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Objectively measured breast symmetry has no influence on quality of life in breast cancer patients
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EJSO 38 (2012) 130e136
www.ejso.com
Objectively measured breast symmetry has no influence on quality of life in breast cancer patients R. Exner a,*, W. Krois a, M. Mittlb€ ock b, P. Dubsky a, R. Jakesz a, M. Gnant a, F. Fitzal a a
Department of Surgery, Medical University Vienna, Breast Health Care Center, Waehringer Guertel 18-20 Vienna, Austria b Center for Medical Statistics, Informatics and Intelligent Systems, Vienna, Austria Accepted 20 October 2011 Available online 5 December 2011
Abstract Aims: This study investigates how quality of life (QoL) of breast cancer patients is related to breast symmetry. Methods: We objectively measured breast symmetry using the breast analyzing tool (BAT) in 101 patients after breast conserving surgery for breast cancer at different time points during follow up. We correlated the results with the quality of life measured at the same time using the breast image scale (BIS), the EORTC QLQ-BR23 scale and a not validated sexual score scale. Age, tumour size, tumour/breast relation and the use of oncoplastic surgery were also correlated with symmetry and quality of life scales. Using multivariate analyses, independent parameters for an improved quality of life were identified. Results: Mean age was 56 (11.6), and 75.2% of patients had T1 or T2 tumours. Patient age ( p ¼ 0.03) and tumour size ( p ¼ 0.01) significantly influenced objectively measured breast symmetry. The cosmetic result was important for 53% of patients while 48% found it not important. Independent from this, neither overall quality of life nor breast self esteem was influenced by breast symmetry in our patients. Conclusions: After breast cancer surgery, breast symmetry is not a major factor for patients’ quality of life and breast self esteem. Cosmetic result seems to be less important than oncologic outcome in patients with breast cancer. Ó 2011 Elsevier Ltd. All rights reserved. Keywords: Breast cancer; Breast symmetry; Quality of life
Introduction The use of breast conserving therapy (BCT) in breast cancer patients increases their quality of life1 beside similar oncologic outcome compared with patients after mastectomy.2 In a multicenter randomised study, BCT was shown to help maintain the patients’ body image, result in higher satisfaction with treatment and yield no significant difference from mastectomy with respect to fear of recurrence.3 A recent study showed that function, aesthetics and breast sensitivity can be interpreted as important time independent influencing factors on QoL.4 The quality of life score measured one year after surgery persists over several years.5 However, there are only few data investigating factors that correlate with a good quality of life or breast self * Corresponding author. Tel.: þ43 01 40400 5621; fax: þ43 01 40400 5641. E-mail address: [email protected] (R. Exner). 0748-7983/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2011.10.012
esteem within the group of patients after BCT. An increased breast deformity and worse cosmetic outcome have been shown after a resection of more than 10% of breast tissue.6 Waljee demonstrated that breast symmetry may in fact play a certain role for postoperative depression. Patients with a good result of subjectively evaluated breast symmetry showed significantly fewer depressive symptoms.7 However, subjectively measured breast symmetry is often not reproducible and may be influenced by several co-factors such as daily mental status of the validating person and other social factors. The breast analyzing tool is a scoring software program that has been developed to objectively analyse breast symmetry.8 This increases reproducibility and comparability of the results. Moreover we measured the hospital anxiety and depression score of the patients and excluded patients with a score above 20, for it was shown that these patients were very likely to suffer from severe anxiety and/or depression,9 which might bias subjective evaluation of quality of life.
R. Exner et al. / EJSO 38 (2012) 130e136
The aim of this study was to investigate patients’ breast self esteem and quality of life after BCT for breast cancer and to correlate these data with the objectively measured breast symmetry. Factors such as oncoplastic surgery were evaluated for their influence on quality of life and symmetry. Patients and methods Study design 101 patients were included into this study. Women after BCT due to unilateral breast cancer were asked to participate in this study during their cancer follow up at the outpatient surgical ward. After written signed informed consent patients were asked to complete the breast image scale form (BIS) and the EORTC QLQ-BR23 form as well as the hospital anxious and depressing form (HAD) after their visit at the outpatient surgical ward. At the same time a digital image was taken in a standardized manner and was used to calculate breast symmetry with the second version of the breast analyzing tool (BAT). This software uses well-defined landmarks (jugulomamillary distance and distances from the nipples to the edge of the breast) and calculates the difference between left and right breasts. This difference in length is multiplied by the surface area difference and is noted as percent difference and as difference factor. The values obtained can be converted to a simplified 3-point Harris scale (good, fair, poor).8 Information was obtained including age, tumour size and T-status from the hospitals own database. Tumour/ breast-ratio was calculated by dividing estimated cup size (ranging from 1 to 5) by tumour size in centimetres. Surgical procedure All patients received BCT for their breast cancer. Intraoperative frozen section was performed in all patients.10 In case of affected or close margins, immediate re-excision was performed. 92 Patients were treated by lumpectomy with sentinel lymph node or complete axillary dissection. 9 Patients received an oncoplastic operation defined as uni- or bilateral reduction mammoplasty combined with lumpectomy (volume displacement technique).11 In these patients, the Hall-Findlay technique was used, where central lumpectomy defects are reconstructed by medial pedicled dermoglandular flap,12,13 the Lejour vertical mammaplasty which uses an upper pedicle for the areola, and a central breast reduction with limited skin undermining without a submammary scar14 or the round block technique.11 These techniques have been demonstrated to be oncologically safe and improve cosmesis.15 All patients underwent postoperative radiotherapy and systemic adjuvant treatment according to the centers’ interdisciplinary tumour board recommendation.
