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Patient evaluation of cosmetic outcome after conserving surgery for treatment of primary breast cancer
European Journal of Surgical Oncology 1999; 25: 344–346
ORIGINAL ARTICLES
Patient evaluation of cosmetic outcome after conserving surgery for treatment of primary breast cancer S. K. Al-Ghazal∗, L. Fallowfield† and R. W. Blamey∗ ∗Breast Unit, Nottingham City Hospital and †CRC Psychosocial Oncology Group, University College London, UK
Aims: To investigate patient self-assessment of and satisfaction with cosmetic outcome following breast-conserving treatment. Methods: A total of 254 patients with primary breast cancer who had been treated by wide local excision (WLE) were assessed objectively for cosmesis. Patients then self-rated their own cosmetic outcome and satisfaction via a questionnaire. Results: Seventy-two per cent of the patients stated that there was little or no difference between the treated and untreated breast. Patient satisfaction was high with 90.5% being ‘moderately’ or ‘very satisfied’ with their cosmetic result. There were very good correlations between the objective assessment and the patient self-assessment of the cosmetic result (v2=77.98; P<0.001) and between the patient satisfaction and the patient self-assessment (v2=122.65; P<0.001). Conclusion: This study shows very good cosmetic outcome with high patient satisfaction. These cosmetic results combined with a low local recurrence rate following wide local excision validate the operative method used. Key words: satisfaction; cosmetic assessment; conserving surgery; breast cancer.
Introduction Cancer control is the primary goal of all breast-cancer treatment. Conservation surgery has the additional goal of achieving cosmetic results that are acceptable to the patient. Techniques vary from quadrantectomy, a radical excision of the tumour with 2–4 cm clearance of the palpable margin, to lumpectomy. The former is often acknowledged to give a worse cosmetic result1 and the latter gives a high rate of local recurrence.2 The technique now used in Nottingham is wide local excision (WLE), excising the tumour with microscopic circumferential clearance of 0.5 mm of normal breast tissue around the tumour and taking all tissue between skin and muscle. This gives a low rate of local recurrence (2.2% at a median follow-up of 36 months).3 Criteria such as breast retraction4 and nipple deviation5 have been used in objective cosmetic assessment; other criteria have been used6,7 for subjective photographic evaluation, using the degree of similarity or difference between treated and untreated breasts.
Correspondence to: Dr Sharif K. Al-Ghazal, Clinical Research Fellow, Professorial Unit of Surgery, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK. Fax: 0115 962 7765. 0748–7983/99/040344+03 $12.00/0
Little is known about the criteria used by patients in their self-evaluation of the cosmetic outcome, as the patient ratings more often are framed in terms of general satisfaction of the outcome. This paper reports results from a study in which patient self-assessment, satisfaction rating and appraisal of the cosmetic outcome were investigated.
Patients and methods A series of 280 patients who had been treated with WLE with or without radiotherapy and who had remained diseasefree agreed to take part in the study. All the patients had been treated in the Breast Unit at Nottingham City Hospital and were aged 70 years or less at the time of operation (mean 52.4 years). They were undergoing follow-up in the Primary Breast Cancer Clinic at Nottingham City Hospital and were seen between June 1997 and November 1997. Of the patients, 254 (91%) completed the study; the others failed to return the questionnaire. The criteria for selection for treatment with breast conservation, surgical methods, histological evaluation and local recurrence rate are reported elsewhere.3 1999 W.B. Saunders Company Limited
345
Cosmesis after breast-conserving surgery Table 1. Self-evaluation questionnaire and results
Table 2. Objective assessment results
Results Questionnaire 1. How different is your treated breast from the other one? Very much (poor) Somewhat (fair) A little (good) Not at all (excellent)
n
(%)
22 49 141 42
(8.7) (19.3) (55.5) (16.5)
2. How satisfied are you with the cosmetic result of your operation generally? Very satisfied Moderately Slightly Not at all
156 74 21 3
(61.4) (29.1) (8.3) (1.2)
3. Would you have preferred to have a different operation from the one you had? Yes No Uncertain
3 233 18
(1.2) (91.7) (7.1)
4. Would you consider further surgery for breast reconstruction? Yes No Uncertain
13 230 11
(5.1) (90.6) (4.3)
The time which had elapsed since surgery varied between 3 and 203 months (median 37 months). Two hundred and nineteen (86%) patients had intact breast irradiation. Methods Objective assessment of the cosmetic outcome was performed by one independent observer (S.K.A.), who was not involved in the treatment, using measuring-tape to measure the breast retraction4 and nipple deviation.5 Skin changes, atrophy and scar length were taken into account and all parameters were graded on a three-point scale to achieve the objective score. A full description will be made in a further paper, primarily reporting cosmetic outcome in the series. Cosmetic self-assessment was achieved by asking patients to rate the difference between the treated and untreated breasts, their general satisfaction and appraisal of the cosmetic outcome via a four-item questionnaire (Table 1). In order to avoid influencing their responses, the patients were given the questionnaires to complete after the clinic visit and send back by post (response rate was 91%). Data were analysed using SPSS for Windows (SPSS Inc., Chicago, USA) and statistical comparisons were made using the chi-squared test and Kruskal–Wallis one-way ANOVA.
