What women wish they knew before prophylactic mastectomy

Although prophylactic mastectomy significantly reduces the incidence and recurrence of breast cancer, little is known about women's information needs before the procedure. We surveyed 967 women, from 6 healthcare systems, with bilateral or contralateral prophylactic mastectomy performed between 1979 and 1999. There were 2 open-ended questions: "What one thing do you wish you had known before your prophylactic mastectomy" and "Is there anything else you would like to share with us?" Three researchers categorized responses, and informational needs were ascertained. Seventy-one percent (684 women) responded, of which 81% answered one or both open-ended questions. There were 386 comments (made by 293 women) that related to information needs; 79% of women had bilateral prophylactic mastectomy and 58% had contralateral prophylactic mastectomy. Most concerns (69%) were related to reconstruction: the longevity; look and feel of implants, pain, numbness, scarring, and reconstruction options. Many women wished they had seen photographs to better prepare them for the final result. Our findings suggest that information needs of many women undergoing prophylactic mastectomy, particularly those selecting bilateral prophylactic mastectomy, have not been sufficiently addressed. Clinicians and health educators should be aware of patient needs and must counsel women accordingly.     

Factors affecting genetic testing and decisions about prophylactic surgery

Both of the articles reviewed here as well as the references, suggest that very little is actually known about the impact of many aspects of genetic testing. How decision are made about genetic testing in people who do not have cancer, how the results of testing are used used to guide care, and ultimately how people adjust to prophylactic surgery, which is the most effective form of prevention currently available to those who do have a mutation are not completely clear. This has many implications for practice in general. Oncology nurses who build relationships with those diagnosed with cancer and their families may be one of the best groups of professionals to provide the education and counseling individuals and families need prior to making any decision about genetic testing. Just as many responses to cancer exist, so do many responses to finding out the results of mutation status. Oncology nurses are challenged to help facilitate adjustment to learning that one carries a mutation that significantly increases risk of developing cancer. More nursing research needs to be conducted on how to facilitate this adjustment. Dealing with the unknown can be a frightening experience. Little is known about the long-term effectiveness of prophylactic mastectomy and oophorectomy in unaffected mutation-positive individuals. Most of what is known is based on retrospective review. Nurses are challenged to interpret this information, along with its inherent strengths and weaknesses, to individuals so they can make the best possible decisions. The psychosocial needs of those who undergo prophylactic surgery are not clearly understood. Surgery can have many psychological outcomes, and how individuals adjust to these changes is not clear. More nursing research is needed not only to understand these needs but also to design interventions to facilitate and improve adjustment to not only the information that one is mutation positive but also to prophylactic surgery. People who do not have cancer but have a high risk for cancer because of their genetic background need comprehensive and consistent care by knowledgeable healthcare providers. Although these individuals have not been diagnosed with cancer, they have complex psychosocial needs related to their family history and the decisions being made about prevention strategies. Oncology nurses can help fill this gap in care and provide the necessary support these individuals need.     

A preliminary study into women’s experiences of undergoing reconstructive surgery after breast cancer

Breast cancer is the most common type of cancer among women. In Sweden, about 40% of women diagnosed with breast cancer undergo a mastectomy; breast reconstruction (BR) may be an option for these women. However, the experience of undergoing reconstructive surgery appears to be only very scarcely researched, despite its importance in clinical nursing.AimThe purpose of this study was to explore women’s experiences of undergoing breast reconstructive surgery after mastectomy due to breast cancer.MethodsSix women participated in narrative interviews about their experiences of reconstructive surgery, and the interview data were analysed using thematic narrative analysis.ResultsAll six women were unprepared for the strenuous experience of undergoing a BR. They described the process as difficult and painful, entailing several operations and an unexpectedly long recovery period. They were also unprepared for how arduous it would be, both physically and emotionally. However, getting a BR had been important to all the women. The BR process was captured in four themes: (1) uninformed care; (2) arduous experiences; (3) body alterations; and (4) moving on.ConclusionsObtaining adequate information and being involved in the decision-making process along the pathway of a BR could help the women to prepare physically and emotionally for the strenuous experiences related to reconstructive surgery.     

