Talking about breast symmetry in the breast cancer clinic: What can we learn from an examination of clinical interaction?

Abstract Background Breast asymmetry is a common post‐operative outcome for women with breast cancer. Quality of cosmetic result is viewed clinically as a critical endpoint of surgery. However, research suggests that aesthetic standards governing breast reconstruction can be unrealistic and may problematically enforce feminine appearance norms. The aim of reconstructive procedures is to help women live well with and beyond breast cancer. Therefore, understanding how patients and clinicians talk about surgical outcomes is important. However, we lack evidence about such discussions. Objective To examine clinical communication about breast symmetry in real‐time consultations in a breast cancer clinic. Design Seventy‐three consultations between 16 clinicians and 47 patients were video‐recorded, transcribed and analysed using conversation analysis. Results In most cases, patients do considerable interactional work to persuade clinicians of the validity of their concerns regarding breast asymmetry, and clinicians legitimize these concerns, aligning with patients. In a significant minority of cases, patients appear more accepting of their treatment outcome, but clinicians prioritize symmetry or treat symmetry with the presence of breast tissue as normative, generating misalignment between clinician and patient. Conclusion Current clinical communication guidelines and practices may inadvertently reinforce culturally normative assumptions regarding the desirability of full, symmetrical breasts that are not held by all women. Clinicians and medical educators may benefit from detailed engagement with recordings of clinical communication like those analysed here, to reflect on which communicative practices may work best to attend to a patient's individual stance on breast symmetry, and optimize doctor‐patient alignment.


| INTRODUC TI ON
Breast cancer is the most common occurring malignancy in women worldwide, accounting for 25.4% of all female cancers diagnosed in 2018. 1 Surgery is the main treatment, with 81% of women undergoing mastectomy (total removal of breast) or lumpectomy (partial removal) procedures. 2 UK guidelines state that all women should be offered cancer surgery provided this is not precluded by a significant comorbidity. 3 The type of surgery elected depends on the grade, stage and location of the tumour, the size of the patient's breasts and their individual preference. 4 Treatment and recovery for breast cancer are complex and multifaceted. 5,6 Insomuch as the disease presents a direct threat of mortality, it is also an assault on a particular body part deemed central to femininity and normative ideals relating to feminine beauty standards. 7,8 Surgical interventions typically involve lumpectomy with breast-conserving surgery or mastectomy with or without reconstruction 9 and may result in loss of one or both breasts, scarring, disfigurement and breast asymmetry. 10,11 The journey through diagnosis, treatment and recovery and into survivorship can present significant challenges to a patient's psychosexual health; her identity, body image, sexuality and confidence become subject to flux, uncertainty and change. 12,13 The contemporary goals of breast cancer surgery are no longer limited to cure alone, as the quality of cosmetic outcome is now considered a key clinical priority. 14,15 Given the centrality of breasts to many women's identity, body image, sexuality and self-esteem, attempts to restore a patient's pre-operative breast aesthetic and achieve breast symmetry are widely recognized as integral to surgical procedures. [16][17][18] However, evidence suggests that following primary surgery for cancer, many women experience post-operative difficulties relating to their breasts' overall appearance, including asymmetry. 19,20 A UK national audit of mastectomy and reconstruction reports that just 59% of patients were satisfied with their post-operative appearance when looking in the mirror naked. 21 In other studies, 77% of women cited body image and attractiveness, 22 and 88.2% reported appearance 23 as major treatment-related concerns: all of which may negatively impact upon a patient's quality of life, with and beyond the disease.
Reconstructive surgery is thought to help women readjust to life and restore a sense of 'normality' after a breast cancer diagnosis. 24,25 Such procedures are referred to as a process rather than a singular event, often requiring more than one operation. 26 Surgery to correct post-operative appearance irregularities is common: one in five women who had primary breast-conserving surgery in England were reported to need reconstructive surgery within three months of their initial operation, 27 and approximately half of patients will require additional surgery within ten years after implant-based reconstructions. 14 Clinical guidelines advise that surgical procedures to optimize breast symmetry are available without time restrictions. 26 However, there are reports of regional variations and unequal access to reconstructive services across the National Health Service (NHS) in England, 28,29 with limits placed on the number of surgeries a patient can have to complete breast reconstruction, the availability of balancing or symmetrization surgery to the unaffected breast and the time in which these procedures must be completed. 17,26 Quality of cosmetic outcome is viewed clinically as a critical endpoint of breast cancer surgery, 3,15 yet feminist literature problematizes this focus, arguing that breast cancer is viewed as an illness journey through which women are expected to reclaim not only their health, but also their pre-cancer identity and appearance. 30,31 Consequently, aesthetic standards governing reconstructive procedures can be unrealistic, constructing healthy bodies as aligning with normative, idealistic concepts of 'traditional femininity' 32,33for example, the beauty ideal to appear full-breasted and symmetrical. Feminist literature suggests that women whose breasts appear asymmetrical, or who lack one or both breasts, are culturally positioned as lying outside of feminine beauty standards. 34,35 For these reasons, research suggests that breast reconstruction may not be a 'universal panacea' for the emotional and physical consequences of breast cancer, 36 but rather a complex, and at times paradoxical, psychological process for many women in breast cancer care. 37 The ways patients and clinicians talk about the impact of breast cancer surgery on a patient's quality of life can profoundly influence their ability to live well, with and beyond the disease. 38,39 Effective communication is widely acknowledged as central to high-quality cancer care and promotes patient satisfaction, psychological functioning and health-related quality of life. [40][41][42] However, patients cite communication as the one aspect of cancer care most in need of improvement 43 : they report that clinicians often gloss over the adverse psychological impact of surgery-related changes to the appearance of their breasts 44,45 and that they encounter personal barriers to raising issues surrounding sexuality, body image and appearance due to embarrassment, or a belief that such matters are irrelevant in the wider context of cancer and mortality. 46,47 Previous research on communication about post-operative breast appearance has primarily used satisfaction questionnaires and post hoc interviews with patients and clinicians. 38,48 These methods rely on participant memories of interaction that do not always accurately represent what happened, neglecting specific, contextualized details of real-life clinical interactions, which are often 'messier' and more nuanced than retrospective accounts of experience. 49 Despite the prevalence of post-operative breast asymmetry amongst patients and the varied stances on the use of reconstructive surgery to help 'restore' a patient's pre-operative breast aesthetic and achieve better symmetry, we do not know if and how these discussions play out in practice.
In this paper, we aim to address this evidence gap by identifying what can be learned from the fine-grained analysis of video recordings of real clinical communication about breast symmetry in a breast cancer clinic. We will develop an understanding of how this topic unfolds in discussion by examining the interactional practices used by patients and clinicians to manage talk: focusing on not just what is said, but how it is said.