Results The results showed that only 22 patients (8.7%) were aware of very much difference between the two breasts; 183 patients (72%) reported a little or no difference at all (Table 1). The large majority of patients reported satisfaction with
Excellent (9, 10 out of 10) Good (7, 8) Fair (5, 6) Poor (<5)
n
(%)
102 99 45 8
(40) (39) (18) (3)
the overall cosmetic outcome, as 230 patients (90.5%) were very or moderately satisfied and only three patients (1.2%) were not satisfied at all. When the patients were asked if they would have preferred a different operation from the one they had undergone, 233 patients (91.7%) said ‘no’. Only 13 patients (5.1%) would consider further surgery to improve the cosmetic outcome. The objective assessment showed that 201 patients (79%) scored excellent or good results (Table 2). There was a strong correlation between patient cosmetic self-assessment and both objective assessment (v2=77.98; P<0.001) and patient satisfaction (v2=122.65; P<0.001).
Discussion The majority of our patients appeared happy with the operation that they had received and few wanted further surgery to improve the cosmetic outcome. Ninety per cent of the patients were very or moderately satisfied with the cosmetic outcome. When they were asked to rate the difference between the two breasts, 72% reported a little (good) or no difference (excellent) between the treated and untreated breast. Patients tended to rate their satisfaction of the outcome slightly higher than their assessment of difference between the two breasts. This may be related to some patients appreciating that the alternative to conserving surgery is total loss of the breast.8 Satisfaction ratings may also reflect that patients were warned prior to treatment to expect a difference in the treated breast. Some patients may have been attempting to please the investigator.9 Despite this, our results showed a highly significant correlation between patient satisfaction and the selfassessment outcome (rating of cosmetic difference between breasts). There was also a good correlation between objective assessment and self-assessment. The factors influencing cosmetic outcomes have been considered in this unit in another forthcoming study. Factors such as radiotherapy, tumour size, location of tumour, breast size and extent of surgery clearly influence cosmetic outcome. However, the purpose of the present study was to investigate patient satisfaction and to compare patient self-assessment with an objective assessment of the cosmetic outcome; therefore, the above factors were not considered. In conclusion, while ratings of treatment-related morbidity derived from subjective or objective assessment by an external observer may provide useful leads for refining the techniques employed in breast-conserving therapy, they appear to offer no advantages over self-assessment. The patient’s own assessment and overall satisfaction is more
346
S. K. Al-Ghazal et al.
important as, in the end, it is the patient who has to live with physical limitations of her treatment. Improving her quality of life is one of the primary goals of treatment of breast cancer.10 This study also showed a good cosmetic outcome with high patient satisfaction. These results, combined with a low local recurrence rate following WLE, validate the operative method used.