131
Questionnaire After a median follow up of 3.6 years (range 0.2e20), questionnaires were handed out in the surgical outpatient ward and completed by the patient alone and immediately returned to the investigators (response rate 100%). The questionnaire contained the body image scale (BIS; Appendix 1),16 the EORTC QLQ-BR23 (Appendix 2)17the hospital anxiety and depression scale (HAD; Appendix 3)9 and some additional self-made non-validated questions about sexual function, cosmetic results and patient satisfaction (Appendix 4). Sex score was calculated from 3 EORTC QLQ-BR23 questions about sexual behaviour, the changes in sexual relationship and one question from BIS score concerning changes in sexual attraction. The evaluated answers were added up to a score (min: 4, max: 14 mean: 9). Objective breast symmetry measurements At the same time point of follow up, a CANON Eos 400D camera with a resolution of 10.1 megapixels was used to take frontal view digital photographs of all patients and the breast symmetry index (BSI) was calculated by the BAT software described elsewhere.8 Briefly, BSI is calculated by comparing the area, the circumference and the nipple position of both breasts and subtracting the data of one breast from the contra-lateral side. Skin changes, atrophy or scar length is not taken into account. Breast symmetry index ranges from 1 to 10 while 1e3 is considered as excellent, 4e6 as good and 7e10 as poor breast symmetry Fig. 1. Statistical analyses Continuous data was described with mean and standard deviation (SD) in case of normal distribution and with median (minimumemaximum) otherwise. Categorical data was described with absolute and relative frequencies. Group differences between two groups for continuous data were tested by t-test for normally distributed data or by the Wilcoxon rank-sum test otherwise. Associations between two continuous variables were assessed by Spearman’s correlation coefficient. Multiple regression models were calculated to assess the simultaneous influence of variables on measured scores. For the regression model a logarithmic transformation was performed on the BIS score, which was first increased by one in order to receive normally distributed homoscedastic residuals. P 0.05 was assumed to be significant. All calculations were performed with SAS (Version 9.2, Cary NC, USA). Results Demographic data 101 patients after BCT and consecutive radiation participated in the study after a median follow up of 3.6 years
132
R. Exner et al. / EJSO 38 (2012) 130e136
Figure 1. a: Breast symmetry index ¼ 1 (good). b: Breast symmetry index ¼ 5 ( fair). c: Breast symmetry index ¼ 8.5 (poor).
(range 0.2e20). Only 9 Patients underwent oncoplastic surgery. Demographic data are shown in Table 1. Correlation between symmetry and demographic data (Tables 2a and 2b) Correlation between the BSI and patient age, follow-up time (time in years between surgery and breast symmetry/ quality of life measurements), tumour size and tumour/ breast ratio is shown in Table 2a. We were able to demonstrate a significant positive correlation of patient age ( p ¼ 0.043) and tumour size ( p ¼ 0.022) with breast symmetry. Higher age correlated with higher breast symmetry Table 1 Patient characteristics. Demographic data (n ¼ 101) age(years) tumour size (cm) tumour/breast-ratio follow up time (years) Breast symmetry index- Score Breast Image Scale EORTC QLQ-BR23 sex-Score Oncoplastic surgery Tumour size Tis T1 T2 T3
56 (11.6) 2 (0.4e8) 1 (0.1e5) 3.6 (0.2e20.0) 5.4 (2.4) 2 (0e18) 19.4 (4.2) 8.5 (2.5) 9 (8.9%) 16 (15.8%) 59 (54.4%) 21 (20.8%) 5 (5.0%)
EORTC ¼ BR23 quality of life questionnaire. Tis ¼ in situ cancer. Data are described as mean (SD), median (min-max) or frequencies (%).
index (rS ¼ 0.20) which means that older patients showed worse breast symmetry. Large tumour size also resulted in worse breast symmetry (rS ¼ 0.23). There was no significant correlation between tumour/ breast ratio and breast symmetry ( p ¼ 0.172). The use of oncoplastic surgical techniques did not influence breast symmetry index ( p ¼ 0.48). In the multivariate analysis, we were also able to show a significant correlation between patient age and tumour size on breast symmetry index -Score ( p ¼ 0.0161 and p ¼ 0.0398; Table 2b). Correlation between quality of life and breast symmetry as well as demographic data (Table 2) There is no significant correlation between breast symmetry and BIS ( p ¼ 0.71), EORTC QLQ-BR23 ( p ¼ 0.21) or sex-score ( p ¼ 0.91). There was no correlation of age, tumour size or tumour breast ratio on BIS or EORTC QLQ-BR23. There was no influence of patient tumour size or tumour/ breast ratio on sex-score. Oncoplastic techniques did not Table 2a Association between symmetry and demographic data, described by Spearman correlation (rS) or mean (SD)
Age (years) Follow-up time Tumour size (cm) Tumour/breast-ratio Oncoplastic no (n¼92) Yes (n¼9)
Breast Symmetry Index
p-value
0.20 0.06 0.23 0.14 5.4 (2.4) 4.8 (2.4)
0.043 0.531 0.022 0.172 0.48
R. Exner et al. / EJSO 38 (2012) 130e136 Table 2b P-values for multiple regression analysis to explain Breast Symmetry Index- Score, BIS, EORTC and sex-score by age, follow-up time, tumour size, tumour/breast-ratio and use of oncoplastic surgery
Age (years) Follow-up time Tumour size (cm) Tumour/breast-ratio Oncoplastic
Breast Symmetry Index
BIS
EORTC
Sex-Score
0.02 0.16 0.04 0.95 0.88
0.22 0.27 0.45 0.72 0.04
0.22 0.70 0.48 0.96 0.58
<0.0001 0.15 0.47 0.05 0.77
The italic values represents the significant with p < 0.05.
