namely: sociodemographic background in-
formation of each patient, body and sexual image,
emotional and symptomatic aspects, daily activ-
ities and questions related to fear of recurrence.
There were 19 questions (items) to address the
issues on body and sexual image (Table 2a).
Another 19 items were used to address emotional
and symptomatic aspects, these included questions
about the patient’s ability to control events and
whether she felt if life was worthwhile. The
problems in family relations were assessed, and
the adequacy of support from husband (if applic-
able), other family relatives, friends as well as
hospital were explored. In addition, symptoms
including anxiety, uneasiness, sadness, anger,
mood disturbances, pessimism about future, loss
of appetite, tearfulness, insomnia, reduction in
libido and uncomfortable feeling in talking about
surgery were assessed.
To measure the impact of breast surgery on
daily activities, six items were asked and these
included change in the degree of being active,
difficulties in working, shopping, leisure activity,
housework, and other daily activities.
At the end of the questionnaire, four items were
directed towards assessing the patient’s fear of
disease recurrence. These included whether she
would choose the same treatment should they have
the choice, her concern about possible recurrences,
whether she would be more conscious of her
health, and the frequencies of her self-breast
examination (weekly vs 4-weekly vs 12-weekly
examination vs no examination at all).
Apart from background information of each
patient, the responses were rated on a 4-point
scale (0–3); items that were not affected were
rated 0, while items that were severely affected
were rated 3.
Where available, each patient’s existing partner
(for convenience, all the partners will be addressed
as ‘husbands’) was being invited to participate in
the study. Those who consented to the study
completed a similar questionnaire separately,
which was subsequently returned to us in a pre-
stamped addressed envelope.
Statistical analysis
Group comparisons (in both patients and
husbands) were performed for qualitative para-
meters, using chi-square test and 2-tailed t-test.
Psycho-Oncology 13: 132–139 (2004)
134 W. YEO ET AL.

Table 1. Sociodemographic background of patients and husbands

Patients Husbands

BCT group TM group p BCT group TM group p

ðn ¼ 36Þ ðn ¼ 36Þ ðn ¼ 23Þ ðn ¼ 25Þ

Mean age in years (standard 42 42.6 >0.05 >0.05

deviation)
Age in years 16 15 4 5
4 40 10 13 7 13
> 40 and 4 49 10 8 11 7
> 49

Mean time since surgery in 19.2 18.5 >0.05 19.2 (16.9) 18.5 (15.9) >0.05
months (standard deviation)
Initial stage of disease:
Stage I 15 8 >0.05 15 8 >0.05
Stage II 20 27 20 27
Stage III 1 1 1 1

Marital status
Married 26 30 >0.05 22 24 >0.05
Single 7 4 0 (co-habiting) 1 (co-habiting)
Divorced/widowed 3 2

Children
Presence 29 30 >0.05
Absence 7 6

Education level
No formal education 12 11 >0.05 9 10 >0.05
Primary school 12 17 10 10
Secondary school or above 12 8 3 5

Occupation
Professional/ 10 7 >0.05 11 15 >0.05
semi-professional
Skilled/unskilled workers 7 4 7 7
Housewife/retired 19 25 4 3

Religion
Buddhist 10 9 >0.05 8 7 >0.05
Taoist 1 1 0 1
Protestant 6 5 1 1
Catholic 0 2 3 0
Others 8 6 6 8
No religion 11 13 4 8
 Pearson’s chi-square test.
 Two-tailed t-test.
 The reason of unavailability included 11 patients being single (unmarried), 2 divorced, 3 widowed, and 9 husbands refused to
participate (4 in the BCT group and 5 in TM group).

