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Which women prefer which treatment for breast cancer
The Brecut (1992) I, 193-195
Which women prefer which treatment T. M., Udaya Kumar, A. Al-Asadi Department
for breast cancer
and J. G. Mosley
of Surgery, Leigh Infirmary, Leigh, UK
S UMMA R Y One hundred women with breast cancer suitable for lumpectomy or Patey mastectomy were studied. These women were seen consecutively and had presented to a consultant surgeon either as NHS or as a private patient. Each patient was offered either lumpectomy or mastectomy and was interviewed 12 months later to ascertain anxiety and depression. 45% of patients requested conservative surgery. 43% of the NHS patients and 67% of private patients favoured lumpectomy. However, age was a more discriminating factor with 88% of those ~55 years choosing lumpectomy but only 22% of those ~55 years of age. The principal reasons for conservative surgery were cosmetic (70%). Mastectomy was chosen by women who wanted ‘to get everything over with’ (80%). When interviewed at 12 months no woman regretted her decision. The psychological disturbance was similar in both lumpectomy and mastectomy patients. However the NHS patients faired better than those treated privately.
INTRODUCTION
were identified by screening mammography. Each patient was suitable for local excision and radiotherapy or mastectomy. 70 presented to district hospitals (NHS) and 30 presented to the local private hospital. Each woman was carefully counselled by the consultant surgeon before being offered mastectomy or lumpectomy and radiotherapy. All the NHS patients also received counselling from a nursing sister both preoperatively in the patient’s home and after discharge. Each woman made her own decision about the operative procedure she preferred. The consultant surgeon had no preference for one or other procedure. Postoperative psychological morbidity was assessed at 12 months by structured interview of each patient in the outpatient department. All interviews were conducted by the same consultant surgeon over a period of 60 min. The technique was as described by Fallowfield et al 1986.’ The interviewer determined the frequency and severity of anxiety and depression in the 4 weeks before interview. During these interviews anxiety or depression were not merely related to mood disturbance but covered the presence of specific symptoms including sleep disturbance, loss of energy and loss of weight. In addition the patient was asked the reasons for her choice of operative procedure and also whether she regretted the decision she had taken.
There have been several reports in medical journals and in the popular press promoting breast conservation over mastectomy.‘--” Some studies have suggested that the more extensive the surgical procedure for breast cancer the greater the number of patients who suffer severe emotional distress,‘.4 while others have shown no difference in psychiatric morbidity between patients undergoing conservative surgery or mastectomy.‘-’ The aim of this study was to find the proportion of women in private and public health sectors choosing breast conservation and their reasons for doing so. The psychosocial outcome of the two different methods of treatment were also compared.
PATIENTS
AND METHODS
This was a prospective study of 100 consecutive women aged between 28 and 70 years with a unifocal breast carcinoma measuring less than 3 cm in size on mammography or clinical examination who presented to one consultant surgeon. 90 had symptomatic disease and 10
Address correspondence to: J. G. Mosley. Department Leigh Infirmary. Leigh. WN7 IHS UK
of Surgery,
193
STATISTICAL ANALYSIS
Table 2
Chi squared tests were used to assess the differences between the treatment groups. Significance was taken as P < 0.05 after Yates correction had been applied.
Psychological
effect at 12 months
Operation Lumpectomy Mastectomy Number of Patients Depression Anxiety
55 25% 57%
45 26% 38%
Health cover Private NHS
30 43% 93%
70 21% 28%
RESULTS 45 chose conservation therapy and 55 chose mastectomy. There were equal numbers of women (50) above and below 55 years. 44 patients (88%) of the women over the age of 55 preferred mastectomy compared to 11 (22%) of those less than 55 years of age. (Chi squared=22.5, DF=l pcO.OOl), of the 70 NHS patients, 40 (57%) chose mastectomy and 30 (43%) lumpectomy, whereas of the 30 private patients, 10 (33%) chose mastectomy and 20 (67%) lumpectomy (Chi squared=4.76 DFl ~~0.05). Marital status did not affect the choice of treatment with 40 of the 75 married women and 10 of the 25 unmarried women choosing lumpectomy. Though several reasons were mentioned for their choice of mastectomy over lumpectomy the most commonly mentioned one was ‘to get over with the problem’. ‘More faith’ in mastectomy and friends being unhappy with lumpectomy were other commonly mentioned reasons. (Table 1). In contrast cosmesis appeared to be the most important reason behind the decision for lumpectomy. When the patients were interviewed one year after operation, psychological morbidity was compared between the two groups. Conservative surgery did not lessen psychological morbidity. (Table 2) When the 30 women who were seen privately were compared with NHS patients, there was a significantly greater level of anxiety in private patients (Chi squared=74 DF=l p
Table 1 The principal reasons each patient gave for her choice of treatment. Some women had several reasons for their decision Reasons for operation Lumpectomy (45 patients)
Mastectomy (55 patients) more faith get it over with worried about irradiation friendunhappy with lumpectomy problem travelling to the Regional Radi+ therapy Centre
16 29
11
15 5
cosmetic can have second go if unsuccessful friend happy with lumpectomy
30 10
5
Comparison of depression and anxiety ratings in all women who had mastectomy or lumpectomy and in all women who were treated privately or as NHS patients.
lumpectomy (this figure was 50% in the private patients) complained of inadequate post operative counselling.