directly impact symmetry, however in the 9 patients who had an oncoplastic operation BIS score was lower ( p ¼ 0.02). In the multivariate analysis we also observed that the use of oncoplastic surgery increased breast self esteem significantly ( p ¼ 0.037). Furthermore a significant negative correlation between age and sex-score could be shown, which means that older patients had a lower sex-score (Table 2c). In this study, 53% of patients regarded the cosmetic result as important while 48% found it not important at the time of follow up. 50% of patients with poor symmetry regarded breast cosmesis as important, for 50% of patients it was not important. Interestingly in 75% of patients with excellent breast symmetry cosmesis was regarded as important (Table 2d), Fig. 2. Discussion We analysed the impact of objectively measured breast symmetry on patients’ quality of life, body image and sexual function after BCT in breast cancer patients after a median follow up of 3.6 years following surgical treatment. Breast symmetry was significantly influenced by patient age and tumour size, but it had no effect on quality of life or breast self esteem. In the 9 patients who underwent oncoplastic surgery breast symmetry was not influenced, however, breast self esteem was increased in these patients in the multivariate analyses. A large variety of studies exists concerning quality of life after breast cancer surgery, but the data are inconsistent due to various instruments and different surgical techniques.18
133
Table 2d Cosmesis importance for categorized breast symmetry index Breast Symmetry Index
Cosmesis important n (%)
Cosmesis not important n (%)
Excellent (score 1e3) Good (score 3.5e6) Poor (score 6.5e10)
18 (75) 16 (41) 19 (50)
6 (25) 23 (59) 19 (50)
The influence of breast symmetry on patients’ quality of life was studied by Walljee, who reported that women with pronounced breast asymmetry were likely to experience poor psychosocial functioning and have a higher risk for the development of depressive symptoms. The authors explained their observation by the hypothesis that breast asymmetry might be a constant reminder of the disease and treatment, impairing the psychological adjustment.7 This analyses, however, is biased by the fact that patients ranked their breast symmetry with a subjective scoring scale. Moreover depressive patients are more likely to score their breast symmetry less than non-depressed women. Subjective scores have been shown to be inconclusive and poorly reproducible,19 which led to the development of an objective scoring software such as the breast analysing tool8 in order to analyse objectively patients’ breast symmetry and postoperative cosmetic outcome. Moreover, with the incorporation of oncoplastic techniques,11 new questions arise as to whether or not these techniques improve symmetry and patients’ breast self esteem and overall quality of life. In our study we used breast cancer specific QOL questionnaires16,17 created to study the patients’ subjective view of their current physical, social, emotional functioning as well as psychological parameters such as body image, sexual function and satisfaction with the cosmetic result of the surgical treatment and, for the first time, correlated it with objectively measured breast symmetry.8 In principle, our patients showed an overall high quality of life (BIS median 2, EORTC QLQ-BR23 median 19) and a high satisfaction with the cosmetic outcome after surgical treatment. Besides the experience that high patients’ satisfaction is a common observation in studies like ours, this may be due to the fact that at our centre breast cancer patients are looked after by a small and consistent breast unit team consisting of surgeons, oncologists and a breast nurse in the surgical outpatient ward. This may improve patientedoctor
Table 2c Associations of QOL with patient demographics described by Spearman correlation (rS); median (min-max) or mean (SD)
Breast Symmetry Index Age (years) Follow-up time Tumour size (cm) Tumour/breast-ratio Oncoplastic no (n¼92) yes (n¼9)
BIS
EORTC QLQ-BR23
Sex-Score
0.04 (p¼0.71) 0.09 (p¼0.35) 0.21 (p¼0.04) 0.08 (p¼0.41) 0.08 (p¼0.40) 2 (0e18) (p¼0.02) 1 (0e3)
0.13 (p¼0.21) 0.04 (p¼0.69) 0.07 (p¼0.51) 0.02 (p¼0.86) 0.04 (p¼0.66) 19.4 ( 4.2) (p¼0.92) 19.2 (4.9)
0.01 (p¼0.91) 0.41 (p < 0.0001) 0.10 (p¼0.30) 0.001 (p¼0.99) 0.06 (p¼0.52) 8.4 (2.5) (p¼0.17) 9.6 ( 2.4)
The italic values represents the significant with p < 0.05.
134
R. Exner et al. / EJSO 38 (2012) 130e136
Figure 2. Distribution (absolute frequencies) of outcome breast symmetry index separated by importance of breast cosmesis.
relation and patient satisfaction. The questionnaire was handed out in the surgical ward and immediately collected after completion, which may, on the other hand, bias the results, for patients may have been attempting to please the investigator.20 Improved cosmetic results can be achieved by developing plastic surgery techniques immediately during appropriate oncologic resection. This is known as oncoplastic surgery.21 A recent study demonstrated a positive impact of oncoplastic surgery on quality of life and self esteem of patients undergoing breast-conserving surgery.22 In this study local flaps or breast reduction techniques were used in only 9 of our patients to achieve a better cosmetic result of the affected breast and quality of life was assessed by validated questionnaires. In these 9 patients we showed significantly improved body image quality of life ( p ¼ 0.02) in patients treated with oncoplastic surgical techniques. Although the aesthetic outcome of the operated breast was improved, the symmetry of both breasts was not influenced, probably because of volume and shape differences of the contra-lateral breast, which was not always corrected at the time of cancer surgery. We have experienced that breast cancer patients often refuse an additional operation and rather accept breast asymmetry, and we could show no effect on overall quality of life in these patients. In an earlier study with only central located breast cancer we were able to demonstrate a significant improvement of breast symmetry with the use of oncoplastic techniques.15 Thus, the location of the tumour is also important regarding symmetry improvement, which may have had an impact in this study.
