The sooner the better: a study of psychological factors in women undergoing immediate versus delayed breast reconstruction.

Patients who had reconstructive breast surgery at the time of mastectomy (immediate) or within 1 year (early) had significantly less recalled distress about their mastectomy than those who had it more than 1 year later (delayed). Women who had immediate or delayed reconstructive surgery had similar levels of psychological symptoms, which were slightly lower than those reported by women in the early reconstructive group. The wish to wear a wider range of clothes and the wish to be rid of the external prosthesis were common motivations for reconstructive surgery. The desire to improve sexual relations or one's marital state was less common and should be viewed with caution when presented as the primary motivation for this procedure.

Physician-patient communication about breast cancer. A challenge for the 1990s.

Rose Kushner, a well-known breast cancer patient advocate and medical journalist who contributed immeasurably to the changes that have taken place in breast cancer management today, summed up the communication dilemma succinctly. She stressed the importance of communication from physician to patient and from patient to physician. "In order for it to work [well]," she said, "it has to go both ways." The essence of a mutually cooperative endeavor in health care assumes that reactions from both parties affect the nature and outcome of the interaction. Therefore, it is mandatory to examine the reciprocal flow of factors that shape the physician-patient interaction. Although public testimony often conveys the conviction that physician communications are limited or altered in an attempt to protect patients from emotional upset and that withholding information is in their best interest, a literature review demonstrated that this was not so. Interestingly, today, a contrary trend may be emerging, where some physicians are so forthright and blunt in their disclosure that the impact of a guarded prognosis is felt as an assault and carries with it a connotation of certainty for disaster. As was stated earlier in this article, a most useful beacon to guide the physician in this dimly lit path is the notion that "congruence not candor" direct the disclosure. The physician-patient interaction is a unique and somewhat fragile connection that must be viewed as more than an implicit service contract. It is a special collaborative effort that requires continuous monitoring and assessment in order to maximize gratification for both parties. Individuals on both sides of the stethoscope have feelings and needs that can operate to enhance or sabotage optimal physician-patient relations.

Psychosocial issues in breast reconstruction. Intrapsychic, interpersonal, and practical concerns.

Because the decision to have or not to have breast reconstruction is multiply determined, in-depth inquiry should be made into the patient's intrapsychic (self-directed) motives and interpersonal factors that contribute to her choice. This article discusses five major variables that enter into the final decision. These include knowledge of the procedure, economic resources, medical conditions, psychological dynamics, and reactions of significant others in the patient's life, including spouse, physicians, and mother.

The psychological contribution of nipple addition in breast reconstruction.

Two groups of consecutive patients from two different plastic surgical practice populations were evaluated to determine psychosocial differences between those who underwent nipple-areola reconstruction in addition to breast reconstruction (N = 33) versus those who did not undergo nipple-areola reconstruction in addition to breast reconstruction (N = 26). Psychological assessment consisted of a standardized symptom inventory (Brief Symptom Inventory) and a specially designed self-report questionnaire investigating reactions unique to surgeries for breast cancer and breast reconstruction. Both groups were equivalent sociodemographically, with the exception of age, where the nipple-added group was significantly younger (P = 0.035) than the nipple-not-added group. The nipple-added group reported significantly greater satisfaction with breast reconstruction with regard to overall satisfaction (P = 0.004), satisfaction with size (P = 0.02), satisfaction with softness (P = 0.0004), sexual sensitivity (P = 0.006), and satisfaction with nude appearance (P = 0.02). Of the nine scales of clinical symptomatology on the Brief Symptom Inventory, the nipple-added group showed more increased symptoms on seven of the nine. The nipple-added group was significantly higher on two of these scales, namely, paranoid ideation (P = 0.009) and anxiety (P = 0.03).

Psychosocial correlates of immediate versus delayed reconstruction of the breast.

Two groups of consecutive patients from two different plastic surgical practice populations were evaluated to determine psychosocial differences between those who underwent immediate (n = 25) versus delayed (n = 38) breast reconstruction. Psychological assessment consisted of a standardized symptom inventory (BSI) and a specially designed self-report questionnaire investigating reactions unique to mastectomy and reconstruction. Both groups were extremely equivalent with regard to sociodemographic data, with the typical subject being a well-educated and employed Caucasian wife. Verbal reports of physical complaints revealed no significant differences between the two groups except for difficulty with arm movement, which was statistically higher for the immediate group (p = 0.006.). This difference most likely was due to the axillary dissection being performed simultaneously at the time of reconstruction. The relationship between timing of reconstruction and self-reported distress over the mastectomy experience revealed that only 25 percent of the women who underwent immediate repair reported "high distress" in recalling their mastectomy surgery compared with 60 percent of the delayed reconstruction group (p = 0.02). In reference to the two scales measuring psychological symptoms, a general trend was present, with the delayed group scoring higher (although not statistically significantly) on 9 of our 12 scales. Ninety-six percent of the immediate group and 89 percent of the delayed group reported satisfaction with results.(ABSTRACT TRUNCATED AT 250 WORDS)

The sexual and intimate consequences of breast cancer treatment.

