medwireNews: Young women who undergo mastectomy for breast cancer report poorer quality of life (QoL) than those treated with breast conserving therapy (BCT) more than 5 years after surgery, particularly when they also receive radiotherapy, research shows.
Laura Dominici (Brigham and Women’s Hospital, Boston, Massachusetts, USA) and co-authors report in JAMA Surgery that their findings were “driven by inferior satisfaction with breasts and psychosocial and sexual wellbeing” among the women who received mastectomy.
They add that the data “are all the more striking considering the recent trends toward bilateral mastectomy for unilateral breast cancer and the fact that most of these women underwent reconstruction.”
Among the 560 women with breast cancer included in the analysis (median age 36 years at diagnosis; 86% stage 0–II), 52% underwent bilateral mastectomy, 20% underwent unilateral mastectomy, and 28% received BCT.
In those that underwent mastectomy, 45% also received radiotherapy and 89% had reconstruction (81% implant reconstruction, 16% autologous reconstruction, 3% complex reconstruction).
All of the women completed the BREAST-Q scores QoL survey, which scores QoL in six different domains on a scale of 0 to 100 points, a median of 5.8 years from diagnosis.
The results of this survey revealed significant differences in breast satisfaction, psychosocial wellbeing, and sexual wellbeing, but not physical wellbeing, among the different therapy strategies.
For example, women who had BCT recorded average BREAST-Q scores of 65.5 points for breast satisfaction, 75.9 points for psychosocial wellbeing, and 57.4 points for sexual wellbeing. The corresponding scores were 54.6, 66.1, and 50.4 points for women who received unilateral mastectomy with radiotherapy, and 55.8, 65.1, and 46.2 points for those who received bilateral mastectomy with radiotherapy.
Of note, the differences between the highest and lowest scores generally exceeded the threshold for a large minimally important difference of 8 to 10 points.
After adjustment for potential confounders, unilateral and bilateral mastectomy plus radiotherapy were both associated with significantly worst BREAST-Q scores for breast satisfaction relative to BCT, while unilateral mastectomy with radiotherapy and bilateral mastectomy with or without radiotherapy were each independently associated worse psychosocial and sexual wellbeing.
The researchers also observed QoL differences among the subgroup of patients who underwent reconstruction, with BREAST-Q scores highest among women who had autologous reconstruction without radiotherapy and lowest in those who had complex reconstruction or implant reconstruction with radiotherapy.
Based on their findings, Dominici et al believe: “Consideration should be given to including QOL data as part of decision support tools for young women with newly diagnosed breast cancer as well as in physician discussions with patients to ensure young women understand the long-term impacts of surgery with and without radiotherapy, which is of particular importance given the extended survivorship period most young patients experience after breast cancer surgery.”
In an accompanying comment, Monica Morrow, from the Memorial Sloan Kettering Cancer Center in New York, USA, agrees with this conclusion. She says: “This study provides information that should be incorporated into patient counseling.”
Morrow adds: “A surgeon’s recommendation against contralateral prophylactic mastectomy is a powerful deterrent against the use of the procedure and is not associated with decreased patient satisfaction with surgical decision-making.
“In addition to the lack of survival benefit and higher risk of surgical complications with mastectomy and low risk of development of contralateral cancer overall, the lower quality-of-life scores after mastectomy compared with BCT should be added to the discussion of the merits of mastectomy vs BCT.”
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JAMA Surg 2021; doi:10.1001/jamasurg.2021.3758
JAMA Surg 2021; doi:10.1001/jamasurg.2021.3759