| DE S I G N
The data for this study were collected as part of a larger project that examines clinical communication about the psychosexual consequences of breast cancer and its treatment in an NHS breast cancer unit in the north-west of England.

| Recruitment and participants
Ethical approval was granted by the NHS's Research Ethics Committee. Forty-seven patients (between 29 and 83 years of age) and sixteen clinicians (three breast surgeons, five breast care nurses, one oncologist, four clinical nursing staff and three health-care assistants) were recruited using convenience sampling.
The breast unit's administrative team sent study information and consent forms to clinic patients with forthcoming appointments.
Clinicians were recruited on-site by the first author, who consented patients on the day of their appointment. Patients agreed to the recording of one to three consultations and clinicians to at least one consultation. Recruitment rates were 100% for clinicians and approximately 65% for patients. to the breast unit after being discharged to discuss ongoing effects of surgery) were also captured. Out of the 73 recordings, 26 were repeat visits. Diagnostic and primary results clinics were not included due to the potentially upsetting nature of these appointments. A video camera was located in the consultation room in advance of each appointment by the first author, who was not present during filming.

| Data analysis
Recordings were viewed repeatedly and transcribed verbatim by the first author, producing over 550 pages of transcript. The corpus was then systematically searched for instances that contained discussions relating to breast symmetry, including talk about the similarity or difference in the shape, position, size or density of one breast in relation to the other. 15 These discussions were most prominent in consultations that took place after the patient's initial cancer surgery.
Twenty-seven relevant instances were identified from consultations between 22 different patients and seven clinicians. These instances were transcribed in detail using conversation analytic conventions (see Figure 1) 52 and analysed using conversation analysis Conversation analysis is grounded in the theoretical framework of 'ethnomethodology': the study of 'members' methods' for producing their everyday affairs, 53 translating it into an empirical approach that examines the detailed and patterned organization of interactions in natural settings. CA has been used to great effect to identify communicative practices in clinical settings and to inform clinical communication, [54][55][56] including the way delicate topics, such as weight, sex and cancer, are managed. 49,57 Analyses proceeded as follows: taking each instance in turn, transcripts were read alongside the original video in order to identify the main actions or 'practices' involved in talk about breast symmetry. Instances were analysed in greater detail by considering the non-verbal actions, words, phrases and grammatical composition of those practices, and their relative position in the sequence. 49,58 The validity of CA findings is established by maintaining focus on data-internal evidence and participants' orientations to one another's actions: each successive turn provides evidence for how the prior speaker's turn has been understood. 59