DISCUSSION Most women welcome the opportunity of choice in the treatment for breast cancer.’ Though only 45 of the 100 patients chose lumpectomy, it has been reported that women who are treated by surgeons who offered choice seem to have less psychiatric morbidity than those referred to a surgeon who offer no choice.’ Although cosmesis is the major reason cited by the patients choosing lumpectomy, the possibility of another cancer and a second operation appears to be a major reason for women choosing mastectomy. Advice from friends who have undergone a lumpectomy and were dissatisfied with this option and fear of radiotherapy also act as deterrents. The most striking discriminant in choice was the patient’s age with younger women more frequently opting for lumpectomy and women over 55 years of age favouring mastectomy.” Preserving a woman’s breast in itself does not prevent anxiety and depression or other psychosocial problems. Lumpectomy patients are often worried that such treatment may be inadequate and that cancer will recur. The depression seems to arise mostly from the knowledge that the patient has cancer rather than from the extent of the surgical procedure.“,” The high level of anxiety at 12 months compared to other studies is largely due to the excess seen amongst private patients, who have not been included in other studies.7 Our study has been the first to compare NHS and private treatment groups with their different socio economic status and their choice of surgery. Though two thirds of the private patients chose conservative surgery this appears to reflect their younger age rather than higher socio economic status. The statistically significant greater anxiety and depression in private patients may be apparent and not real because the numbers receiving private treatment were small and these women were younger when compared to the NHS group. Nevertheless a striking difference was that during recruitment into this study the consultant surgeon did not utilise the nurse counsellor for his private patients. This
Which women prefer which treatment for breast cancer
deficiency has now been corrected. In addition, women seeking private treatment may have an inherent tendency to be more anxious about their health. Postoperative counselling for lumpectomy patients is often neglected. The fears of these patients need to be understood and patients counselled regarding further therapy and follow up. Though a patient may not volunteer psychological distress the surgeon needs to recognise the signs of anxiety and depression that may be present and initiate treatment accordingly. Following this study and other similar findings” equal emphasis is now given to postoperative counselling of women after lumpectomy and mastectomy. Our nurse counsellor is employed by the District Health Authority and keeps a record of NHS patients with breast cancer and would not see private patients unless specifically referred. It is beholden on all surgeons to ensure that all patients receive comparable care.
References I. Morris T. Psychological adjustment to mastectomy. Cancer Treat Rev 1976: 6: 41-61. 2. Ashford R F U, Philips R H. Coe M A, Pickering D G L, Bailey B. Ellis H. Conservative excision and radiotherapy for early breast cancer - an acceptable alternative? Br J Clin One 1984; IO: 15-58.
I95
3. McArdle J M, Hughon A U M, McArdle C S. Reduced psychological morbidity after breast conservation. Br J Surg 1990 77: 1221-3. 4. Winnick L, Robbins G F Physical and psychological readjustments after mastectomy: an evaluation of Memorial Hospitals’ PMRG Program Cancer 1977; 39: 478-86 5. Meyer L. Aspergren K Long term psychological sequelae of mastectomy and breast conserving treatment for breast cancer Acta Oncol 1989 82: 124 6. Maunsell E, Brisson J, Deschenes L Psychological distress after initial treatment for breast cancer: a comparison of partial and total mastectomy J Clin Epid 1989; 42: 765-71 7. Fallowfield L J, Hall A, Maguire G P. Baum M Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial Br Med J 1990; 301: 575-80 8. Fallowtield L J, Baum M, Maguire G P Effects of breast conservation on psychological morbidity associated with diagnosis and treatment of early breast cancer Br Med J 1986; 293: I3314 9. Wilson R G, Hart A, Davies P J D K Mastectomy or conservation: the patient’s choice Br Med J 1988; 297: 1167-9 10. Locker, A P. Cotton T C, Jackson L, Morgan D A L. Blarney R W A prospective study of patient choice in treatment for primary breast cancer Br J Surg 1990; 77: A697 11. Fallowfield L J, Baum M, Maguire, G P Addressing the psychological needs of the conservatively treated breast cancer patient J Roy Sot Med 1987; p 80: 696-700 12. Dean C The emotional impact of mastectomy Br J Hosp Med 1988: 39: 32-9
Date received 20 November I99 I Date accepted after revision 26 June 1992
Which women prefer which treatment T. M., Udaya Kumar, A. Al-Asadi Department
for breast cancer
and J. G. Mosley
of Surgery, Leigh Infirmary, Leigh, UK
S UMMA R Y One hundred women with breast cancer suitable for lumpectomy or Patey mastectomy were studied. These women were seen consecutively and had presented to a consultant surgeon either as NHS or as a private patient. Each patient was offered either lumpectomy or mastectomy and was interviewed 12 months later to ascertain anxiety and depression. 45% of patients requested conservative surgery. 43% of the NHS patients and 67% of private patients favoured lumpectomy. However, age was a more discriminating factor with 88% of those ~55 years choosing lumpectomy but only 22% of those ~55 years of age. The principal reasons for conservative surgery were cosmetic (70%). Mastectomy was chosen by women who wanted ‘to get everything over with’ (80%). When interviewed at 12 months no woman regretted her decision. The psychological disturbance was similar in both lumpectomy and mastectomy patients. However the NHS patients faired better than those treated privately.