The subjective importance of the cosmetic result after treatment of breast cancer had no significant correlation with quality of life (data not shown). Interestingly in 75% of patients with excellent breast symmetry cosmesis was regarded as important while only 50% of patients with poor symmetry regard cosmesis as important (Table 2d). We suppose that patients with a life threatening disease like breast cancer are less concerned about their breast symmetry than their oncologic outcome. We conclude that breast symmetry is not a major factor for patients’ quality of life after breast cancer surgery. The improved breast self esteem in our patients after the use of oncoplastic techniques is independent of symmetry, but our numbers are small and further investigation is needed. Conflict of interest No conflict of interest.
Acknowledgements The authors would like to thank Brian Schroeder for his help in preparation of the manuscript.
Appendix. Supplementary material Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ejso.2011.10.012.
R. Exner et al. / EJSO 38 (2012) 130e136
135
Appendix 1. Body image scale (BIS) [Hopwood, 2001 #12]. Not at all
A little
Quite a bit
Very much
Have you been feeling self-conscious about your appearance? Have you felt less physically attractive as a result of your disease or treatment? Have you been dissatisfied with your appearance when dressed? Have you been feeling less feminine as a result of your disease or treatment? Did you find it difficult to look at yourself naked? Have you been feeling less sexually attractive as a result of your disease or treatment? Did you avoid people because of the way you feel about your appearance? Have you been feeling the treatment has left your body less whole? Have you felt dissatisfied with your body? Have you been dissatisfied with the appearance of your scar?
Appendix 2. EORTC QLQ-BR23 [Sprangers, 1996 #11] symptomes during the last weeks. Not at all
A little
Quite a bit
Very much
To what extent were you interested in sex? To what extent were you sexually active? To what extent was sex enjoyable for you? Did you have any pain in your arm or your shoulder? Did you have a swollen arm or hand? Was it difficult to raise your arm? Have you had any pain in the area of your affected breast? Was the area of your affected breast swollen? Was the area of your affected breast oversensitive? Have you had skin problems on or in the area of your affected breast (e.g., itchy, dry, flaky)?
Appendix 3. Hospital anxiety and depression scale (HAD) [Zigmond, 1983 #14]. Not at all
A little
Quite a bit
Very much
I feel tense or wound up I still enjoy the things I used to enjoy I get sort of frightened feeling as if something awful is about to happen I can laugh an see the funny side of things Worrying thoughts go through my mind I feel cheerful I can sit at ease and feel relaxed I feel as if I am slowed down I get sort of frightened like ‘butterflies’ in the stomach I have lost interest in my appearance I feel restless as if I have to be on the move I look forward with enjoyment to things I get sudden feelings of panic I can enjoy a good book or radio or TV programme
Appendix 4. Non-validated questions about sexual function, cosmetic results and patient satisfaction (sex-score). Did the operation change anything in your sexual relationship?
Have you been feeling less sexually attractive as a result of your disease or treatment? To what extent were you interested in sex? To what extent were you sexually active? To what extent was sex enjoyable for you?
No
Yes, positively
Yes, negatively
Not at all
A little
Quite a bit
Very much
136
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References 1. Ohsumi S, Shimozuma K, Kuroi K, et al. Quality of life of breast cancer patients and types of surgery for breast cancerecurrent status and unresolved issues. Breast Cancer 2007;14:66–73. 2. Jakesz R, Samonigg H, Gnant M, et al. Significant increase in breast conservation in 16 years of trials conducted by the Austrian Breast & Colorectal Cancer Study Group. Ann Surg 2003;237:556–64. 3. Curran D, van Dongen JP, Aaronson NK, et al. Quality of life of early-stage breast cancer patients treated with radical mastectomy or breast-conserving procedures: results of EORTC Trial 10801. The European Organization for Research and Treatment of Cancer (EORTC), Breast Cancer Co-operative Group (BCCG). Eur J Cancer 1998;34:307–14. 4. Heil J, Czink E, Golatta M, et al. Change of aesthetic and functional outcome over time and their relationship to quality of life after breast conserving therapy. Eur J Surg Oncol 2011;37:116–21. 5. Arndt V, Merx H, Stegmaier C, et al. Persistence of restrictions in quality of life from the first to the third year after diagnosis in women with breast cancer. J Clin Oncol 2005;23:4945–53. 6. Cochrane RA, Valasiadou P, Wilson AR, et al. Cosmesis and satisfaction after breast-conserving surgery correlates with the percentage of breast volume excised. Br J Surg 2003;90:1505–9. 7. Waljee JF, Hu ES, Ubel PA, et al. Effect of esthetic outcome after breast-conserving surgery on psychosocial functioning and quality of life. J Clin Oncol 2008;26:3331–7. 8. Fitzal F, Krois W, Trischler H, et al. The use of a breast symmetry index for objective evaluation of breast cosmesis. Breast 2007;16: 429–35. 9. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361–70. 10. Riedl O, Fitzal F, Mader N, et al. Intraoperative frozen section analysis for breast-conserving therapy in 1016 patients with breast cancer. Eur J Surg Oncol 2009;35:264–70.
