In young breast cancer survivors, how does the type of surgery received affect the overall quality of life? That’s what Laura Dominici, M.D., FACS, Division Chief of Breast Surgery at Dana-Farber/Brigham and Women’s Cancer Center and her colleagues set out to find with their recent study, the results of which were presented at the 2018 San Antonio Breast Cancer Symposium (SABCS) in San Antonio.
Dominici sat down with OncLive
, a sister publication of CURE
, to discuss the study and its findings in greater detail:
Can you explain your rationale for creating this study?
We recognized that more and more women were undergoing mastectomy – and particularly bilateral mastectomy – when they might have been a candidate for breast conservation. Given modern data, we know that women who have breast conservation surgery and women who have mastectomy essentially have equivalent outcomes in terms of survival and local recurrence, but what we didn’t know was what the quality of life was after these different options. So, given the rising rate of mastectomy and equivalent oncologic outcomes, we wanted to see whether there’s a difference in quality of life following breast conserving surgery versus unilateral mastectomy versus bilateral mastectomy.
How was the study designed, and what were the findings?
There was a prospective cohort that my colleague Ann Partridge, M.D., MPH, had designed, which looked at young women with breast cancer, age 40 years old and younger. We were specifically interested in this cohort because this is a group in which the rates of bilateral mastectomy have gone up most sharply.
So we sent those women who were enrolled from 2006-2016 a one-time survey of a quality of life instrument called BREAST-Q
. It’s an internationally used and validated survey that focuses on quality of life after breast surgery by examining different domains. We focused on the domains of satisfaction with the breast, psychosocial wellbeing, sexual wellbeing and physical wellbeing. We had a 79 percent response rate with 561 women that were available for evaluation.
We found that in all domains but physical wellbeing, the women who had breast-conserving surgery reported better quality of life than those women who had unilateral or bilateral mastectomy. There wasn’t a huge difference in physical wellbeing between the different types of surgery.
Then we performed a multivariate analysis to see what predictors for poor outcomes would be, and we found that people who reported being financial uncomfortable at the time of their diagnosis had worse quality of life in all domains. Another interesting finding was that unilateral or bilateral mastectomy were associated with worse quality of life as far as the satisfaction with the breast, psychosocial and sexual wellbeing domains were concerned.
Was the survey open-ended? How far after surgery was the survey sent?
It’s not an open-ended survey. Within the multiple domains there are rankings from 0 to 4 and women can reply on that scale. They can skip questions but there is no space for comments. Additionally, we surveyed women who were a median of 5.8 years out from their surgery, and the range was 1.6 to 10.4 years.
What are the immediate next steps following this study?
First, we know that about 10 percent of women in this group had a BRCA mutation, so we did want to look at the impact of that on surgical choice and quality of life.
Second, within the mastectomy group, we know that 89 percent of these women had reconstruction. Their scores were still lower even though they had reconstruction, but we don’t know about the impact of the different types of reconstruction or how the timing may impact quality of life.
Lastly, 45 percent of the women who had mastectomy also had post-mastectomy radiation therapy. That was also associated with worse quality of life in many of the domains, so we’d like to do a subset analysis of the mastectomy group to look at the impact of radiation.
Do you think this will decrease the rate of mastectomy going forward?
I don’t think that this study on its own should be used to say that breast conservation is better for all women. I think that one limitation of our study is that we do not know what the pre-operative quality of life was for these women; it may be that women who choose breast conservation are just different than women who choose mastectomy. So, I think we do need data around that, which would need to be collected prospectively moving forward, and we’re doing that.
Additionally, it highlights the need for us to talk about the long-term impacts of surgery with women because it’s clearly something that we know impacts their quality of life moving forward.
Beyond surgery, do you think that patient-reported outcomes should be standardized in all studies, or generally used more in practice?
I’d really like to see patient-reported outcomes used both in clinical practice more often as well as in studies. In a perfect world, we could talk with a patient about their options and be able to predict for them what we thought their quality of life would be like after certain surgeries so that they would be able to choose which one they wanted.