INTRODUCTION
were identified by screening mammography. Each patient was suitable for local excision and radiotherapy or mastectomy. 70 presented to district hospitals (NHS) and 30 presented to the local private hospital. Each woman was carefully counselled by the consultant surgeon before being offered mastectomy or lumpectomy and radiotherapy. All the NHS patients also received counselling from a nursing sister both preoperatively in the patient’s home and after discharge. Each woman made her own decision about the operative procedure she preferred. The consultant surgeon had no preference for one or other procedure. Postoperative psychological morbidity was assessed at 12 months by structured interview of each patient in the outpatient department. All interviews were conducted by the same consultant surgeon over a period of 60 min. The technique was as described by Fallowfield et al 1986.’ The interviewer determined the frequency and severity of anxiety and depression in the 4 weeks before interview. During these interviews anxiety or depression were not merely related to mood disturbance but covered the presence of specific symptoms including sleep disturbance, loss of energy and loss of weight. In addition the patient was asked the reasons for her choice of operative procedure and also whether she regretted the decision she had taken.
There have been several reports in medical journals and in the popular press promoting breast conservation over mastectomy.‘--” Some studies have suggested that the more extensive the surgical procedure for breast cancer the greater the number of patients who suffer severe emotional distress,‘.4 while others have shown no difference in psychiatric morbidity between patients undergoing conservative surgery or mastectomy.‘-’ The aim of this study was to find the proportion of women in private and public health sectors choosing breast conservation and their reasons for doing so. The psychosocial outcome of the two different methods of treatment were also compared.
PATIENTS
AND METHODS
This was a prospective study of 100 consecutive women aged between 28 and 70 years with a unifocal breast carcinoma measuring less than 3 cm in size on mammography or clinical examination who presented to one consultant surgeon. 90 had symptomatic disease and 10
Address correspondence to: J. G. Mosley. Department Leigh Infirmary. Leigh. WN7 IHS UK
of Surgery,
193
STATISTICAL ANALYSIS
Table 2
Chi squared tests were used to assess the differences between the treatment groups. Significance was taken as P < 0.05 after Yates correction had been applied.
Psychological
effect at 12 months
Operation Lumpectomy Mastectomy Number of Patients Depression Anxiety
55 25% 57%
45 26% 38%
Health cover Private NHS
30 43% 93%
70 21% 28%
RESULTS 45 chose conservation therapy and 55 chose mastectomy. There were equal numbers of women (50) above and below 55 years. 44 patients (88%) of the women over the age of 55 preferred mastectomy compared to 11 (22%) of those less than 55 years of age. (Chi squared=22.5, DF=l pcO.OOl), of the 70 NHS patients, 40 (57%) chose mastectomy and 30 (43%) lumpectomy, whereas of the 30 private patients, 10 (33%) chose mastectomy and 20 (67%) lumpectomy (Chi squared=4.76 DFl ~~0.05). Marital status did not affect the choice of treatment with 40 of the 75 married women and 10 of the 25 unmarried women choosing lumpectomy. Though several reasons were mentioned for their choice of mastectomy over lumpectomy the most commonly mentioned one was ‘to get over with the problem’. ‘More faith’ in mastectomy and friends being unhappy with lumpectomy were other commonly mentioned reasons. (Table 1). In contrast cosmesis appeared to be the most important reason behind the decision for lumpectomy. When the patients were interviewed one year after operation, psychological morbidity was compared between the two groups. Conservative surgery did not lessen psychological morbidity. (Table 2) When the 30 women who were seen privately were compared with NHS patients, there was a significantly greater level of anxiety in private patients (Chi squared=74 DF=l p
Table 1 The principal reasons each patient gave for her choice of treatment. Some women had several reasons for their decision Reasons for operation Lumpectomy (45 patients)
Mastectomy (55 patients) more faith get it over with worried about irradiation friendunhappy with lumpectomy problem travelling to the Regional Radi+ therapy Centre
16 29
11
15 5
cosmetic can have second go if unsuccessful friend happy with lumpectomy
30 10
5
Comparison of depression and anxiety ratings in all women who had mastectomy or lumpectomy and in all women who were treated privately or as NHS patients.
lumpectomy (this figure was 50% in the private patients) complained of inadequate post operative counselling.