Survival Comparisons for Breast Conserving Surgery and Mastectomy Revisited: Community Experience and the Role of Radiation Therapy

ObjectivesEvidence suggests superiority of breast conserving surgery (BCS) plus radiation over mastectomy alone for treatment of early stage breast cancer. Whether the superiority of BCS plus radiation is related to the surgical approach itself or to the addition of adjuvant radiation therapy following BCS remains unclear.ResultsData from 5335 women were included, of which two-thirds had BCS and one-third had mastectomy. Surgical decision trends changed over time with more women undergoing mastectomy in recent years. Women who underwent BCS versus mastectomy differed significantly regarding age, cancer stage/grade, adjuvant radiation, chemotherapy, and endocrine treatment. Overall survival was similar for BCS and mastectomy. When BCS plus radiation was compared to mastectomy alone, 3-, 5-, and 10-year overall survival was 96.5% vs 93.4%, 92.9% vs 88.3% and 80.9% vs 67.2%, respectively.ConclusionThese analyses suggest that survival benefit is not related only to the surgery itself, but that the prognostic advantage of BCS plus radiation over mastectomy may also be related to the addition of adjuvant radiation therapy. This conclusion requires prospective confirmation in randomized trials.     

Are patients with breast cancer satisfied with their decision making?: a comparison over time

Choosing between lumpectomy with radiation versus mastectomy is difficult for women with early-stage breast cancer, and doubt can decrease women's confidence and satisfaction. As a result, the current study surveyed satisfaction before and after surgery in a convenience sample of women with early-stage breast cancer from a single practice. All women received either total mastectomy or lumpectomy plus radiation based on their informed choice of surgical options. The surgeon and the principal investigator educated patients about both surgeries at the time of consent. Participants answered a survey about satisfaction with their decision making before their chosen surgical procedure and again by telephone six months later. Participants felt that they had made an informed choice at the time of decision (87%) and at follow-up (93%). In addition, most women were satisfied with their choice of surgical procedure at time of decision (87%) as well as six months after surgery (96%). This study allowed women to significantly participate in their care through surgical decision making, which improved satisfaction. Nurses are uniquely positioned to support women with early-stage breast cancer in their decision-making process.     

The role of magnetic resonance imaging in screening women at high risk of breast cancer

Most women at very high risk of breast cancer because of a mutation in the genes BRCA1 or BRCA2, or a very strong family history of breast cancer, opt for intensive breast screening rather than bilateral prophylactic mastectomy. Annual screening mammography has low sensitivity in this population in part because of the greater breast density and faster tumor growth of younger women, resulting in cancers being detected at a suboptimal stage. In 11 prospective comparative studies, the addition of annual contrast-enhanced magnetic resonance imaging (MRI) of the breast to mammography demonstrated more than 90% sensitivity, more than twice that of mammography alone. False-positive rates were higher with the addition of MRI, but specificity improved on successive rounds of screening. Although survival data are not yet available, the stage distribution of these tumors predicts a significant reduction in breast cancer mortality rate compared with that of screening without MRI. Accordingly, annual MRI plus mammography is now the standard of care for screening women aged 30 years or older who are known or likely to have inherited a strong predisposition to breast cancer (based on the above evidence) and for women who received radiation therapy to the chest before the age of 30 years (based on expert opinion). Further research is necessary to define the optimal screening schedule for different subgroups. Formal studies of other high-risk populations (eg, biopsy showing lobular neoplasia or atypical ductal hyperplasia, dense breasts, and personal history of breast cancer at a young age) should be done before MRI screening is routinely adopted for these women.     

Incidence and risk of arm oedema following treatment for breast cancer: a three-year follow-up study

BACKGROUND: Breast-cancer-related lymphoedema is a chronic condition with estimates of incidence ranging from 6 to 83%. Lymphoedema has been associated with a variety of risk factors. However, this evidence has suffered from methodological weaknesses, and so has had little impact upon clinical practice. AIM: To examine incidence and risk factors [hospital skin puncture, surgical procedure, Body Mass Index (BMI), age, axillary node status, number of axillary nodes removed, radiotherapy and surgery on dominant side] for breast cancer-related arm lymphoedema. DESIGN: Prospective observational study, with measurement of limbs pre-operatively and at regular intervals post-operatively. METHODS: We recruited 251 women who had surgical treatment for breast cancer that involved sampling, excision or biopsy of axillary nodes, aged > or = 18 years, and free of advanced disease and psychological co-morbidities. Of these, 188 (74.9%) were available for 3-year follow-up. RESULTS: At follow-up, 39 (20.7%) had developed lymphoedema. Hospital skin puncture (vs. none) (RR 2.44, 95%CI 1.33-4.47), mastectomy (vs. wide local excision or lumpectomy) (RR 2.04, 95%CI 1.18-3.54), and BMI > or = 26 (vs. BMI 19-26) (RR 2.02, 95%CI 1.11-3.68) were the only significant risk factors. DISCUSSION: Lymphoedema remains a significant clinical problem, with 1:5 women in this sample developing the condition following treatment for breast cancer. Risk factors are identified in the development of lymphoedema that should be taken into account in clinical practice.     

