Marie Wickman

Psychological Reactions, Quality of Life, and Body Image After Bilateral Prophylactic Mastectomy in Women At High Risk for Breast Cancer: A Prospective 1-Year Follow-Up Study

PURPOSE To prospectively evaluate body image, sexuality, emotional reactions (anxiety, depression), and quality of life in a sample of women having increased risk for breast cancer before and 6 months and 1 year after bilateral prophylactic mastectomy (BPM), and to compare preoperative expectations of the operation with postoperative reactions concerning the impact on six areas of the womens lives. PATIENTS AND METHODS A total of 90 of 98 consecutive women who underwent BPM during October 1997 to December 2005 were included. Data were collected by self-administered questionnaires (eg, Hospital Anxiety and Depression scale, Swedish Short Term-36 Health Survey, Body Image Scale, Sexual Activity Questionnaire) before the operation (n = 81), and 6 (n = 71) and 12 months (n = 65) after BPM. RESULTS Anxiety decreased over time (P = .0004). No corresponding difference was found for depression. No differences in health-related quality of life over time were found, with one exception. A substantial proportion of the women reported problems with body image 1 year after BPM (eg, self consciousness, 48%; feeling less sexually attractive, 48%; and dissatisfaction with the scars, 44%). Sexual pleasure was rated lower 1-year post-BPM as compared with before operation (P = .005), but no differences over time in habit, discomfort, or activity were found. CONCLUSION No negative effects on anxiety, depression, and quality of life were found. Anxiety and social activities improved. Negative impact on sexuality and body image was reported.

Bilateral prophylactic mastectomy in women with inherited risk of breast cancer – Prevalence of pain and discomfort, impact on sexuality, quality of life and feelings of regret two years after surgery

BACKGROUND Mastectomy due to breast cancer is associated with chronic pain and a negative impact on sexuality. The purposes of the study were to analyze the prevalence of pain and discomfort in the breasts, impact on sexuality, quality of life, and feelings of regret after bilateral prophylactic mastectomy and immediate reconstruction with implants. METHODS Fifty-nine women operated 2004-2006 were included. A questionnaire was sent out two years after the procedure. Complications and re-operations were recorded. RESULTS Mean follow-up time was 29 months. 93% of patients answered the questionnaire. 69% reported pain and 71% discomfort in the breasts. Lost or much reduced sexual sensations were reported by 85% and enjoyment of sex was negatively impacted for 75% of patients. Quality of life was not affected and feelings of regret were almost non-existent. CONCLUSIONS It is important to inform women approaching this prophylactic procedure about the risk of having unwanted secondary effects.

Quality of life, patients' satisfaction, and aesthetic outcome after pedicled or free TRAM flap breast surgery.

Breast reconstructions after breast cancer surgery are primarily performed to improve patients’ quality of life. This study was performed to investigate patients’ satisfaction with breast reconstruction and quality of life after pedicled or free transverse rectus abdominis musculocutaneous (TRAM) flap surgery and to evaluate the aesthetic result of the breast reconstruction both objectively and subjectively. Sixty‐three patients (36 with pedicled flaps and 27 with free TRAM flaps) answered two questionnaires; of this group, 53 (27 with pedicled flaps and 26 with free TRAM flaps) participated in an aesthetic evaluation. The questionnaires consisted of two parts: one study‐specific part concerning satisfaction with the result of the breast reconstruction, the other a standardized health‐related quality of life part, the Short Form‐36 questionnaire. The aesthetic examination consisted of an objective part in which various distances on the reconstructed and contralateral breast were measured. The volumes of the breasts were measured using a thermoplastic cast system. The softness of the breasts was assessed using applanation tonometry. A panel consisting of three plastic surgeons looked at four standardized photographs of each patient and evaluated the aesthetic outcome subjectively. The panel evaluated the breast reconstruction on 10 subscales. No statistically significant difference between the surgical groups was seen regarding the patients’ satisfaction with the reconstruction. In the patients’ self‐assessment of the cosmetic outcome, the degree of symmetry was assessed higher in the free TRAM flap group. The healthrelated quality of life Short Form‐36 questionnaire revealed no difference between the pedicled and free flap groups. Compared with a reference population, the breast‐reconstructed group felt more tired and “worn out,” less peaceful, more unhappy, and more restless. The free flap group reached a higher degree of symmetry in the objective evaluation and received generally higher scores from the three‐member panel, compared with the pedicled TRAM flap group. A strong correlation between the patients’ and the panels evaluations of the cosmetic outcome was seen; generally, the panels evaluation of the cosmetic result of the breast correlated with the satisfaction of the patients. (Plast. Reconstr. Surg. 107: 1142, 2001.)