DISCUSSION Most women welcome the opportunity of choice in the treatment for breast cancer.’ Though only 45 of the 100 patients chose lumpectomy, it has been reported that women who are treated by surgeons who offered choice seem to have less psychiatric morbidity than those referred to a surgeon who offer no choice.’ Although cosmesis is the major reason cited by the patients choosing lumpectomy, the possibility of another cancer and a second operation appears to be a major reason for women choosing mastectomy. Advice from friends who have undergone a lumpectomy and were dissatisfied with this option and fear of radiotherapy also act as deterrents. The most striking discriminant in choice was the patient’s age with younger women more frequently opting for lumpectomy and women over 55 years of age favouring mastectomy.” Preserving a woman’s breast in itself does not prevent anxiety and depression or other psychosocial problems. Lumpectomy patients are often worried that such treatment may be inadequate and that cancer will recur. The depression seems to arise mostly from the knowledge that the patient has cancer rather than from the extent of the surgical procedure.“,” The high level of anxiety at 12 months compared to other studies is largely due to the excess seen amongst private patients, who have not been included in other studies.7 Our study has been the first to compare NHS and private treatment groups with their different socio economic status and their choice of surgery. Though two thirds of the private patients chose conservative surgery this appears to reflect their younger age rather than higher socio economic status. The statistically significant greater anxiety and depression in private patients may be apparent and not real because the numbers receiving private treatment were small and these women were younger when compared to the NHS group. Nevertheless a striking difference was that during recruitment into this study the consultant surgeon did not utilise the nurse counsellor for his private patients. This
Which women prefer which treatment for breast cancer
deficiency has now been corrected. In addition, women seeking private treatment may have an inherent tendency to be more anxious about their health. Postoperative counselling for lumpectomy patients is often neglected. The fears of these patients need to be understood and patients counselled regarding further therapy and follow up. Though a patient may not volunteer psychological distress the surgeon needs to recognise the signs of anxiety and depression that may be present and initiate treatment accordingly. Following this study and other similar findings” equal emphasis is now given to postoperative counselling of women after lumpectomy and mastectomy. Our nurse counsellor is employed by the District Health Authority and keeps a record of NHS patients with breast cancer and would not see private patients unless specifically referred. It is beholden on all surgeons to ensure that all patients receive comparable care.
References I. Morris T. Psychological adjustment to mastectomy. Cancer Treat Rev 1976: 6: 41-61. 2. Ashford R F U, Philips R H. Coe M A, Pickering D G L, Bailey B. Ellis H. Conservative excision and radiotherapy for early breast cancer - an acceptable alternative? Br J Clin One 1984; IO: 15-58.
I95
3. McArdle J M, Hughon A U M, McArdle C S. Reduced psychological morbidity after breast conservation. Br J Surg 1990 77: 1221-3. 4. Winnick L, Robbins G F Physical and psychological readjustments after mastectomy: an evaluation of Memorial Hospitals’ PMRG Program Cancer 1977; 39: 478-86 5. Meyer L. Aspergren K Long term psychological sequelae of mastectomy and breast conserving treatment for breast cancer Acta Oncol 1989 82: 124 6. Maunsell E, Brisson J, Deschenes L Psychological distress after initial treatment for breast cancer: a comparison of partial and total mastectomy J Clin Epid 1989; 42: 765-71 7. Fallowfield L J, Hall A, Maguire G P. Baum M Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial Br Med J 1990; 301: 575-80 8. Fallowtield L J, Baum M, Maguire G P Effects of breast conservation on psychological morbidity associated with diagnosis and treatment of early breast cancer Br Med J 1986; 293: I3314 9. Wilson R G, Hart A, Davies P J D K Mastectomy or conservation: the patient’s choice Br Med J 1988; 297: 1167-9 10. Locker, A P. Cotton T C, Jackson L, Morgan D A L. Blarney R W A prospective study of patient choice in treatment for primary breast cancer Br J Surg 1990; 77: A697 11. Fallowfield L J, Baum M, Maguire, G P Addressing the psychological needs of the conservatively treated breast cancer patient J Roy Sot Med 1987; p 80: 696-700 12. Dean C The emotional impact of mastectomy Br J Hosp Med 1988: 39: 32-9
Date received 20 November I99 I Date accepted after revision 26 June 1992