Pharmacokinetics and tissue penetration of vancomycin in patients undergoing prosthetic mammary surgery

Vancomycin concentrations in periprosthetic breast tissues were evaluated in 24 women undergoing reconstructive surgery after mastectomy for breast cancer. Patients were given a single prophylactic dose of vancomycin (1 g iv) 1-8 h before surgery, and mean capsular and pericapsular tissue concentrations were measured by HPLC. Vancomycin was not detectable in the majority of patients belonging to the 1-3 h post-dose groups, whereas in the 4-8 h post-dose groups, mean capsular and pericapsular concentrations were as follows: at 4 h, 4.0 mg/kg and 5.9 mg/kg; at 6 h, 4.1 mg/kg and 4. 8 mg/kg; at 8 h, 5.9 mg/kg and 11.1 mg/kg, respectively. Vancomycin tissue concentrations thus were equal to or exceeded the breakpoint of 4 mg/L in most samples collected 4-8 h after dosing. In conclusion, our data suggest that appropriate timing of vancomycin prophylaxis should be considered to allow the maintenance of adequate tissue concentrations throughout the surgical procedure.     

Identifying and counseling women at increased risk for breast cancer

Women at increased risk for breast cancer should be identified and counseled about options for risk reduction. Identifying such women is simplified with use of the National Cancer Institute Risk Assessment tool, a computer-based tool that incorporates information on 6 risk factors for estimating an individual's risk of developing breast cancer. However, the tool does not incorporate all known or possible risk factors and may underestimate risk, particularly among women with a complex family history of breast cancer for whom alternative models of risk assessment are more appropriate. Women found to have an increased risk of breast cancer should be counseled about options for management, including close surveillance, lifestyle modifications, chemoprevention with tamoxifen, enrollment in a breast cancer prevention clinical trial, and prophylactic mastectomy and/or oophorectomy. In the absence of consensus about which risk level is best suited to which option, decisions about risk reduction depend as much on an individual's priorities and risk aversion as on numerical risk estimates.     

乳腺癌根治术病人手术前后焦虑状态的调查及分析

[目的]了解乳腺癌病人行根治术前后的焦虑状态,为心理评估和心理护理提供科学依据。[方法]采用问卷调查法,应用焦虑自评量表（SAS）对78例乳腺癌根治术病人的焦虑状态进行调查分析。[结果]乳腺癌根治术病人手术前后SAS评分均高于常模组（P＆lt;0.05）,且手术前SAS评分显著高于手术后（P＆lt;0.05）。[结论]乳腺癌根治术病人手术前后存在不同程度的焦虑及焦虑状态,亟须加强相应的心理护理。     

心理干预对乳腺癌术后病人负性情绪和应对方式影响的研究

目的 探讨心理干预对乳腺癌根治术后病人负性情绪和应对方式的影响.方法 采用随机分组法将120例乳腺癌根治术患者分为干预组65例,对照组55例.干预组进行综合性心理干预,对照组给予常规护理,采用抑郁自评量表(SDS)和焦虑自评量表(SAS)医学应对问卷(McMQ)对其负性情绪及应对方式的相关因素进行问卷调查.结果 对照组和干预组各项指标差异具有统计学意义.结论 心理干预对改善乳腺癌根治术病人负性情绪,建立积极的应对方式有显著效果.     

Psychological Issues Associated with Breast Augmentation

The American Society of Plastic Surgeons (ASPS) reported that 329,396 women have undergone breast augmentation in the United States, an increase of 55% between 2000 and 2006, making it the most frequent US surgical cosmetic procedure for 2006 (). Although many studies have explored psychological aspects of this type of surgery, the consistently dramatic increase in numbers of breast augmentations, some that result in adverse psychological outcomes, remains a serious concern for health care providers. Surprisingly, very little is known about either the psychological characteristics of cosmetic surgery patients or the psychological impact of the surgical procedures. This literature review focuses on psychological issues in relation to breast augmentation procedures, including recent suicide findings related to this procedure. Conclusion of this review supports the necessity by health care providers to consistently screen patients for psychological disorders, such as Body Dysmorphic Disorder (BDD), prior to conducting cosmetic surgical procedures, specifically breast augmentation.     