Comparisons of patient’s own assessment be- recurrences, using Mann-Whitney 2-tailed t-test
tween the BCT and TM groups were made with for asymmetrical significance.
respect to their body and sexual image, emotional Comparisons of husband’s assessment between
and symptoms changes, daily activities and fear of the two groups were made with respect to his

Copyright # 2003 John Wiley & Sons, Ltd. Psycho-Oncology 13: 132–139 (2004)
PSYCHOLOGICAL IMPACT OF SURGERY IN CHINESE BREAST CANCER PATIENTS AND THEIR SPOUSES 135

Table 2a. Sexual and body image as assessed by patients

Scores BCT Group TM Group p

(% of patients in each score) (% of patients in each score)

0 1 2 3 0 1 2 3

Don’t like myself anymore 75.0 22.2 0 2.8 57.1 28.6 14.3 0 0.08
Feel self-conscious about nude appearance 55.6 27.8 11.1 5.6 39.4 33.3 18.2 9.1 0.16
Feel self-conscious about dress appearance 80.6 11.1 5.6 2.8 51.4 31.4 11.4 5.7 0.01
Feel self-conscious in groups of women 86.1 8.3 0 5.6 68.6 25.7 5.7 0 0.11
Don’t feel as if my body belongs to me 91.7 5.6 0 2.8 82.9 11.4 5.7 0 0.28
Ashamed of my body 88.9 5.6 2.8 2.8 76.5 14.7 5.9 2.9 0.19
Feel less sexually desirable 82.1 7.1 7.1 3.6 61.8 17.6 20.6 0 0.11

Feel self-conscious about nude appearance in 81.5 11.1 3.7 3.7 43.8 34.4 15.6 6.3 50.01
front of husband #,
Feel self-conscious about dressing in front 81.5 14.8 0 3.7 43.8 34.4 15.6 6.3 50.01
of husband #,
Feel a change in my husband’s attitude #, 85.2 7.4 7.4 0 87.1 0 12.9 0 0.92
Feel a change in my attitude towards my 92.6 7.4 0 0 71.6 15.6 9.4 3.1 0.04
husband #,

Feel less attractive 60.0 31.4 5.7 2.9 45.5 39.4 12.1 3.0 0.21
Feel less feminine 77.8 11.1 5.6 5.6 51.5 36.4 9.1 3.0 0.04
Feel like having a change in clothing style 80.0 8.6 8.6 2.9 33.3 51.5 12.1 3.0 50.01
Feel like having a change in my night clothes 83.3 5.6 8.3 2.8 57.6 27.3 12.1 3.0 0.04

Problems in sexual relationship 93.1 0 6.9 0 75.0 15.6 9.4 0 0.08

Problems in marital status # 93.1 3.4 3.4 0 83.9 6.5 9.7 0 0.27

Like my look just the way they are 55.6 16.7 16.7 11.1 65.6 18.8 12.5 3.1 0.28
Feel good about my body 55.6 27.8 8.3 8.3 31.3 25.0 40.6 3.1 0.03

Mean and median scores of each group for each question are based on response categories as follows: 0= not at all; 1= slightly;
2= moderately; 3= extremely affected.
# Where applicable.
p50.05, Mann-Whitney test.

Table 2b. Sexual and body image as assessed by husbands

Scores BCT Group TM Group p

(% of husbands in each score) (% of husbands in each score)

0 1 2 3 0 1 2 3

Don’t feel like herself anymore 86.4 9.1 4.5 0 64.0 28.0 8.0 0 0.09
Feel conscious about wife’s nude appearance 77.3 22.7 0 0 40.0 48.0 12.0 0 50.01
Feel conscious about wife’s dress appearance 90.9 9.1 0 0 56.0 36.0 8.0 0 50.01
Feel wife conscious in groups of women 90.9 9.1 0 0 72.0 16.0 12.0 0 0.09
Don’t feel as if wife’s body belongs to herself 95.5 4.5 0 0 68.0 24.0 8.0 0 0.02
Ashamed of her body 95.5 4.5 0 0 68.0 20.0 12.0 0 0.02
Feel wife less sexually desirable 85.7 14.3 0 0 64.0 16.0 16.0 4.0 0.07

Feel conscious about wife nude appearance in 86.4 13.6 0 0 48.0 28.0 20.0 4.0 50.01
front of myself
Feel conscious about wife dressing in front 86.4 13.6 0 0 44.0 36.0 12.0 8.0 50.01
of myself
Feel a change in my attitude towards my wife 90.9 9.1 0 0 68.0 16.0 16.0 0 0.04
Feel a change in wife’s attitude towards myself 81.8 18.2 0 0 60.0 32.0 8.0 0 0.09

Copyright # 2003 John Wiley & Sons, Ltd. Psycho-Oncology 13: 132–139 (2004)
136 W. YEO ET AL.

