Patient Reported Cosmetic Outcomes and Complications after Breast Conserving Treatment

Reviewer: Lara Bonner Millar, MD
The Abramson Cancer Center of the University of Pennsylvania
Ultima Vez Modificado: 2 de noviembre del 2010

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Authors: C. E. Hill-Kayser, C. Vachani, M. K. Hampshire, G. A. Di Lullo, J. M. Metz
Institution: University of Pennsylvania Medical Center, Philadelphia, PA

Background

  • Over the past 30 years, much work in treatment of breast cancer has contributed to improvement of cosmetic and functional outcomes.
  • Over 50% of women with breast cancer get are now treated with breast conservation treatment (BCT). The goal of BCT is avoidance of mastectomy through use of lumpectomy and adjuvant radiation, while preserving cosmesis. Modern data demonstrates "excellent" or "good" cosmesis in 90% of patients treated with BCT (Ben-David, 2007).
  • Several studies have defined factors which contribute to the overall cosmesis and that the cosmetic outcome evolves over time.

Materials and Methods

  • Patient-reported data was gathered via a convenience sample frame from breast cancer survivors utilizing a publically available, free, Internet-based tool for creation of survivorship care plans.
  • The tool is available at www.livestrongcareplan.com and through the OncoLink website. Survivors electing to use it are asked to enter the data regarding diagnosis, demographics, treatments received, and side effects/late effects experienced. In turn, they receive a customized survivorship care plan outlining guidelines for future care.
  • Breast cancer survivors answered the following question: “How would you rate the cosmetic appearance of the affected breast compared to your other breast?” The answer options were "Excellent" (almost identical to untreated breast), "Good" (minimal difference between breasts), "Fair" (obvious difference without major distorrion), and "Poor" (major functional and aesthetic sequelae).

Results

  • One thousand forty-six breast cancer survivors voluntarily completed the survivorship care plan questionnaire.
  • 48% reported being treated with BCT and 49% reported having mastectomy
  • Their median diagnosis age was 49, and median current age 52. Seventy-seven percent were residents of the US, 13% UK, and 5% Australia.
  • Five hundred and three (48%) of breast cancer survivors using this tool reported having undergone lumpectomy followed by radiotherapy.
  • "Excellent" cosmesis was reported by 16% (n = 80), "Good" by 52% (n = 264), "Fair" by 30% (n = 149), and "Poor" by 2% (n = 10).
  • Survivor assessments after BCT were similar to those of survivors using the tool after mastectomy: "Excellent" 13% (n = 69), "Good" 48% (n = 248), "Fair 30% (n = 160), Poor 9% (n = 45)].
    • The cosmetic assessments of breast cancer survivors after BCT versus mastectomy were not significantly different (p = 0.54).
  • Among survivors treated with BCT, 43% (n =208) reported chronic skin/soft tissue changes, 22% (n = 107) chronic pain in the breast or arm, 21% (n = 101) loss of arm/shoulder flexibility, and 8% (n = 39) chronic swelling.

Author's Conclusions

  • Among the BCT population, self- reported assessment of cosmesis is less likely to be "excellent" or "good" than is reported in the literature, with 30% of BCT survivors reporting "fair" cosmesis.
  • Patient reported cosmesis after BCT is similar to mastectomy in this population.
  • Patient reported incidence of chronic pain and local musculoskeletal deficits also appears higher than expected.
  • As more techniques for treatment of breast cancer become available, attention to patient, rather than physician, reported outcomes will continue to gain importance.

Clinical Implications

  • Women who opt for breast conservation are making a statement that breast-preserving treatment is important to them, but their self-reports indicate that the treatment has not resulted in the desired cosmetic outcome in a large minority of women. These findings indicate that patient treatment expectations may differ from their physicians', and reveal a need for more patient education about potential outcomes.
  • Because these women were treated in different settings (and countries), surgical and radiation techniques could have varied widely. Breast size, dose and fractionation of radiation, the type of boost (photon vs. electron) surgical technique (lumpectomy scar centered over the mass vs peri-areolar scar) could have also influenced the cosmesis. The limited information available as part of this study is one of its limitations.
  • Inherent limitations are also present any time that a convenience sample frame is employed. These include potential for data to be skewed based on the population choosing to participate.
  • Still, patient reported cosmetic outcomes are potentially more meaningful than physician-reported. Particularly with the anonymity of the internet, the survey respondents may have been more forthcoming than they would be in the presence of health care providers.
  • The 21% rate of loss of arm flexibility is high and could be related to surgery (axillary dissection vs sentinel node biopsy) and radiation fields (2 vs. 3 vs. 4 field).
  • Physicians should be attuned to early recognition of lymphedema, and intervene early to prevent functional deficits in the affected arm.

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