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- Conflict of interest
- Appendix: The body image scale
Psychosexual changes after breast cancer treatment include fear of loss of fertility, negative body image, loss of femininity and attractiveness, and depression and anxiety [1-4]. A range of sexual complaints, such as dyspareunia, vaginal dryness, decreased sexual desire and/or sexual pleasure and numbness of the breasts, have been reported as a consequence of breast cancer treatment [5-13].
Generally, no differences have been found in body image and sexual satisfaction between women with breast-conserving therapy, mastectomy only, or mastectomy with breast reconstruction (BR); however, conflicting results have been reported [14-16]. This discrepancy suggests that different factors play a role in satisfaction with body image and sexuality after BR: direct and indirect effects of surgery, radiation, chemotherapy and hormonal therapy, as well as lowered physical and mental functionalities [5-13].
Several BR options exist after mastectomy: immediate as well as delayed reconstruction with implants, autologous tissue or a combination of both . The deep inferior epigastric artery perforator (DIEP) flap is a relatively new technique using abdominal tissue generally leading to high patient satisfaction [18, 19] as well as more positive body image compared with implant BR [20-23].
As multiple factors affect outcomes after breast surgery, it is important to prospectively investigate these aspects in homogenous groups. The primary aim of this study was to prospectively investigate the impact of delayed implant and DIEP flap BR on body image and sexual satisfaction, which to the best of our knowledge has never been performed by others [21, 23, 24]. Secondly, to study whether other clinical and psychological variables were significantly related to changes in body image and/or sexual satisfaction.
Patients and methods
This study is part of a multicenter prospective follow-up study on the psychological impact of BR [25-27]. For the current study, women opting for a delayed BR after a history of breast cancer were included. Some women also underwent a contralateral prophylactic mastectomy followed by bilateral reconstruction. Reconstructions were either implant based usually preceded by tissue expansion or using a free vascularized DIEP flap1 from the abdomen .
Exclusion criteria were a previous BR, detection of recurrent locoregional or distant disease, and not being able to understand and speak the Dutch language sufficiently. Women who did not consent or who did not react 2 weeks after the invitation were considered as non-respondents. Patients were approached between December 2007 and May 2010, and ethics approval was obtained from all participating hospitals.2
Of the 131 invited patients who were scheduled for delayed BR, 105 women (80%) consented to participate (Figure 1).
Preoperatively, an invitation letter explaining the procedure and purpose of the study, an informed consent and a prepaid envelope were sent to all women on the BR waiting lists of the participating hospitals. A reminder was sent by letter if patients did not respond within 2 weeks, or they received a reminder by phone if surgery was planned on short term. Patients who returned informed consent received the survey, including a range of demographic, clinical and psychological questionnaires, which they were requested to complete preoperatively (T0), 6 months postoperatively (T1) and at the end of the BR procedure (T2), including nipple reconstruction if this was planned within the duration period of the study. T2 was on average 20 months after the initial breast mound reconstruction. Women who had not completely finished their BR course completed the questionnaires regarding the preliminary end result.
Demographic information and clinical data were collected in the survey, and the latter were confirmed by checking medical records. The following questionnaires had to be completed for at least 75% of the items to calculate scale scores.
Primary outcome measures
A study-specific body image scale (BIS) was developed on the basis of Lodder et al. , and it is described elsewhere . The scale consists of 13 items, which are scored on a 5-point Likert scale, ranging from 1 to 5 (totally disagree, disagree, neutral, agree and totally agree, respectively). After recoding the negative items (items 4, 5, 11 and 13), a mean scale score was calculated (1–5) where a higher score indicates a more positive body image. Two items were only completed by patients with a partner; nevertheless, for the single women, a mean scale score was calculated for the remaining 10 items (75%). The internal consistency of the BIS scale was high in the current study sample (Cronbach's a = 0.89).
Sexual relationship satisfaction
To investigate the course of satisfaction with the sexual relationship, the subscale ‘sexuality’ of the Dutch Relationship Questionnaire (NRV) was used . The NRV has shown good psychometric properties and a total score on the subscale sexuality below eight (range 0–12) indicates below average or low sexual relationship satisfaction and a bad sexual compatibility with the partner . The NRV was completed only by women with a partner.
Secondary outcome measures
Satisfaction with the overall partner relationship was investigated with the NRV as well. Normally, the total score of the NRV can be used to provide this satisfaction score. However, to correct for the impact of sexual satisfaction, the score of the sexuality subscale was subtracted from the total score. Therefore, scores under 49 (range 0–68) indicate below average or low satisfaction with the partner relationship, excluding sexual satisfaction.