Peroperative Adenosine Infusion Reduces the Requirements for Isoflurane and Postoperative Analgesics

The aims of this study were to investigate the influence of adenosine infusion, firstly, on postoperative analgesic requirements, and secondly, on peroperative isoflurane requirements.Seventy-five women, aged 18-70 yrs, ASA grades I and II, scheduled for breast surgery, were randomly assigned to peroperatively receive a double-blind intravenous infusion of either adenosine, 80 micro gram centered dot kg-1 centered dot min-1, or placebo, during surgery under isoflurane/N2 O/O2 anesthesia. The peroperative isoflurane requirements were significantly reduced at 30 and 90 min of surgery during adenosine treatment. The number of patients reporting pain when regaining consciousness after surgery was reduced by 57% in the adenosine group, 8/31 vs 19/32 (P < 0.02). Further, the postoperative 24-h opioid requirements were reduced by 27% in the adenosine group (P < 0.03). In conclusion, we found that a peroperative infusion of a small dose of adenosine during breast surgery, reduces the peroperative anesthetic requirements, and the demand for post-operative analgesics. (Anesth Analg 1995;80:1145-9)

Measurement of Breast Volume with Thermoplastic Casts

A pilot study was carried through to assess the reproducibility of a new method of measuring breast volume. Twenty healthy female volunteers participated. A negative replica of the breast was made with thermoplastic cast material. The volume was measured by filling the cast with water until it reached two opposite points of the boundaries of the breast delineated on the cast. Three measurements were made of every cast and the mean was calculated. The range of the three measurements expressed as a percentage of the mean volume was 2.9 (SD 1.6)%. Each volunteers breasts were measured twice with a brief intervening pause. The coefficient of variation between the two corresponding measurements was 6%.

Timing of radiotherapy in head and neck free flap reconstruction – a study of postoperative complications

The local treatment protocol of preoperative radiotherapy in head and neck cancer treatment at the Karolinska University Hospital has resulted in a unique cohort of preoperatively high dose-irradiated patients. In total 216 consecutive patients were reviewed, of whom 221 free flaps, for head and neck cancer reconstruction, were operated between 1984 and 2002. In 194 cases radiotherapy was administered preoperatively and 27 operations were performed without prior radiation. The radiation dose was 64 Gy in 147 cases, 54 Gy or less in 45 cases and uncertain in two cases. In order to study whether the time elapsed between the end of radiotherapy and surgery had any significance regarding postoperative events, the cohort was subsequently divided into three groups: patients operated on within 4 weeks (n=27), between 4 and 6 weeks (n=88) and more than 6 weeks (n=78) after the last radiotherapy session. Postoperative complications were analysed in relation to preoperative dose and timing of radiotherapy. Preoperative radiotherapy was related to an increased risk of free flap necrosis as 22 complete and eight partial flap necroses occurred in the group that had received preoperative radiotherapy and none were observed in the non-irradiated group (P<0.05). Furthermore, a linear trend of increased flap loss (P<0.001), infections (P<0.001) and delayed wound healing (P<0.001) was seen when time increased between the last radiotherapy session and surgery. The largest increase in all complication rates was seen when more than 6 weeks elapsed between last radiotherapy session and surgery. Postoperative complications were independent of the radiation dose given. Our data show an increased morbidity in free flap surgery in the head and neck region after preoperative radiotherapy. Furthermore, time elapsed between the last radiotherapy session and surgery is associated with the risk of developing postoperative complications. We strongly suggest that free flap reconstruction should be performed within 6 weeks of the last radiotherapy session.

Mitotic activity in expanded human skin

In 20 patients subjected to breast reconstruction by means of tissue expansion, a skin biopsy was obtained at the vertex of the breast before and the day after expansion. Samples were incubated in [3H]thymidine, and the number of labeled cells were counted. A statistically significant rise in the number of labeled basal and supra-basal keratinocytes was seen after expansion. The findings suggest a net gain of tissue not only by stretching but also by formation of new tissue generated by tissue expansion.