Table 2b (continued)

Scores BCT Group TM Group p

(% of patients in each score) (% of patients in each score)

0 1 2 3 0 1 2 3

Feel less attractive 86.4 13.6 0 0 60.0 28.0 12.0 0 0.04

Feel less feminine 90.9 9.1 0 0 60.0 32.0 8.0 0 0.02
Feel a change in wife’s clothing style 81.8 13.6 4.5 0 56.0 36.0 8.0 0 0.07
Feel a change in wife’s night clothes 95.5 4.5 0 0 79.2 16.7 4.2 0 0.10

Problems in sexual relationship 81.8 13.6 4.5 0 72.0 16.0 8.0 4.0 0.39
Problems in marital status 95.5 4.5 0 0 80.0 12.0 8.0 0 0.11

Like wife’s look just the way they are 81.0 4.8 4.8 9.5 76.0 16.0 8.0 0 0.85
Feel good about her body 76.4 4.8 9.5 9.5 76.0 16.0 4.0 4.0 0.85

Mean and median scores of each group for each question are based on response categories as follows: 0= not at all; 1= slightly;
2= moderately; 3= extremely affected.
p50.05, Mann-Whitney test.

emotional and symptoms changes and daily
activities, body and sexual image of his wife
and fear of recurrences for his wife, using
Mann-Whitney 2-tailed t-test for asymmetrical
significance.
RESULTS
Sociodemographic background
The patients’ sociodemographic background is
listed in Table 1a. There were no statistical
differences between the two groups with respect
to age, time since initial surgery, stage of disease at
presentation, marital status, presence of children,
religious background, levels of education and
occupation.
The husbands’ sociodemographic background
are listed in Table 1b. There were 23 husbands
(including one couple who were cohabiting) in the
BCT group and 25 in the TM group who were
available and agreed to participate in this study.
Again, there were no statistical differences between
the two groups.
Sexual and body image
their dress appearance, and increased self-con-
sciousness about dressing and appearing in nude in
front of their husbands. There was also signifi-
cantly larger change in their attitude towards their
husbands, an increased feeling of being less
feminine, an increased feeling of the need of a
change in clothing style and night clothes, and a
more negative feeling about their body.
The responses of husbands are listed in Table
2b. Over 95% of the husbands responded to each
question. In the TM group, there was significantly
increased awareness of their wives’ nude and dress
appearance, they were more conscious about their
wives’ nude and dress appearance in front of them,
and they did not feel as if their wives’ body
belonged to themselves. They were also signifi-
cantly more ashamed of their wives’ body and had
a larger change in their attitude towards their
wives, and an increased feeling that their wives
were less feminine and less attractive. Although
other questions did not show statistical signifi-
cance, the TM group was more affected than the
BCT group.
EMOTIONAL AND SYMPTOMATIC
ASPECTS

The responses of the patients are listed in Over 80% of the patients responded to each
Table 2a. Over 80% of the patients responded to question. Most of the items affected at least 20%
each of the questions. The TM group showed of the patients in a moderate to severe degree, but
significantly increased self-consciousness about no difference existed between the groups.