Confronting the loss of sexual desire, feelings of sexual attractiveness, range of sexual activities, and ability to reproduce is often a seriously neglected area in oncology and a great source of distress for the breast cancer patient. Addressing the problem early in the doctor-patient relationship and simply giving the woman permission to discuss these critical concerns with the person managing her care will do much to reduce some of the anguish that accompanies breast cancer and its treatments.

Barriers to clinical trials. Part II: Knowledge and attitudes of potential participants.

The reasons why less than 3% of cancer patients receive treatment in a clinical trial are complex and multiply determined. Because an individual cannot sign herself into a research study, an understanding of the doctor-patient interaction must be considered in addition to individual patient dynamics. Patients may be concerned that a physician's primary allegiance is to the requirements of the trial, not the specific health needs of the individual. Physicians may worry about the effects that placing an individual in a trial will have on the special doctor-patient relationship. Specific psychologic factors that may make a patient reluctant to enter a trial include self-protectiveness, time and travel constraints, concern about the quality of research versus clinical care, the nature of the informed consent, and worry about the usual low level priority assigned to quality-of-life issues in biomedical research. Enrollment in and adherence to investigative research may be served better by the construction of studies that combine questions about both medical outcome and impact of treatment on patient quality of life. Individuals who require high levels of personal control, want to feel they are a high priority with their physician, and need frequent feedback about results are not likely to be good candidates for investigative research.

Patients' rights in decision making: the case for personalism versus paternalism in health care.

The purpose of this presentation is to shine a psychological spotlight on the role of the breast cancer patient in the process of her decision making about her medical care and the specific influence that the nature of the physician-patient interaction has on that behavior. The vision of the parental physician as unilateral authority in decisions about health care is dimming. The picture is being supplanted by a new image that promotes a view of personalism and a concept of "shared responsibility." The wave of consumerism is washing the shores of medical practice, and women are establishing their beachhead. Women are demonstrating their knowledge, their competence, and their responsibility in exercising decisions about their medical treatments and the quality of their survival. Therefore, it is essential to educate patients to exhibit informed consumer behavior and encourage physicians to recognize the value of a patient's participation. Such collaborative endeavors could result in increased patient satisfaction, reduced burdens for the physician, and preserved patients' feelings of individuality, autonomy, and sense of personal dignity.

Psychosocial outcome in a randomized surgical trial for treatment of primary breast cancer.

A study of the differences in the psychosocial effects of mastectomy versus segmentectomy was done on a group of women who were in a prospective randomized protocol for treatment of primary breast cancer. Through questionnaires designed for this study and standardized psychologic tests, women with segmentectomies responded as significantly less anxious, less sad, and more in control of their life events than women with mastectomies. The women with segmentectomies had a statistically more positive sexual and body image than those with mastectomies. The trauma of viewing the surgery was much greater in patients with mastectomies. The concern about cancer recurrence was less in the segmentectomy group. The differences in psychosexual adaptation to mastectomy or segmentectomy and the fears of cancer recurrence were significantly better in the segmentectomy group. The adequacies of cancer therapy was the same for both groups in the national study. This study restresses the importance of the segmentectomy option for women with breast cancer in leading to a better quality of life.

Psychological functioning of daughters of breast cancer patients. Part II: Characterizing the distressed daughter of the breast cancer patient.

Sixty daughters whose mothers had breast cancer were cross-sectionally studied. Daughters age 11-20 reported feeling significantly more uncomfortable about involvement in their mothers' illness than daughters age 20+. Daughters whose mothers died were more likely to report long-term life plan changes and role changes with their mothers during the mothers' illness. The Global Symptom Index was predicted by the daughter's perceived degree of involvement with her mother (during her mother's illness), current emotional resolution (about her mother's illness), and sexual satisfaction. Sexual satisfaction was predicted by role changes during the mother's illness, frequency of sexual relations, and a depression scale.

Psychological functioning of daughters of breast cancer patients. Part I: Daughters and comparison subjects.