11. Fitzal F, Nehrer G, Hoch D, et al. An oncoplastic procedure for central and medio-cranial breast cancer. Eur J Surg Oncol: J Eur Soc Surg Oncol Br Assoc Surg Oncol 2007;33:1158–63. 12. Fitzal F, Nehrer G, Deutinger M, et al. Novel strategies in oncoplastic surgery for breast cancer: immediate partial reconstruction of breast defects. Eur Surg 2007;39:330–9. 13. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg 1999;104:748–59. discussion 760e3. 14. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg 1994;94:100–14. 15. Fitzal F, Mittlboeck M, Trischler H, et al. Breast-conserving therapy for centrally located breast cancer. Ann Surg 2008;247:470–6. 16. Hopwood P, Fletcher I, Lee A, et al. A body image scale for use with cancer patients. Eur J Cancer 2001;37:189–97. 17. Sprangers MA, Groenvold M, Arraras JI, et al. The European Organization for Research and Treatment of Cancer breast cancer-specific quality-of-life questionnaire module: first results from a threecountry field study. J Clin Oncol 1996;14:2756–68. 18. Pockaj BA, Degnim AC, Boughey JC, et al. Quality of life after breast cancer surgery: what have we learned and where should we go next? J Surg Oncol 2009;99:447–55. 19. Cardoso MJ, Cardoso J, Santos AC, et al. Interobserver agreement and consensus over the esthetic evaluation of conservative treatment for breast cancer. Breast 2006;15:52–7. 20. Noguchi M, Saito Y, Mizukami Y, et al. Breast deformity, its correction, and assessment of breast conserving surgery. Breast Cancer Res Treat 1991;18:111–8. 21. Hernanz F, Regano S, Redondo-Figuero C, et al. Oncoplastic breastconserving surgery: analysis of quadrantectomy and immediate reconstruction with latissimus dorsi flap. World J Surg 2007;31:1934–40. 22. Veiga DF, Veiga-Filho J, Ribeiro LM, et al. Quality-of-life and selfesteem outcomes after oncoplastic breast-conserving surgery. Plast Reconstr Surg 2010;125:811–7.
EJSO 38 (2012) 130e136
www.ejso.com
Objectively measured breast symmetry has no influence on quality of life in breast cancer patients R. Exner a,*, W. Krois a, M. Mittlb€ ock b, P. Dubsky a, R. Jakesz a, M. Gnant a, F. Fitzal a a
Department of Surgery, Medical University Vienna, Breast Health Care Center, Waehringer Guertel 18-20 Vienna, Austria b Center for Medical Statistics, Informatics and Intelligent Systems, Vienna, Austria Accepted 20 October 2011 Available online 5 December 2011
Abstract Aims: This study investigates how quality of life (QoL) of breast cancer patients is related to breast symmetry. Methods: We objectively measured breast symmetry using the breast analyzing tool (BAT) in 101 patients after breast conserving surgery for breast cancer at different time points during follow up. We correlated the results with the quality of life measured at the same time using the breast image scale (BIS), the EORTC QLQ-BR23 scale and a not validated sexual score scale. Age, tumour size, tumour/breast relation and the use of oncoplastic surgery were also correlated with symmetry and quality of life scales. Using multivariate analyses, independent parameters for an improved quality of life were identified. Results: Mean age was 56 (11.6), and 75.2% of patients had T1 or T2 tumours. Patient age ( p ¼ 0.03) and tumour size ( p ¼ 0.01) significantly influenced objectively measured breast symmetry. The cosmetic result was important for 53% of patients while 48% found it not important. Independent from this, neither overall quality of life nor breast self esteem was influenced by breast symmetry in our patients. Conclusions: After breast cancer surgery, breast symmetry is not a major factor for patients’ quality of life and breast self esteem. Cosmetic result seems to be less important than oncologic outcome in patients with breast cancer. Ó 2011 Elsevier Ltd. All rights reserved. Keywords: Breast cancer; Breast symmetry; Quality of life
Introduction The use of breast conserving therapy (BCT) in breast cancer patients increases their quality of life1 beside similar oncologic outcome compared with patients after mastectomy.2 In a multicenter randomised study, BCT was shown to help maintain the patients’ body image, result in higher satisfaction with treatment and yield no significant difference from mastectomy with respect to fear of recurrence.3 A recent study showed that function, aesthetics and breast sensitivity can be interpreted as important time independent influencing factors on QoL.4 The quality of life score measured one year after surgery persists over several years.5 However, there are only few data investigating factors that correlate with a good quality of life or breast self * Corresponding author. Tel.: þ43 01 40400 5621; fax: þ43 01 40400 5641. E-mail address: [email protected] (R. Exner). 0748-7983/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2011.10.012
esteem within the group of patients after BCT. An increased breast deformity and worse cosmetic outcome have been shown after a resection of more than 10% of breast tissue.6 Waljee demonstrated that breast symmetry may in fact play a certain role for postoperative depression. Patients with a good result of subjectively evaluated breast symmetry showed significantly fewer depressive symptoms.7 However, subjectively measured breast symmetry is often not reproducible and may be influenced by several co-factors such as daily mental status of the validating person and other social factors. The breast analyzing tool is a scoring software program that has been developed to objectively analyse breast symmetry.8 This increases reproducibility and comparability of the results. Moreover we measured the hospital anxiety and depression score of the patients and excluded patients with a score above 20, for it was shown that these patients were very likely to suffer from severe anxiety and/or depression,9 which might bias subjective evaluation of quality of life.