Copyright # 2003 John Wiley & Sons, Ltd. Psycho-Oncology 13: 132–139 (2004)
PSYCHOLOGICAL IMPACT OF SURGERY IN CHINESE BREAST CANCER PATIENTS AND THEIR SPOUSES
Over 92% of the husbands responded to each
question. The TM group was generally more
affected and showed significantly increased inabil-
ity in controlling events, increased mood distur-
bances and insomnia, and reduced libido.
Although not statistically significant, the TM
group was generally more emotionally disturbed
with more severe symptoms.
Activities
Over 97% of the patients and all the husbands
responded to each question. There was no
difference in the two groups.
Fear of recurrences
Two patients (6%) in the BCT group and 5
(14%) in the TM group would not choose the
same surgical treatment were they had the chance
to reconsider. Patients in the TM group were
slightly more concern about possible recurrences
and more conscious of their health. The majority
of the patients opted for more frequent self-
examination; 18 (50%) in each group opted for
weekly examination, while 15 (42%) in the BCT
group and 11 (31%) in the TM group opted for 4-
weekly examination. However, overall, there was
no significant difference between the two groups.
Husbands in the TM group were slightly more
conscious of their wives’ health, less inclined to
choose the same treatment for their wives (4% in
the BCT group vs 20% in the TM group), while
husbands in the BCT group were more concerned
about possible recurrences. However, overall,
there was no significant difference between the
two groups.
DISCUSSION
The incidence of breast cancer is continuing to rise
in Asia. However, little is known about the
psychosocial and psychosexual impact of breast
cancer surgery in this population. A recent study
on quality of life of Chinese patients who under-
went different types of breast surgery has reported
that patients who underwent BCT had a better
body image scores when compared with those who
underwent TM; the lack of difference in other
aspects could be related to the small number of
Copyright # 2003 John Wiley & Sons, Ltd.
137
cases studied, as there were only 15–17 patients in
each group (Fung et al., 2001).
To our knowledge, the present study is the first
to investigate the psychosocial and psychosexual
impact of BCT and TM in Chinese breast cancer
patients together with their husbands. In agree-
ment with previous studies from the West (Barte-
link et al., 1985; Schain et al., 1983; Al-Ghazal
et al., 2000), the most consistent and marked
differences in the psychological reactions of
women undergoing different types of breast cancer
surgeries lay in subjective changes to their
perceived body image (Dorval et al., 1998; Row-
land et al., 2001; Arora et al., 2001).
In our patient population, over 20% of the
patients in both groups were moderately to
severely affected in emotional and symptomatic
aspects. However, there was no difference between
the BCT and TM patients with respect to
symptoms and emotional aspects and daily activ-
ities. This concurs with previous studies, which
reported that other aspects of psychosocial mor-
bidity after surgery might not necessarily be
dependent on the type of surgery (Fallowfield
et al., 1986; Dorval et al., 1998; Kiebert et al.,
1991; Dow and Lafferty, 2000).
With serial assessment, patients who had under-
went BCT were found to have more pronounced
level of emotional distress during the initial stages
(Ganz et al., 1992). This suggests that BCT does
not necessarily eliminate all psychological morbid-
ity (Fallowfield et al., 1986; Arora et al., 2001;
Sneew et al., 1992); the need for radiotherapy
could bring about an increase in physical pain
(Amichetti et al., 2003) and anxiety (Dorval et al.,
1998; Dow and Lafferty, 2000). On the other hand,
the distress among patients who underwent TM
has been found to decrease over time as they
became less preoccupied with the absence of a
breast, and their ability to adjust their altered body
images into a subjectively more acceptable revised
form increased (Schain et al., 1983). Irrespective of
the type of surgery, patients who had mood
disturbance and poorer body image one month
after operation tend to have poorer psychosocial
adjustment thereafter (Mcguire et al., 1978;
Shimozuma et al., 1999; Carver et al., 1998).
By assessing matched couples, the present study
revealed that husbands of the patients were also
affected psychosocially. The level of distress
among the husbands had previously been reported
to be as high as the patients themselves (Omne-
Ponten et al., 1993), and the strongest predictor of