Metabolism in pedicled and free TRAM flaps: a comparison using the microdialysis technique.

The most common complication in flap surgery is of a circulatory nature. Impeded blood flow leads to altered metabolism in the tissue. Possible metabolic differences between different zones of the transverse rectus abdominis muscle (TRAM) flap were studied and the metabolism of pedicled and free TRAM flaps was compared intraoperatively and postoperatively. The method used was microdialysis, which is a useful technique for following local metabolic changes continuously in various tissues.Twenty-two patients with a pedicled or free TRAM flap were monitored using the microdialysis technique. Two microdialysis catheters were placed subcutaneously in the flap (zone I and zone II), and a third one was placed subcutaneously in the flank to serve as a control. The flaps were monitored intraoperatively and postoperatively for 3 days with repeated analyses of extracellular glucose, lactate, and glycerol concentrations. An additional analysis of pyruvate was performed in some patients to calculate the lactate-to-pyruvate ratio. This study showed that glucose, lactate, and glycerol change in a characteristic way when complete ischemia (i.e., complete inhibition of the blood circulation) is present. A slower stabilization with prolonged metabolic signs of ischemia, such as lower glucose and higher lactate and glycerol concentrations, was seen in zone II compared with zone I, and more pronounced metabolic signs of ischemia, but with a faster recovery, were detected in the free TRAM flap group than in the pedicled TRAM flap group. The fact that the metabolites returned to normal earlier in free flaps than in pedicled flaps may indicate that free TRAM flaps sustain less ischemic damage because of better and more vigorous perfusion.

Management, morbidity, and oncologic aspects in 100 consecutive patients with immediate breast reconstruction.

AbstractBackground: Immediate breast reconstruction (IBR) is indicated when breast-conserving surgery is inappropriate and the patient refuses mastectomy as the sole procedure. Methods: Management, morbidity, and oncologic aspects were studied in 100 consecutive patients treated between 1990 and 1994 with a minimum follow-up time of 2 years. Indications for mastectomy and IBR always were discussed within a multidisciplinary group. Eighty-four patients had primary breast cancer, 12 patients underwent salvage mastectomy for an ipsilateral breast tumor recurrence, two patients had benign breast disease, and two patients underwent prophylactic mastectomy because of familial breast cancer. Results: Saline and silicone gel-filled implants were used predominantly (88%), but free and pedicled TRAM flaps were performed in 12 patients (12%). The overall complication rate was 16%. Seven patients lost their implants, three of whom had been irradiated to the chest wall. Sixty-five patients completed breast reconstruction (nipple and areola) within a median time of 418 days (range 40 to 1471 days). At follow-up, eight patients had locoregional recurrences after a median time of 7.2 months (range 1 to 23 months), and nine patients had died from disseminated breast cancer. Conclusion: IBR is time-consuming, but it is well tolerated and does not interfere with oncologic adjuvant treatment. IBR can be performed with low morbidity by a dedicated multidisciplinary team.

Ductal carcinoma in situ of the breast. Long-term follow-up of health-related quality of life, emotional reactions and body image

AIMS To investigate and compare long-term health-related quality of life (HRQoL), body image, and emotional reactions in women with ductal carcinoma in situ of the breast (DCIS) treated with different surgical methods. PATIENTS AND METHODS A total of 162 women were included in the study (47 had mastectomy and immediate breast reconstruction (IBR), 51 sector resection alone and 64 sector resection and postoperative radiotherapy). All women included in the study were asked to complete three questionnaires 4-15 years after surgery: the SF-36 for HRQoL, the Hospital Anxiety and Depression (HAD) scale, and the Body Image Scale (BIS). The response rate was 81%. RESULTS Women in all three study groups had, overall, a very satisfactory HRQoL in the long term, similar to women in the general population. Women who underwent mastectomy and IBR scored significantly higher on physical functioning and bodily pain than the other two study groups as well as their age-adjusted norm groups. The addition of radiotherapy to breast-conserving therapy did not seem to have any negative impact on long-term HRQoL. Our results show significant differences between the three study groups for six of ten BIS items, with a greater proportion of women in the mastectomy and IBR group reporting problems. CONCLUSIONS Women treated for DCIS have a very satisfactory long-term HRQoL. However, body image appeared to be negatively affected in mastectomy and IBR patients. Our results indicate that these women need more preoperative information about what changes in body image to expect after surgery.