R. Exner et al. / EJSO 38 (2012) 130e136
The aim of this study was to investigate patients’ breast self esteem and quality of life after BCT for breast cancer and to correlate these data with the objectively measured breast symmetry. Factors such as oncoplastic surgery were evaluated for their influence on quality of life and symmetry. Patients and methods Study design 101 patients were included into this study. Women after BCT due to unilateral breast cancer were asked to participate in this study during their cancer follow up at the outpatient surgical ward. After written signed informed consent patients were asked to complete the breast image scale form (BIS) and the EORTC QLQ-BR23 form as well as the hospital anxious and depressing form (HAD) after their visit at the outpatient surgical ward. At the same time a digital image was taken in a standardized manner and was used to calculate breast symmetry with the second version of the breast analyzing tool (BAT). This software uses well-defined landmarks (jugulomamillary distance and distances from the nipples to the edge of the breast) and calculates the difference between left and right breasts. This difference in length is multiplied by the surface area difference and is noted as percent difference and as difference factor. The values obtained can be converted to a simplified 3-point Harris scale (good, fair, poor).8 Information was obtained including age, tumour size and T-status from the hospitals own database. Tumour/ breast-ratio was calculated by dividing estimated cup size (ranging from 1 to 5) by tumour size in centimetres. Surgical procedure All patients received BCT for their breast cancer. Intraoperative frozen section was performed in all patients.10 In case of affected or close margins, immediate re-excision was performed. 92 Patients were treated by lumpectomy with sentinel lymph node or complete axillary dissection. 9 Patients received an oncoplastic operation defined as uni- or bilateral reduction mammoplasty combined with lumpectomy (volume displacement technique).11 In these patients, the Hall-Findlay technique was used, where central lumpectomy defects are reconstructed by medial pedicled dermoglandular flap,12,13 the Lejour vertical mammaplasty which uses an upper pedicle for the areola, and a central breast reduction with limited skin undermining without a submammary scar14 or the round block technique.11 These techniques have been demonstrated to be oncologically safe and improve cosmesis.15 All patients underwent postoperative radiotherapy and systemic adjuvant treatment according to the centers’ interdisciplinary tumour board recommendation.
131
Questionnaire After a median follow up of 3.6 years (range 0.2e20), questionnaires were handed out in the surgical outpatient ward and completed by the patient alone and immediately returned to the investigators (response rate 100%). The questionnaire contained the body image scale (BIS; Appendix 1),16 the EORTC QLQ-BR23 (Appendix 2)17the hospital anxiety and depression scale (HAD; Appendix 3)9 and some additional self-made non-validated questions about sexual function, cosmetic results and patient satisfaction (Appendix 4). Sex score was calculated from 3 EORTC QLQ-BR23 questions about sexual behaviour, the changes in sexual relationship and one question from BIS score concerning changes in sexual attraction. The evaluated answers were added up to a score (min: 4, max: 14 mean: 9). Objective breast symmetry measurements At the same time point of follow up, a CANON Eos 400D camera with a resolution of 10.1 megapixels was used to take frontal view digital photographs of all patients and the breast symmetry index (BSI) was calculated by the BAT software described elsewhere.8 Briefly, BSI is calculated by comparing the area, the circumference and the nipple position of both breasts and subtracting the data of one breast from the contra-lateral side. Skin changes, atrophy or scar length is not taken into account. Breast symmetry index ranges from 1 to 10 while 1e3 is considered as excellent, 4e6 as good and 7e10 as poor breast symmetry Fig. 1. Statistical analyses Continuous data was described with mean and standard deviation (SD) in case of normal distribution and with median (minimumemaximum) otherwise. Categorical data was described with absolute and relative frequencies. Group differences between two groups for continuous data were tested by t-test for normally distributed data or by the Wilcoxon rank-sum test otherwise. Associations between two continuous variables were assessed by Spearman’s correlation coefficient. Multiple regression models were calculated to assess the simultaneous influence of variables on measured scores. For the regression model a logarithmic transformation was performed on the BIS score, which was first increased by one in order to receive normally distributed homoscedastic residuals. P 0.05 was assumed to be significant. All calculations were performed with SAS (Version 9.2, Cary NC, USA). Results Demographic data 101 patients after BCT and consecutive radiation participated in the study after a median follow up of 3.6 years
132
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Figure 1. a: Breast symmetry index ¼ 1 (good). b: Breast symmetry index ¼ 5 ( fair). c: Breast symmetry index ¼ 8.5 (poor).
(range 0.2e20). Only 9 Patients underwent oncoplastic surgery. Demographic data are shown in Table 1. Correlation between symmetry and demographic data (Tables 2a and 2b) Correlation between the BSI and patient age, follow-up time (time in years between surgery and breast symmetry/ quality of life measurements), tumour size and tumour/ breast ratio is shown in Table 2a. We were able to demonstrate a significant positive correlation of patient age ( p ¼ 0.043) and tumour size ( p ¼ 0.022) with breast symmetry. Higher age correlated with higher breast symmetry Table 1 Patient characteristics. Demographic data (n ¼ 101) age(years) tumour size (cm) tumour/breast-ratio follow up time (years) Breast symmetry index- Score Breast Image Scale EORTC QLQ-BR23 sex-Score Oncoplastic surgery Tumour size Tis T1 T2 T3
56 (11.6) 2 (0.4e8) 1 (0.1e5) 3.6 (0.2e20.0) 5.4 (2.4) 2 (0e18) 19.4 (4.2) 8.5 (2.5) 9 (8.9%) 16 (15.8%) 59 (54.4%) 21 (20.8%) 5 (5.0%)
EORTC ¼ BR23 quality of life questionnaire. Tis ¼ in situ cancer. Data are described as mean (SD), median (min-max) or frequencies (%).