Psycho-Oncology 13: 132–139 (2004)
138 W. YEO ET AL.
their long-term capability of adjustment were their
ability of adjustment at the time when their wives’
illness was diagnosed (Northouse et al., 2001).
Further, it has been suggested that the psychoso-
cial impact is associated with the pre-crisis marital
relationship as well as the treatment received
(Neuling et al., 1988). Couples who were in a
stable long-term relationship with a sense of
security and comfort, and those who were highly
involved in decision-making in initial management
of the patient’s breast cancer, coped better in the
subsequent recovery phase of the physical trauma
(Maguire, 1981; Steinberg et al., 1985; Lewis et al.,
1989).
In conclusion, our study suggested that Chinese
women who undergo BCT feel less disruption in
body integrity and greater body intactness and
correspondingly greater self-esteem than those
who undergo TM. The lack of differences in other
aspects may be due to the design of the study; the
study was not a randomized trial, the number of
patients accrued was limited, and information on
the extent that an individual patient had in actively
involving in the choice of treatment was not
available. Further, in an attempt to simplify the
questionnaire, only four questions were raised to
measure fear of cancer recurrence, this was
probably inadequate and has presumably limited
the usefulness of the questionnaire as a tool in
assessing the patients properly. Thus, no defini-
tively significant conclusion could be drawn.
None-the-less, it remains possible that our study
underestimates the true frequency of psycho-
pathology since emotionally distressed patients
tend to decline recruitment into the study (Stein-
berg et al., 1985), and this is evident in our study
where two patients in the TM group declined to
participate after reading the questionnaire.
Although the psychological morbidity of breast
cancer may be a consequence of a mutilating
surgery which results in the loss of a breast,
it is essential to determine if other factors, such
as the diagnosis of cancer pre se, or the lack of
opportunity to choose and decide one’s own
treatment, have contributed to this. This pilot
study provides basis for further study into this
patient population where serial assessment of the
psychosocial functioning of a larger cohort at
various intervals (before, during treatment and
subsequently in the follow-up period) would
provide more detailed information, which in turn,
would enable a more appropriate planning in
improvising psychosocial support for the patients
Copyright # 2003 John Wiley & Sons, Ltd.
concerned. And since rehabilitation of breast
cancer patients is influenced by the available
support (Ell et al., 1988; Lewis et al., 1989;
Omne-Ponten et al., 1993; Wortman, 1984;
Bultz et al., 2000), research into the psychosocial
impact and adaptations of the patients’ family is
important.
REFERENCES
Al-Ghazal SK, Fallowfield L, Blamey RW. 2000.
Comparison of psychological aspects and patient
satisfaction following breast conserving surgery,
simple mastectomy and breast reconstruction. Eur J
Cancer 36(15): 1938–1943.
Amichetti M, Caffo O. 2001. Quality of life in patients
with early stage breast carcinoma treated with
conservation surgery and radiotherapy. An Italian
monoinstitutional study. Tumori 87(2): 78–84.
Amichetti M, Caffo O. 2003. Pain after quadrantectomy
and radiotherapy for early stage breast cancer:
Incidence, characteristics and influence on quality of
life. Results from a retrospective study. Oncology
65(1): 23–28.
Arora NK, Gustafson DH, Hawkins RP et al. 2001.
Impact of surgery and chemotherapy on the quality of
life of younger women with breast carcinoma: A
prospective study. Cancer 92(5): 1288–1298.
Bartelink H, van Dam F, van Dongen J. 1985.
Psychological effects of breast conserving therapy in
comparison with radical mastectomy. Rad Oncol Biol
Phys 11: 381–385.
Bultz BD, Speca M, Brasher PM, Geggie PH, Page SA.
2000. A randomized controlled trial of a brief
psychoeducational support group for partners of
early stage breast cancer patients. Psycho-Oncology
9(4): 303–313.
Carver CS, Pozo-Kaderman C, Price AA et al. 1998.
Concern about aspects of body image and adjustment
to early stage breast cancer. Psychosom Med 60(2):
168–174.
Dorval M, Maunsell E, Deschenes L, Brisson J. 1998.
Type of mastectomy and quality of life for long
term breast carcinoma survivors. Cancer 83(10):
2130–2138.
Dow KH, Lafferty P. 2000. Quality of life, survivorship,
and psychosocial adjustment of young women
