Women trust their own instincts when choosing breast cancer surgery

The manuscript -- which is scheduled for publication this fall in the Annals of Surgical Oncology and was presented at the New England Association of Gynecologic Oncologists annual meeting -- is entitled "Influential Forces in Breast Cancer Surgical Decision-Making and Impact on Body Image and Sexual Function." In addition to Dr. Kwait, the research team included: Sarah Pesek, MD; Michaela Onstad, MD; David Edmonson, MD; Melissa A. Clark, PhD; Christina Raker, ScD; Ashley Stuckey, MD; and Jennifer Gass, MD, co-director of The Breast Health Center and surgeon-in-chief at Women & Infants.

"With the great advances in screening and treatment for breast cancer, leading to prolonged survival rates as high as 98 percent, survivorship outcomes have become an increasingly important consideration among patients. Women must consider quality of life and intimacy after surgery, these become influencing factors when they make decisions about their care," Dr. Kwait explains.

The proportion of early stage breast cancer patients choosing mastectomy with reconstruction surgery over lumpectomy has been steadily increasing, prompting the team to wonder what factors are driving the decisions. In addition, while there is substantial research available showing the relationship between surgery and a woman's self-confidence and sexual pleasure, there was nothing identifying who or what influences her surgery-related decisions.

"We know that women feel especially vulnerable when they receive a breast cancer diagnosis and turn to their support system, including their partner," Dr. Kwait says. "We also know that the greater the support she receives from her partner leads to greater relationship satisfaction and less sexual difficulty in the long run.

"However, the partner's role in treatment decision-making remained nuanced. No studies to date, that we were aware of, had evaluated the influence of a partner in surgical decision-making."

Close to 400 women returned surveys as part of the study. Of those, 67.9 percent had lumpectomy; 8.6 percent had a mastectomy; and 23.5 percent had a mastectomy with breast reconstruction. More than 77 percent of participants were in a relationship, and almost 75 percent of those women reported that their partner attended their surgical consultation.

To the researchers' surprise, the majority of women having a mastectomy identified themselves as the most important influence on their surgical decision (56.6 percent of those having mastectomy with reconstruction, 46.3 percent having a mastectomy, and 42.7 percent having a lumpectomy). Those women who chose a lumpectomy identified their surgeon as the most influential (44.2 percent having lumpectomy versus 39 percent having a mastectomy and 23.2 percent having a mastectomy with reconstruction).

"Only 7.5 percent of patients identified their partner as the greatest influence on their surgical choice," Dr. Kwait notes. "Yet, within this subgroup, patients who chose a mastectomy with reconstruction valued their partner's opinion more than those who chose a mastectomy alone or a lumpectomy."

Post-surgical satisfaction

The researchers also asked about the patients' satisfaction with their breast appearance and the breast's role in intimacy both before and after cancer surgery. All levels of satisfaction dropped dramatically after surgery, with a significantly greater decrease in breast intimacy for women having a mastectomy with reconstruction.

"Nearly half of the patients -- or 48.6 percent -- who chose a mastectomy with reconstruction devalued the breast in intimacy post-operatively," Dr. Kwait says. "Comparatively, only 20.4 percent of patients who chose lumpectomy experienced this change."

The reason, she says, is simple.

"The breast relates to attraction, intimacy and sexuality. A woman must define a new normal for herself and her breasts in survivorship."

This correlates with their finding that despite most patients making their own surgical choices, the type of surgery they have significantly impacts their romantic relationships. The majority of women surveyed reported that after surgery they were less comfortable undressed in front of their partner and experiencing less pleasure from caresses during intimacy. This was particularly true for patients who were eligible for a lumpectomy but instead opted for a mastectomy with reconstruction.

"Our findings highlighted a need for clinicians to mention specific things as part of the informed surgical consent discussions they have with their patients," Dr. Kwait notes.