Breast cancer specific distress was measured using the 15-item Impact of Event Scale (IES) [31, 32]. The total IES score was used in this study ranging from 0 to 75. Reported reliability and validity of the IES are satisfactory [31, 33]. The categorization of the IES score is not indicative for specific clinical diagnoses, but a cutoff score of 20 or higher can be used to indicate high symptom levels [33, 34].
Changes between baseline and follow-up measurements of general mental and physical health were assessed with the Dutch version of the 36-item Short-Form Health Survey (SF-36), designed to measure health related quality of life. General physical and mental complaints were measured with the Physical Component Summary (PCS) and the Mental Component Summary (MCS) of the SF-36, respectively [35-37]. In this norm-based scoring method, each scale has the same mean value (50) and standard deviation (10). Consequently, a scale score below 50 indicates a health status below average .
Descriptive statistics were calculated for all variables. Differences between respondents and non-respondents, and between implant and DIEP flap BR patients were investigated using Student's t-tests, Mann–Whitney U-tests and Fisher's Exact tests.
To investigate changes in time in the primary psychological outcome measures (body image and sexual satisfaction) after implant and DIEP flap BR, multilevel regression analyses (MLA) were performed, which can handle incomplete time-series data efficiently with a minimal loss of information. These analyses also compensate for different numbers of participants within the subgroups and for dropout when dropout is dependent on variables that are included in the regression model . Saturated models were postulated with time, time squared and relevant covariates. The time variable was coded 0, 6 and 20, respecting the uneven time spans between the measurements. The number of covariates in the models is limited by the number of participants and repeated measures. The number of 98 participants is sufficient for the determination of 6 medium-sized covariates . This is a conservative calculation, the three repeated measures allow for more covariates.
In the first step, we reduced the number of relevant potential covariates, by calculating Spearman's correlation coefficients with all clinical pretreatment characteristics (Table 1) and with an estimate of change of the psychological outcomes during the entire BR course (partner relationship satisfaction, cancer distress, general mental and physical health, and body image or sexual satisfaction). Secondly, the variables that significantly correlated with change in the primary outcomes (p < 0.05) were entered in the MLA as covariates. Continuous covariates (e.g., age, cancer distress and general mental health) were centered for ease of interpretation. In this way, the intercept indicates the estimated value for a woman at the mean of the covariates. Changes in the secondary outcomes were investigated with separate MLA for each outcome including time effects only.
Table 1. Baseline characteristics of 98 women with either a delayed implant or deep inferior epigastric perforator (DIEP) flap breast reconstruction after mastectomy for breast cancer
| ||Implant BR||DIEP-flap BR|| |
| ||N = 25||N = 73||p-valueb|
|Mean age at time of breast reconstruction (sd)||48.7 (9.2)||49.4 (7.9)||0.73c|
|Mean years since mastectomy (sd)||2.9 (4.1)||3.2 (2.7)||0.03c|
|Having a partner (%)||24 (96.0)||59 (80.8)||0.11|
|Having children (%)||23 (92.0)||63 (86.3)||0.73|
|Education level (%)|| || || |
|Low||6 (24.0)||11 (15.1)|| |
|Intermediate||7 (28.0)||28 (38.4)|| |
|High||12 (48.0)||34 (46.6)||0.77d|
|Inherited predisposition for BCa (%)||7 (28.0)||15 (20.5)||0.58|
|Laterality (%)|| || || |
|Unilateral M + BR because of BC||13 (52.0)||62 (84.9)||0.002|
|Bilateral M + BR because of BC||4 (16.0)||4 (5.5)||0.20|
|Immediate contralateral prophylactic||8 (32.0)||7 (9.6)||0.02|
|M + BR|
|Mean BMI (sd)||24.8 (4.4)||27.5 (3.6)||10.004c|
|Radiation therapy (%)||13 (52.0)||49 (67.1)||0.23|
|Chemotherapy therapy (%)||6 (24.0)||24 (32.9)||0.46|
|Hormonal therapy (%)||8 (32.0)||40 (54.8)||0.06|
|Body image (1–5) (sd)||3.0 (0.8)||3.0 (0.7)||20.63c|
|Sexual relationship satisfaction (0–12) (sd)||8.8 (3.1)||7.3 (3.3)||0.07c|
|Partner relationship satisfaction (0–68) (sd)||58.0 (8.7)||57.7 (8.6)||0.88c|
|Cancer distress (0–75) (sd)||25.2 (15.4)||19.5 (12.6)||0.12c|
|General mental health (sd)||49.8 (10.5)||49.7 (10.5)||0.96c|
|General physical health (sd)||55.0 (6.7)||52.8 (8.7)||0.28c|
In a backward procedure all non-significant effects (p > 0.05) were removed from the model, until a parsimonious model was reached. Effect sizes (Cohen's d) were calculated by dividing the difference between the follow-up estimates and baseline by the estimated standard deviation. An effect size of 0.20 was considered small, 0.50 medium and 0.80 large . Two-sided p-values < 0.05 were considered statistically significant. Version 20 of IBM-SPSS Statistics (SPSS Inc., Chicago, IL, USA) was used for statistical analyses.