index (rS ¼ 0.20) which means that older patients showed worse breast symmetry. Large tumour size also resulted in worse breast symmetry (rS ¼ 0.23). There was no significant correlation between tumour/ breast ratio and breast symmetry ( p ¼ 0.172). The use of oncoplastic surgical techniques did not influence breast symmetry index ( p ¼ 0.48). In the multivariate analysis, we were also able to show a significant correlation between patient age and tumour size on breast symmetry index -Score ( p ¼ 0.0161 and p ¼ 0.0398; Table 2b). Correlation between quality of life and breast symmetry as well as demographic data (Table 2) There is no significant correlation between breast symmetry and BIS ( p ¼ 0.71), EORTC QLQ-BR23 ( p ¼ 0.21) or sex-score ( p ¼ 0.91). There was no correlation of age, tumour size or tumour breast ratio on BIS or EORTC QLQ-BR23. There was no influence of patient tumour size or tumour/ breast ratio on sex-score. Oncoplastic techniques did not Table 2a Association between symmetry and demographic data, described by Spearman correlation (rS) or mean (SD)
Age (years) Follow-up time Tumour size (cm) Tumour/breast-ratio Oncoplastic no (n¼92) Yes (n¼9)
Breast Symmetry Index
p-value
0.20 0.06 0.23 0.14 5.4 (2.4) 4.8 (2.4)
0.043 0.531 0.022 0.172 0.48
R. Exner et al. / EJSO 38 (2012) 130e136 Table 2b P-values for multiple regression analysis to explain Breast Symmetry Index- Score, BIS, EORTC and sex-score by age, follow-up time, tumour size, tumour/breast-ratio and use of oncoplastic surgery
Age (years) Follow-up time Tumour size (cm) Tumour/breast-ratio Oncoplastic
Breast Symmetry Index
BIS
EORTC
Sex-Score
0.02 0.16 0.04 0.95 0.88
0.22 0.27 0.45 0.72 0.04
0.22 0.70 0.48 0.96 0.58
<0.0001 0.15 0.47 0.05 0.77
The italic values represents the significant with p < 0.05.
directly impact symmetry, however in the 9 patients who had an oncoplastic operation BIS score was lower ( p ¼ 0.02). In the multivariate analysis we also observed that the use of oncoplastic surgery increased breast self esteem significantly ( p ¼ 0.037). Furthermore a significant negative correlation between age and sex-score could be shown, which means that older patients had a lower sex-score (Table 2c). In this study, 53% of patients regarded the cosmetic result as important while 48% found it not important at the time of follow up. 50% of patients with poor symmetry regarded breast cosmesis as important, for 50% of patients it was not important. Interestingly in 75% of patients with excellent breast symmetry cosmesis was regarded as important (Table 2d), Fig. 2. Discussion We analysed the impact of objectively measured breast symmetry on patients’ quality of life, body image and sexual function after BCT in breast cancer patients after a median follow up of 3.6 years following surgical treatment. Breast symmetry was significantly influenced by patient age and tumour size, but it had no effect on quality of life or breast self esteem. In the 9 patients who underwent oncoplastic surgery breast symmetry was not influenced, however, breast self esteem was increased in these patients in the multivariate analyses. A large variety of studies exists concerning quality of life after breast cancer surgery, but the data are inconsistent due to various instruments and different surgical techniques.18
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Table 2d Cosmesis importance for categorized breast symmetry index Breast Symmetry Index
Cosmesis important n (%)
Cosmesis not important n (%)
Excellent (score 1e3) Good (score 3.5e6) Poor (score 6.5e10)
18 (75) 16 (41) 19 (50)
6 (25) 23 (59) 19 (50)
The influence of breast symmetry on patients’ quality of life was studied by Walljee, who reported that women with pronounced breast asymmetry were likely to experience poor psychosocial functioning and have a higher risk for the development of depressive symptoms. The authors explained their observation by the hypothesis that breast asymmetry might be a constant reminder of the disease and treatment, impairing the psychological adjustment.7 This analyses, however, is biased by the fact that patients ranked their breast symmetry with a subjective scoring scale. Moreover depressive patients are more likely to score their breast symmetry less than non-depressed women. Subjective scores have been shown to be inconclusive and poorly reproducible,19 which led to the development of an objective scoring software such as the breast analysing tool8 in order to analyse objectively patients’ breast symmetry and postoperative cosmetic outcome. Moreover, with the incorporation of oncoplastic techniques,11 new questions arise as to whether or not these techniques improve symmetry and patients’ breast self esteem and overall quality of life. In our study we used breast cancer specific QOL questionnaires16,17 created to study the patients’ subjective view of their current physical, social, emotional functioning as well as psychological parameters such as body image, sexual function and satisfaction with the cosmetic result of the surgical treatment and, for the first time, correlated it with objectively measured breast symmetry.8 In principle, our patients showed an overall high quality of life (BIS median 2, EORTC QLQ-BR23 median 19) and a high satisfaction with the cosmetic outcome after surgical treatment. Besides the experience that high patients’ satisfaction is a common observation in studies like ours, this may be due to the fact that at our centre breast cancer patients are looked after by a small and consistent breast unit team consisting of surgeons, oncologists and a breast nurse in the surgical outpatient ward. This may improve patientedoctor
Table 2c Associations of QOL with patient demographics described by Spearman correlation (rS); median (min-max) or mean (SD)
Breast Symmetry Index Age (years) Follow-up time Tumour size (cm) Tumour/breast-ratio Oncoplastic no (n¼92) yes (n¼9)
BIS
EORTC QLQ-BR23
Sex-Score
0.04 (p¼0.71) 0.09 (p¼0.35) 0.21 (p¼0.04) 0.08 (p¼0.41) 0.08 (p¼0.40) 2 (0e18) (p¼0.02) 1 (0e3)
0.13 (p¼0.21) 0.04 (p¼0.69) 0.07 (p¼0.51) 0.02 (p¼0.86) 0.04 (p¼0.66) 19.4 ( 4.2) (p¼0.92) 19.2 (4.9)
0.01 (p¼0.91) 0.41 (p < 0.0001) 0.10 (p¼0.30) 0.001 (p¼0.99) 0.06 (p¼0.52) 8.4 (2.5) (p¼0.17) 9.6 ( 2.4)
The italic values represents the significant with p < 0.05.