with breast cancer after breast-conserving surgery
and radiation therapy. Oncol Nurs Forum 27(10):
1555–1564.
Ell K, Nishimoto R, Mantell J, Hamovitch M. 1988.
Longitudinal analysis of psychological adaption
among family members of partients with cancer.
J Psychosom Res 32: 429–438.
Fallowfield LJ, Baum M, Maguire P. 1986. Effects
of breast conservation on psychological morbidity
Psycho-Oncology 13: 132–139 (2004)
PSYCHOLOGICAL IMPACT OF SURGERY IN CHINESE BREAST CANCER PATIENTS AND THEIR SPOUSES
associated with diagnosis and treatment of early
breast cancer. Br Med J 293: 1311–1314.
Fisher B, Bauer M, Marlolese M et al. 1985. Five years
of a randomized clinical trial comparing total
mastectomy and segmental mastectomy with or
without irradiation in the treatment of breast cancer.
New Eng J Med 312: 665–673.
Fung KW, Lau Y, Fielding R, Or A, Yip AWC. 2001.
The impact of mastectomy, breast-conserving treat-
ment an immediate breast reconstruction on the
quality of life of Chinese women. ANZ J Surg 71:
202–206.
Ganz PA, Coscarelli Schag CA, Lee JJ, Polinsky ML,
Tan S. 1992. Breast conservation versus mastectomy:
Is there a difference in psychological adjustment or
quality of life in the first year after surgery? Cancer 69:
1729–1738.
Gilbar O, Ungar L, Fried G, Taller Y, Cohen M,
Robinson E. 1997. Living with mastectomy and breast
conservation treatment: Who suffers more? Support
Care Cancer 5(4): 322–326.
Hong Kong Hospital Authority. Hong Kong Cancer
Registry 2003. Available at: http://www3.ha.org.hk/
cancereg/stat.asp
Kiebert GM, De Hues CJM, Van de Velde CJH. 1991.
The impact of breast cancer treatment and mastect-
omy on the quality of life of early stage breast cancer
patients: A review. J Clin Oncol 9: 1059–1070.
Lewis FM, Woods NF, Hough EE, Bensley LS. 1989.
The family’s functioning with chronic illness in the
mother: The spouse’s perspective. Soc Sci Med 29:
1261–1269.
Lilja A, Smith G, Malmstrom P, Salford LG, Idvall I,
Horstman V. 2003. Psychological profile in patients
with Stages I and II breast cancer: Associations of
psychological profile with tumor biological prognos-
ticators. Psychol Rep 92: 1187–1198.
Maguire L. 1981. The repercussions of mastectomy on
the family. Int J Family Psychiatry 1: 485–503.
Mcguire MM, Lee EG, Bevington DJ, Kuchemann CS,
Crabtree RJ, Cornell CE. 1978. Psychiatric problems
in the first year after mastectomy. Br Med J 279:
963–965.
Neuling SJ, Winefield HR. 1988. Social support and
recovery after surgery for breast cancer: Frequency
Copyright # 2003 John Wiley & Sons, Ltd.
139
and correlates of supportive behaviours by family,
friends and surgeons. Soc Sci Med 27: 385–392.
Noguchi M, Saito Y, Nishijima H et al. 1993. The
psychological and cosmetic aspects of breast conser-
ving therapy compared with radical mastectomy. Jpn
J Surg 23: 598–602.
Northouse L, Templin T, Mood D. 2001. Couples’
adjustment to breast disease during the first year
following diagnosis. J Behav Med 24(2): 115–136.
Northouse LL. 1984. The impact of cancer on the
family; husbands: An overview. Int J Psychiatr Med
14: 215–242.
Omne-Ponten M, Berstrom R, sjoden PO, Burns T.
1993. Psychosocial adjustment among husbands of
women treated for breast cancer; mastectomy vs.
breast conserving surgery. Eur J Cancer 29A(10):
1393–1397.
Rowland JH, Desmond KA, Meyerowitz BE, Belin TR,
Wyatt GE, Ganz PA. 2001. Role of breast recon-
structive surgery in physical and emotional outcomes
among breast cancer survivors. J Natl Cancer Inst
92(17): 1422–1429.
Schain E, Edwards B, Gorell CR et al. 1983. Psycho-
logical and physical outcomes of breast cancer
therapy: Mastectomy vs excisional biopsy and irra-
diation. Breast Cancer Res Treat 3: 377–382.
Shimozuma K, Ganz PA, Petersen L, Hirji K. 1999.
Quality of life in the first year after breast cancer
surgery: Rehabilitation needs and patterns of recov-
ery. Breast Cancer Res Treat 56(1): 45–57.
Sneew KCA, Aaronson NK, Yarnold JR et al. 1992.
Cosmetic and functional outcomes of breast conser-
ving treatment for early stage breast cancer. 2.
Relationship with psychosocial functioning. Radiother
Oncol 25: 160–166.
Steinberg MD, Julian MA, Wise L. 1985. Psychological
outcome of lumpectomy versus mastectomy in the
treatment of breast cancer. Am J Psychiat 142: 34–39.
Veronesi U, Luini A, Del Vecchio M et al. 1993.
Radiotherapy after breast preserving surgery in
women with localized cancer of the breast. New Eng
J Med 328: 1587–1591.
Wortman CB. 1984. Social support and cancer patient:
Conceptual and methological issues. Cancer
15(Suppl): 2339–2369.
Psycho-Oncology 13: 132–139 (2004)