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- Conflict of interest
- Appendix: The body image scale
This is the first prospective study showing that body image improves after delayed implant as well as DIEP flap BR and that it is not related to type of BR.
The two patient groups did not significantly differ in most baseline variables. However, the fact that DIEP flap BR was only performed at specialized centers may impede the generality of the results, as the team of experts may be more aware of impact on body image and therefore, may be more focused to reach the best outcomes after BR. Furthermore, most bilateral BRs were performed using implants, which can be explained by logistic and financial limitations for bilateral DIEP flap BR in the Netherlands .
Evidently, DIEP flap BR patients had a significantly higher BMI as this type of surgery requires sufficient autologous tissue. Additionally, a high BMI may have been a contraindication for implant BR as this enhances the complication risk and a poor outcome . The majority of patients had received radiotherapy previously, which could potentially lead to complications, particularly after implant BR. There might have been an interaction between radiotherapy and type of BR, which was not investigated in this study.
A significant improvement in sexual satisfaction after both reconstruction types was detected, after correcting for relevant variables. Partner relationship satisfaction was positively related to sexual relationship satisfaction, highlighting the significant impact on the partner relationship if sexual function or satisfaction changes after breast cancer [43, 44]. Hormonal therapy was related to a lower sexual relationship satisfaction score, as adjuvant therapy may induce premature menopause with negative sexual side effects including loss of libido and vaginal dryness [4, 5, 7, 8, 10-13, 45]. BMI was not related to the sexual satisfaction score, but there might have been an interaction with the type of BR as well as women with DIEP flap BR had a higher BMI . However, these were not the main research questions and therefore, not investigated in the current study.
A large improvement in body image was observed, which was significantly related to less cancer distress, higher satisfaction with the partner relationship and a better general mental health during the entire BR course. It has been previously demonstrated that changes in body image are related to psychological distress after mastectomy with or without reconstruction [47-49]. In accordance with previous findings, we found that mental health is positively related to body image as well .
To our knowledge, this is the first prospective study on body image and sexual satisfaction in patients with either delayed implant or DIEP flap BR . We could not detect a statistically significant difference in body image and sexual satisfaction between implant and DIEP flap BR, whereas previous findings suggested a better outcome after autologous techniques, such as DIEP flap BR [18, 20-23]. This can be explained by the retrospective designs and/or the inclusion of heterogeneous patient groups, such as patients with immediate as well as delayed BR. Timing of BR is important for body image and sexual satisfaction, as more positive outcomes have been found after autologous reconstructions if BR was delayed [18, 20, 22, 51]. In addition, a relatively new approach of delayed-immediate BR might reduce complication rates after radiotherapy, while preserving the skin and delaying breast reconstruction until radiotherapy is completed, which might positively influence body image as well.
The current study concerned a homogenous group of patients all having delayed BR. However, these women may experience a greater increase in body image compared with women with immediate BR, as the latter never have to live without their breast(s).
Ideally, each BR group in the present study should have included patients with immediate BR as well; however, in the Netherlands, immediate DIEP flap BR after mastectomy for breast cancer is hardly performed because of logistic limitations . In contrast, the delayed implant BR group was relatively small, as generally, immediate implant BR is provided. Understandably, patients could not be assigned randomly to a reconstruction type, as patients would subsequently have been withdrawn from complete information provision. Suggestions for the future include comprehensive validation of the BIS questionnaire, the use of a breast reconstruction-specific questionnaire such as the Breast-Q  and the inclusion of sexual satisfaction measurements of single women.
In conclusion, body image improved significantly after both BR techniques and a better general mental health, less cancer distress and a better partner relationship satisfaction were related to a better body image during the entire BR course. Sexual relationship satisfaction also improved, particularly if higher partner relationship satisfaction was reported. However, the psychosexual consequences of previous hormonal therapy for breast cancer should be taken into account. Future follow-up measurements should identify the longer term outcomes after BR, and patient needs should be explored as well, with regard to potential counseling for intimate problems after mastectomy and adjuvant breast cancer treatment.
It is important for clinicians to be aware of psychosocial aspects during the process of mastectomy followed by BR, next to satisfaction with aesthetic outcome. During postoperative follow-up consultations, the plastic surgeon and/or mamma-care nurse could specifically ask for the psychosocial impact of the breast cancer diagnosis and treatment, including the reconstructive procedure. Patients expressing they experience problems should be referred for psychological help to improve mental health, which can positively affect body image as well as physical health [53-55].