Sixty daughters of mothers with breast cancer were matched for age, educational level, and race with 60 comparison subjects without a maternal history of breast cancer to assess the impact on psychological adjustment, coping, body image, sexual functioning, and health knowledge and practices of having had a mother with breast cancer. Daughters of breast cancer patients showed significantly less frequent sexual intercourse, lower sexual satisfaction, and greater feelings of vulnerability to breast cancer, and they could identify a greater number of symptoms of breast cancer. No differences between groups were found in psychological symptoms, coping styles, breast self-examination practices, mammography practices, health knowledge, or body-image ratings. Contrary to clinical studies, women at risk for breast cancer showed good overall coping with few signs of significant dysfunctions in relation to comparison subjects.

Mastectomy versus conservative surgery and radiation therapy. Psychosocial consequences.

BACKGROUND: Clinical trials comparing mastectomy to conservative surgery plus radiation therapy in the treatment of breast cancer have provided an opportunity to increase understanding of the biology of this disease and the psychological adaptation of the breast cancer patient. Because these local treatments appear to be equal in terms of survival, the question remains as to whether conservative surgery plus radiation therapy confers a measure of psychological comfort superior to that of mastectomy for women diagnosed with early-stage breast cancer. METHODS: One hundred forty-two women participating in a clinical trial randomizing patients to mastectomy or lumpectomy and radiation therapy were prospectively evaluated for psychological response to their respective local therapy. A baseline assessment before randomization and subsequent questionnaires at 6, 12, and 24 months after treatment were completed by patients entered in the clinical trial. RESULTS: At 6 months, mastectomy patients reported significantly less control over events in their lives (P = 0.003) and more problems with sexual relations (P = 0.021) than did their conservatively treated counterparts. In addition, there were marked differences between mastectomy patients and lumpectomy and radiation therapy patients in the degree of distress over their nude bodies, with P = 0.001 at 6 months, P = 0.019 at 12 months, and P = 0.057 at 24 months. CONCLUSIONS: From our findings, it appears that breast conservation therapy protects women's perception of their body but does not, over time, contribute to a more positive sexual adjustment.

Comparison of pain, motion, and edema after modified radical mastectomy vs. local excision with axillary dissection and radiation.

Recent data suggest that prognosis is similar for women with primary breast cancer whether they receive modified radical mastectomy (MRM) or local excision and axillary dissection with radiation (XRT). The effects of either of these treatments on arm mobility, pain, or edema have not been compared. To assess the impact of MRM or XRT on mobility, pain, or edema, we evaluated patients treated in a prospective randomized trial designed to assess prognosis following MRM or XRT. All were provided a standardized physical therapy program including arm mobilization, shoulder strengthening, prevention and treatment of upper extremity edema, and education about arm function. Patients were evaluated for chest wall pain, arm motion, muscle strength, and edema as determined by circumferential measurements at the wrist, forearm, and arm. Evaluations were performed preoperatively and at yearly anniversaries of their surgery. Women receiving XRT had more chest wall tenderness at 1 and 2 years after surgery than those receiving MRM (p2 less than 0.0001 and p2 = 0.0007 respectively). Those receiving MRM were slower to reach their preoperative range of motion (ROM) (p2 = 0.043). Incidence of muscle weakness was similar in both groups. The few patients with local recurrence of tumor had more upper extremity edema than those who did not recur (p2 = 0.085) at 1 year and (p2 = 0.02) at 2 years. In patients who did not develop local recurrence, those who had received XRT had greater but nonsignificant increases in upper extremity circumferential measures compared with those receiving MRM at any anniversary evaluation. Patients receiving MRM and XRT are likely to have some differences in functional outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychosocial outcomes of breast cancer therapies: lumpectomy versus mastectomy.

The psychological status of 50 patients who had been treated for breast cancer was assessed an average of 21 months after treatment. The patients were grouped according to major treatment modalities: mastectomy with breast reconstruction, mastectomy without breast reconstruction, or lumpectomy. Lumpectomy patients had a significantly more intact body image (p less than .008) and a greater sense of sexual desirability (p less than .009) than patients in the other groups. The patients did not differ on frequency of sexual relations or on emotional symptomatology. The results of this study generally validate those found in comparable studies showing that lumpectomy promotes a more intact body image but that no surgical procedure either produces or inhibits psychological symptomatology.

Psychosocial and physical outcomes of primary breast cancer therapy: mastectomy vs excisional biopsy and irradiation.

Thirty-eight patients treated for primary breast cancer as part of a prospective randomized clinical trial were questioned retrospectively as to their psychosocial adaptation to treatment. Twenty patients had received mastectomy and eighteen had received excisional biopsy plus radiation of the intact breast. Aside from body image concerns, there were no marked psychosocial differences detected between these groups. Previous studies emphasizing serious psychological problems in mastectomy patients and fewer such problems in nonmastectomy patients may be influenced by biases that are not present in a randomized study design.