PS1-16: Patterns of Surgical Care for Ductal Carcinoma In-situ

Background/Aims Overall prognosis for ductal carcinoma in-situ (DCIS), a non-invasive breast malignancy, is generally quite positive with a mortality rate of < 2%. DCIS may progress to invasive breast cancer if left undetected or inadequately treated. Age, family history and individual preference are factors influencing quality and extent of surgical treatment of DCIS. Breast conserving surgery with or without radiation is commonly used to treat limited DCIS, with consideration for adjuvant endocrine therapy. Re-excision is not uncommon for DCIS, as it may be difficult to initially obtain a negative margin and also there may be suspicion of co-existing invasive breast cancer. Sentinel lymph node biopsy and prophylactic mastectomy have been considered over-treatment for DCIS, except in cases where DCIS is high grade, diffuse, large size, or has components of microinvasion. Our study aim was to evaluate patient characteristics and impact of features of DCIS on surgical patterns of care for DCIS. Methods Data relating to initial surgical treatment of stage 0-III breast cancer was collected both electronically and by manual chart abstraction to develop the multicenter Breast Cancer and Surgical Outcomes database. Study sites included the University of Vermont, Marshfield Clinic (Wisconsin), Kaiser Permanente (Colorado) and Group Health (Seattle). Women with a pre-operative diagnosis of DCIS (n=943) between 2003-2008 were included in this analysis. Results Of 943 women with a pre-operative diagnosis of DCIS, 932 (99.0%) had post-operative final diagnosis of DCIS. Planned analyses include determination of variability in surgical treatment of DCIS, including initial mastectomy and sentinel node biopsy, and incidence of positive margins following initial surgical excisions. Variability will also be examined based on factors unique to this dataset such as surgeon-specific and regional variation patterns of surgical care. Patient characteristics, DCIS features, MRI use and prophylactic contralateral mastectomy rate will also be reported. Discussion Understanding the variability of surgical treatment for DCIS may lead to improved quality of care and better outcome for patients with DCIS.     

Breast cancer: The new biology in conflict with the old dogma

Let us summarize the pathophysiology of breast cancer according to the new biology. One or more unknown factors, (eg, hormonal, hereditary) lead to the development of proliferative changes in the glandular tissue of the breast. These changes are premalignant and render the patient at higher risk for breast cancer. Among those who show proliferative change, a smaller group (less than 4% of women who have breast biopsies and about 12% of those with proliferative change) develop atypical changes and are at particularly high risk.The explanation for these histologic events may be as follows: the etiologic agents of breast cancer produce a series of mutations that may activate oncogenes necessary for malignant transformation. Activation of these genes may produce in sequence proliferative growth, proliferative growth with atypia, in situ carcinoma, low grade invasive intraductal carcinoma, and subsequently overt clinical breast cancer. At some point this sequence becomes autonomous, ie, no longer dependent on the original etiologic factors. The cancer enters a progression phase in which its cells develop the capacity to invade blood vessels, survive in metastatic sites, lose their estrogen receptors, accelerate their growth rate, and develop resistance to chemotherapeutic agents. Not all precancerous lesions or in situ cancers evolve into clinical disease. Autopsy studies on women with no evidence of breast cancer show that 20% have invasive or in situ cancer of the breast.²⁸By the time we interrupt this chain with detection of a palpable or mammographically visible breast mass, it may be too late to completely reverse the process. Early detection may help some. Adjuvant chemotherapy may contribute a bit more. In view of the recent histologic data, it might be desirable to investigate the possibility of identifying women at special high risk by means of biopsy. Such women could then be given either special diagnostic attention or considered for prophylactic mastectomy. One might speculate that women at special high risk of breast cancer might be protected by prophylactic radiation of both breasts. Such a procedure might be far less cosmetically unsatisfactory than prophylactic mastectomy.With our better understanding of cancer biology, we may be able to develop therapy that will substantially improve cure rates. We need new clinical trials designed to test various aspects of the new biology of cancer. Dupont and Page have identified a very high risk group: can we devise acceptable and effective prophylaxis for this group? Adjuvant chemotherapy seems to modestly improve survival: can we confirm this and increase the salvage with better regimens? According to the new biology, certain steps in cancer progression can be predicted: can we develop therapeutic strategies that take advantage of this theoretic possibility? These and other questions demand attention in future studies.     