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Figure 2. Distribution (absolute frequencies) of outcome breast symmetry index separated by importance of breast cosmesis.
relation and patient satisfaction. The questionnaire was handed out in the surgical ward and immediately collected after completion, which may, on the other hand, bias the results, for patients may have been attempting to please the investigator.20 Improved cosmetic results can be achieved by developing plastic surgery techniques immediately during appropriate oncologic resection. This is known as oncoplastic surgery.21 A recent study demonstrated a positive impact of oncoplastic surgery on quality of life and self esteem of patients undergoing breast-conserving surgery.22 In this study local flaps or breast reduction techniques were used in only 9 of our patients to achieve a better cosmetic result of the affected breast and quality of life was assessed by validated questionnaires. In these 9 patients we showed significantly improved body image quality of life ( p ¼ 0.02) in patients treated with oncoplastic surgical techniques. Although the aesthetic outcome of the operated breast was improved, the symmetry of both breasts was not influenced, probably because of volume and shape differences of the contra-lateral breast, which was not always corrected at the time of cancer surgery. We have experienced that breast cancer patients often refuse an additional operation and rather accept breast asymmetry, and we could show no effect on overall quality of life in these patients. In an earlier study with only central located breast cancer we were able to demonstrate a significant improvement of breast symmetry with the use of oncoplastic techniques.15 Thus, the location of the tumour is also important regarding symmetry improvement, which may have had an impact in this study.
The subjective importance of the cosmetic result after treatment of breast cancer had no significant correlation with quality of life (data not shown). Interestingly in 75% of patients with excellent breast symmetry cosmesis was regarded as important while only 50% of patients with poor symmetry regard cosmesis as important (Table 2d). We suppose that patients with a life threatening disease like breast cancer are less concerned about their breast symmetry than their oncologic outcome. We conclude that breast symmetry is not a major factor for patients’ quality of life after breast cancer surgery. The improved breast self esteem in our patients after the use of oncoplastic techniques is independent of symmetry, but our numbers are small and further investigation is needed. Conflict of interest No conflict of interest.
Acknowledgements The authors would like to thank Brian Schroeder for his help in preparation of the manuscript.
Appendix. Supplementary material Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ejso.2011.10.012.
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Appendix 1. Body image scale (BIS) [Hopwood, 2001 #12]. Not at all
A little
Quite a bit
Very much
Have you been feeling self-conscious about your appearance? Have you felt less physically attractive as a result of your disease or treatment? Have you been dissatisfied with your appearance when dressed? Have you been feeling less feminine as a result of your disease or treatment? Did you find it difficult to look at yourself naked? Have you been feeling less sexually attractive as a result of your disease or treatment? Did you avoid people because of the way you feel about your appearance? Have you been feeling the treatment has left your body less whole? Have you felt dissatisfied with your body? Have you been dissatisfied with the appearance of your scar?
Appendix 2. EORTC QLQ-BR23 [Sprangers, 1996 #11] symptomes during the last weeks. Not at all
A little
Quite a bit
Very much
To what extent were you interested in sex? To what extent were you sexually active? To what extent was sex enjoyable for you? Did you have any pain in your arm or your shoulder? Did you have a swollen arm or hand? Was it difficult to raise your arm? Have you had any pain in the area of your affected breast? Was the area of your affected breast swollen? Was the area of your affected breast oversensitive? Have you had skin problems on or in the area of your affected breast (e.g., itchy, dry, flaky)?
Appendix 3. Hospital anxiety and depression scale (HAD) [Zigmond, 1983 #14]. Not at all
A little
Quite a bit
Very much
I feel tense or wound up I still enjoy the things I used to enjoy I get sort of frightened feeling as if something awful is about to happen I can laugh an see the funny side of things Worrying thoughts go through my mind I feel cheerful I can sit at ease and feel relaxed I feel as if I am slowed down I get sort of frightened like ‘butterflies’ in the stomach I have lost interest in my appearance I feel restless as if I have to be on the move I look forward with enjoyment to things I get sudden feelings of panic I can enjoy a good book or radio or TV programme
Appendix 4. Non-validated questions about sexual function, cosmetic results and patient satisfaction (sex-score). Did the operation change anything in your sexual relationship?
Have you been feeling less sexually attractive as a result of your disease or treatment? To what extent were you interested in sex? To what extent were you sexually active? To what extent was sex enjoyable for you?
No
Yes, positively
Yes, negatively
Not at all
A little
Quite a bit
Very much
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