References 1. Saccini A, Luini A, Tana S, Lozza L, Galimberti V, Merson M, Agresti R, Veronesi P, Greco M. Quantitative and qualitative cosmetic evaluation after conservative treatment for breast cancer. Eur J Cancer 1991; 27: 1395–400. 2. Locker AP, Ellis IO, Morgan DAL, Elston CW, Mitchell A, Blamey RW. Factors influencing local recurrence after excision and radiotherapy for primary breast cancer. Br J Surg 1989; 76: 890–4. 3. Sibbering DM, Galea MH, Morgan DAL, Elston CW, Ellis IO, Robertson JFR, Blamey RW. Safe selection criteria for breast conservation without radical excision in primary operable invasive breast cancer. Eur J Cancer 1995; 31A: 2191–5.
4. Pezner R, Patterson M, Hill R, Vora N, Desai K, Archambeau J, Lipsett J. Breast retraction assessment: an objective evaluation of cosmetic results of patients treated conservatively for breast cancer. Int J Radiat Oncol Biol Phys 1985; 11: 575–8. 5. Noguchi M, Saito Y, Mizukami Y, Nonomura A, Ohta N, Koyasaki N, Taniya T, Miyazaki I. Breast deformity, its correction, and assessment of breast conserving surgery. Breast Cancer Res Treat 1991; 18: 111–8. 6. Harris JR, Levene MB, Svensson G, Helman S. Analysis of cosmetic results following primary radiation therapy for stages I and II carcinoma of the breast. Int J Radiat Oncol Biol Phys 1979; 5: 257–61. 7. Christie DRH, O’Brien MY, Christie JA, Kron T, Ferguson SA, Hamilton CS, Denham JW. A comparison of methods of cosmetic assessment in breast conservation treatment. Breast 1996; 5: 358–67. 8. Hamilton CS, Nield JM, Alder GF, Clingan PR. Breast appearance and function after breast conserving surgery and radiotherapy. Acta Oncol 1990; 29: 291–5. 9. Liljegren G, Holmberg L, Westman G and the Uppsala-Orebro Breast Cancer Study Group. The cosmetic outcome in early breast cancer treated with sector resection with or without radiotherapy. Eur J Cancer 1993; 29A: 2083–9. 10. Fallowfield LJ. Assessment of quality of life in breast cancer. Acta Oncol 1995; 34: 689–94. Accepted for publication 24 February 1999
ORIGINAL ARTICLES
Patient evaluation of cosmetic outcome after conserving surgery for treatment of primary breast cancer S. K. Al-Ghazal∗, L. Fallowfield† and R. W. Blamey∗ ∗Breast Unit, Nottingham City Hospital and †CRC Psychosocial Oncology Group, University College London, UK
Aims: To investigate patient self-assessment of and satisfaction with cosmetic outcome following breast-conserving treatment. Methods: A total of 254 patients with primary breast cancer who had been treated by wide local excision (WLE) were assessed objectively for cosmesis. Patients then self-rated their own cosmetic outcome and satisfaction via a questionnaire. Results: Seventy-two per cent of the patients stated that there was little or no difference between the treated and untreated breast. Patient satisfaction was high with 90.5% being ‘moderately’ or ‘very satisfied’ with their cosmetic result. There were very good correlations between the objective assessment and the patient self-assessment of the cosmetic result (v2=77.98; P<0.001) and between the patient satisfaction and the patient self-assessment (v2=122.65; P<0.001). Conclusion: This study shows very good cosmetic outcome with high patient satisfaction. These cosmetic results combined with a low local recurrence rate following wide local excision validate the operative method used. Key words: satisfaction; cosmetic assessment; conserving surgery; breast cancer.
Introduction Cancer control is the primary goal of all breast-cancer treatment. Conservation surgery has the additional goal of achieving cosmetic results that are acceptable to the patient. Techniques vary from quadrantectomy, a radical excision of the tumour with 2–4 cm clearance of the palpable margin, to lumpectomy. The former is often acknowledged to give a worse cosmetic result1 and the latter gives a high rate of local recurrence.2 The technique now used in Nottingham is wide local excision (WLE), excising the tumour with microscopic circumferential clearance of 0.5 mm of normal breast tissue around the tumour and taking all tissue between skin and muscle. This gives a low rate of local recurrence (2.2% at a median follow-up of 36 months).3 Criteria such as breast retraction4 and nipple deviation5 have been used in objective cosmetic assessment; other criteria have been used6,7 for subjective photographic evaluation, using the degree of similarity or difference between treated and untreated breasts.