Observation interval for evaluating the costs of surgical interventions for older women with a new diagnosis of breast cancer

OBJECTIVE: To estimate the episodic costs of surgical treatments for breast cancer. METHODS: The surgical treatment period as the 6 weeks following diagnosis is defined. Using a sample of 205 women aged 65 and older and their Medicare claim files, the cost of treatment is estimated and the progression from first to subsequent surgical procedures during the 6-week interval is demonstrated with a decision tree. Two equations are then estimated: the probability of mastectomy versus breast conserving surgery (BCS) as first surgery using Probit regression and the log of total charges using a generalized linear regression model. RESULTS: It was found that only stage predicts the probability of mastectomy versus BCS and that 54% of women receiving BCS undergo a second surgery. Once all treatments in the initial surgical period are accounted, the difference between the adjusted cost of mastectomy alone and BCS followed by a second surgery was not statistically significant. Only a successful first BCS is statistically significantly (P <0.05) less costly than a mastectomy alone ($4,955 vs. $9,049). CONCLUSIONS: By defining a 6-week surgical treatment episode it is shown that BCS followed by subsequent surgeries is the more costly option for initial treatment. Given the high prevalence of second surgeries, previous work may have underestimated the costs of surgical interventions for breast cancer.     

Knowledge and expectations of women in the preoperative mastectomy

The objective of this study was to understand the knowledge, concerns and expectations of patients suffering from breast cancer in relation to mastectomy. Interviews were performed with 11 women before their being submitted to surgery at the Hospital das Clinicas in Fortaleza (Ceará state) on December 2008. The hermeneutic-dialectical method was used for discourse analysis, and three theme categories were defined: Knowledge about the surgery, Feelings and expectations surrounding mastectomy, and Removing the breast. It was found that women go through a stressful preoperative period, lack knowledge about the surgery, experience anxiety and fear of what they should expect, as well as feelings of panic and shock before their breast is removed. It is, therefore, observed that the health team caring for those patients has an important role in education and in providing emotional support so as to minimize the tragedy those women are experiencing.     

The relationship of membership in research networks to compliance with treatment guidelines for early-stage breast cancer

BACKGROUND: Research has shown that older women with breast cancer are less likely than younger women to receive treatment in accordance with accepted guidelines. Cancer-related research networks (eg, Comprehensive Cancer Centers) have been funded by the National Cancer Institute to increase the dissemination of new treatment strategies, but little is known about their relationship to cancer treatment patterns. OBJECTIVES: We used a 3-level hierarchical regression model to examine the relationship of treating facilities' memberships in cancer research networks to compliance with guidelines for primary treatment of early stage breast cancer, controlling for patient and facility factors. RESEARCH DESIGN: We analyzed data from a database linking SEER registry data and Medicare claims in patients aged 65 years of age or older with early-stage breast cancer to data on the treating facility, including variables that indicate membership(s) in cancer research networks. SUBJECTS: A total of 16,600 women with stage I or stage II breast cancer, diagnosed between 1990 and 1994, and who received treatment in one of 423 facilities were studied. MEASURES: The key independent variable in this analysis was membership in NCI-funded cancer research networks. The outcome measure is a 3-category variable defined as (1) mastectomy (MAST), (2) breast-conserving surgery plus radiation therapy (BCS+RT), or (3) BCS alone. RESULTS: Patients treated at facilities that were members of 2 or more cancer research networks were more likely to receive guideline-concordant treatment (ie, MAST or BCS+RT) than similar patients treated at non-member facilities. CONCLUSIONS: Organizational factors may influence compliance with treatment guidelines and be useful in improving the quality of care.     

Patients' lived experiences of excisional breast biopsy: a phenomenological study

Aims. The purpose of this study was to explore the lived experience of patients undergoing an excisional breast biopsy. Background. It has been determined that women who feel a lump or a lesion in their breast delay seeking medical treatment because it could be cancer and they might need a mastectomy and/or the cancer may not be treatable. After women go to a health‐care facility and are told that they need to have a biopsy to make a clear diagnosis they want to have the biopsy performed as soon as possible. Method. A phenomenological approach from a Heideggerian hermeneutical perspective was used. Participants were 20 patients who had an excisional breast biopsy in the day surgery of a university research and training hospital general surgery division under general anaesthesia between the dates of 1 December 2004–30 June 2005 and who returned one week later for monitoring, who were over 18 years old and who volunteered to participate in the research. Data were collected using in‐depth interviewing and analysed using the principles of Heideggerian hermeneutics. Results. Three themes were identified: need for information, fear, spiritual needs. Conclusion. It was determined that patients undergoing excisional breast biopsy had significant information and spiritual needs and experienced a fear of having cancer, losing their breasts and dying in surgery. Relevance to clinical practice. Although there are many studies about breast cancer and day surgery patients’ experiences in the literature, no studies were found about patients’ experiences with day surgery excisional breast biopsy procedures. The results provide a possible framework for patient care.