Correspondence to: Dr Sharif K. Al-Ghazal, Clinical Research Fellow, Professorial Unit of Surgery, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK. Fax: 0115 962 7765. 0748–7983/99/040344+03 $12.00/0
Little is known about the criteria used by patients in their self-evaluation of the cosmetic outcome, as the patient ratings more often are framed in terms of general satisfaction of the outcome. This paper reports results from a study in which patient self-assessment, satisfaction rating and appraisal of the cosmetic outcome were investigated.
Patients and methods A series of 280 patients who had been treated with WLE with or without radiotherapy and who had remained diseasefree agreed to take part in the study. All the patients had been treated in the Breast Unit at Nottingham City Hospital and were aged 70 years or less at the time of operation (mean 52.4 years). They were undergoing follow-up in the Primary Breast Cancer Clinic at Nottingham City Hospital and were seen between June 1997 and November 1997. Of the patients, 254 (91%) completed the study; the others failed to return the questionnaire. The criteria for selection for treatment with breast conservation, surgical methods, histological evaluation and local recurrence rate are reported elsewhere.3 1999 W.B. Saunders Company Limited
345
Cosmesis after breast-conserving surgery Table 1. Self-evaluation questionnaire and results
Table 2. Objective assessment results
Results Questionnaire 1. How different is your treated breast from the other one? Very much (poor) Somewhat (fair) A little (good) Not at all (excellent)
n
(%)
22 49 141 42
(8.7) (19.3) (55.5) (16.5)
2. How satisfied are you with the cosmetic result of your operation generally? Very satisfied Moderately Slightly Not at all
156 74 21 3
(61.4) (29.1) (8.3) (1.2)
3. Would you have preferred to have a different operation from the one you had? Yes No Uncertain
3 233 18
(1.2) (91.7) (7.1)
4. Would you consider further surgery for breast reconstruction? Yes No Uncertain
13 230 11
(5.1) (90.6) (4.3)
The time which had elapsed since surgery varied between 3 and 203 months (median 37 months). Two hundred and nineteen (86%) patients had intact breast irradiation. Methods Objective assessment of the cosmetic outcome was performed by one independent observer (S.K.A.), who was not involved in the treatment, using measuring-tape to measure the breast retraction4 and nipple deviation.5 Skin changes, atrophy and scar length were taken into account and all parameters were graded on a three-point scale to achieve the objective score. A full description will be made in a further paper, primarily reporting cosmetic outcome in the series. Cosmetic self-assessment was achieved by asking patients to rate the difference between the treated and untreated breasts, their general satisfaction and appraisal of the cosmetic outcome via a four-item questionnaire (Table 1). In order to avoid influencing their responses, the patients were given the questionnaires to complete after the clinic visit and send back by post (response rate was 91%). Data were analysed using SPSS for Windows (SPSS Inc., Chicago, USA) and statistical comparisons were made using the chi-squared test and Kruskal–Wallis one-way ANOVA.
Results The results showed that only 22 patients (8.7%) were aware of very much difference between the two breasts; 183 patients (72%) reported a little or no difference at all (Table 1). The large majority of patients reported satisfaction with
Excellent (9, 10 out of 10) Good (7, 8) Fair (5, 6) Poor (<5)
n
(%)
102 99 45 8
(40) (39) (18) (3)
the overall cosmetic outcome, as 230 patients (90.5%) were very or moderately satisfied and only three patients (1.2%) were not satisfied at all. When the patients were asked if they would have preferred a different operation from the one they had undergone, 233 patients (91.7%) said ‘no’. Only 13 patients (5.1%) would consider further surgery to improve the cosmetic outcome. The objective assessment showed that 201 patients (79%) scored excellent or good results (Table 2). There was a strong correlation between patient cosmetic self-assessment and both objective assessment (v2=77.98; P<0.001) and patient satisfaction (v2=122.65; P<0.001).
Discussion The majority of our patients appeared happy with the operation that they had received and few wanted further surgery to improve the cosmetic outcome. Ninety per cent of the patients were very or moderately satisfied with the cosmetic outcome. When they were asked to rate the difference between the two breasts, 72% reported a little (good) or no difference (excellent) between the treated and untreated breast. Patients tended to rate their satisfaction of the outcome slightly higher than their assessment of difference between the two breasts. This may be related to some patients appreciating that the alternative to conserving surgery is total loss of the breast.8 Satisfaction ratings may also reflect that patients were warned prior to treatment to expect a difference in the treated breast. Some patients may have been attempting to please the investigator.9 Despite this, our results showed a highly significant correlation between patient satisfaction and the selfassessment outcome (rating of cosmetic difference between breasts). There was also a good correlation between objective assessment and self-assessment. The factors influencing cosmetic outcomes have been considered in this unit in another forthcoming study. Factors such as radiotherapy, tumour size, location of tumour, breast size and extent of surgery clearly influence cosmetic outcome. However, the purpose of the present study was to investigate patient satisfaction and to compare patient self-assessment with an objective assessment of the cosmetic outcome; therefore, the above factors were not considered. In conclusion, while ratings of treatment-related morbidity derived from subjective or objective assessment by an external observer may provide useful leads for refining the techniques employed in breast-conserving therapy, they appear to offer no advantages over self-assessment. The patient’s own assessment and overall satisfaction is more
346
S. K. Al-Ghazal et al.
important as, in the end, it is the patient who has to live with physical limitations of her treatment. Improving her quality of life is one of the primary goals of treatment of breast cancer.10 This study also showed a good cosmetic outcome with high patient satisfaction. These results, combined with a low local recurrence rate following WLE, validate the operative method used.
References 1. Saccini A, Luini A, Tana S, Lozza L, Galimberti V, Merson M, Agresti R, Veronesi P, Greco M. Quantitative and qualitative cosmetic evaluation after conservative treatment for breast cancer. Eur J Cancer 1991; 27: 1395–400. 2. Locker AP, Ellis IO, Morgan DAL, Elston CW, Mitchell A, Blamey RW. Factors influencing local recurrence after excision and radiotherapy for primary breast cancer. Br J Surg 1989; 76: 890–4. 3. Sibbering DM, Galea MH, Morgan DAL, Elston CW, Ellis IO, Robertson JFR, Blamey RW. Safe selection criteria for breast conservation without radical excision in primary operable invasive breast cancer. Eur J Cancer 1995; 31A: 2191–5.
4. Pezner R, Patterson M, Hill R, Vora N, Desai K, Archambeau J, Lipsett J. Breast retraction assessment: an objective evaluation of cosmetic results of patients treated conservatively for breast cancer. Int J Radiat Oncol Biol Phys 1985; 11: 575–8. 5. Noguchi M, Saito Y, Mizukami Y, Nonomura A, Ohta N, Koyasaki N, Taniya T, Miyazaki I. Breast deformity, its correction, and assessment of breast conserving surgery. Breast Cancer Res Treat 1991; 18: 111–8. 6. Harris JR, Levene MB, Svensson G, Helman S. Analysis of cosmetic results following primary radiation therapy for stages I and II carcinoma of the breast. Int J Radiat Oncol Biol Phys 1979; 5: 257–61. 7. Christie DRH, O’Brien MY, Christie JA, Kron T, Ferguson SA, Hamilton CS, Denham JW. A comparison of methods of cosmetic assessment in breast conservation treatment. Breast 1996; 5: 358–67. 8. Hamilton CS, Nield JM, Alder GF, Clingan PR. Breast appearance and function after breast conserving surgery and radiotherapy. Acta Oncol 1990; 29: 291–5. 9. Liljegren G, Holmberg L, Westman G and the Uppsala-Orebro Breast Cancer Study Group. The cosmetic outcome in early breast cancer treated with sector resection with or without radiotherapy. Eur J Cancer 1993; 29A: 2083–9. 10. Fallowfield LJ. Assessment of quality of life in breast cancer. Acta Oncol 1995; 34: 689–94. Accepted for publication 24 February 1999