| FINDING S
Analysis identified two main ways in which breast symmetry is discussed: 1. Patients do significant interactional work to persuade clinicians of the validity of their concerns about breast asymmetry, and clinicians legitimize, and attend to, these concerns (n = 19 instances from consultations between 16 different patients and seven clinicians. Fourteen of these patients were seeking further treatment).
2. Clinicians prioritize a symmetry agenda or treat it as normative, while patients are more accepting of asymmetry (n = eight instances, from consultations between six different patients and six clinicians. Two of these patients were seeking further treatment).
The six extracts below (featuring five different patients and seven clinicians) are representative of the two main communicative practices identified above. They exemplify common interactional features of these practices and important variations within each practice. Extract headers identify clinicians and patients by number.

| Set One: Patients work to persuade clinicians of the validity of their concerns about breast asymmetry, and clinicians legitimize these concerns
The first set of instances represents the most common practice used by patients in discussions about breast symmetry across the data. In these sequences, patients do a significant amount of interactional work to persuade surgeons of the validity of their concerns about asymmetry and their need for reconstructive surgery, and surgeons attend to and legitimize these concerns.
The patient in Extract 1 (see Table 1) has had a lumpectomy of the left breast with breast-conserving surgery. She is attending a reconstruction clinic three months after completing chemotherapy and radiotherapy treatment.
The patient's orientation to breast asymmetry, and wish for both breasts to be the same (lines 2-4), is prefaced in negative terms, as the second of two concerns that are currently 'bothering' her (line 1). 60 The patient expands her concern, describing a stark difference between her newly constructed 'young woman's boob' and her healthy untouched '↑old woman's br:east' (lines 9-13).
Using reported speech, the patient builds a contrast between what others say about her breast appearance and her own stance on the matter (lines 13-21): others reportedly either cannot detect any difference between her breasts (lines [14][15] or construct asymmetrical breasts as normative and everyday (lines 18-19). The contrast allows the patient to index her epistemic authority and steadfastness vis-àvis the views of others 61 : no matter what other people say to her, and how many times they say it, she can tell the difference (lines 15-16) and desires both breasts 'to be the same you know' (line 21). She thereby invites the surgeon to witness how her subjective experience has been devalued, how this impacts her, and invites her support and alignment.
This reported dissatisfaction with her post-operative appearance and assessment of its negative impact on her experience: it is 'n::ot (1.2) m:anageable' (line 7), could be heard as a potential complaint directed at the co-present surgeon, who performed her surgery. 62 This may account, in part, for why, after multiple attempts to seek the participation of the surgeon which are not always successful (note the multiple 'you know's' in lines [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32], the patient works to minimize the significance of her concerns, reformulating her dissatisfaction with her breasts as 'little (.) leftover bits' (line 26). Research shows that patients may downplay the seriousness of aforementioned concerns in a bid to secure the clinician's acknowledgement of their presenting problem. 63,64 Here, by minimizing her concerns, the patient further invites the surgeon's support and alignment-which she now gets. 65 The surgeon validates and demonstrates her 'empathic attunement' to the patient's concerns, 66 by acknowledging the magnitude F I G U R E 1 Transcription symbolsadapted from Jefferson 52 Aspects of the relative placement/timing of utterances Extract 2a (see Table 2) shares some similar features. This patient has had a unilateral lumpectomy of her left breast with breast-conserving surgery. She is attending a complex clinic twelve months after being discharged from the breast unit. . 60 Although she concedes that her breasts are perfectly healthy in terms of being cancer free (lines [11][12], she attends to their far-from-perfect asymmetrical appearance: 'But one seems a >h:ell of a lot smaller< than the other to me' (lines [15][16] Later in the same consultation (Extract 2b), the patient expands on her aforementioned concerns about asymmetry, and we see a variation on the above sequence (see Table 3): Once again, the patient: 1. Minimizes the significance of the concerns she has expressed, in this case through the self-deprecatory meta-comment, 65 'shouldn't be making such a fuss' (lines 2-3);

TA B L E 3 Extract 2b
The surgeon: Extract 3 (see Table 4) demonstrates the robustness of the sequence described so far. This patient is attending a delayed reconstruction clinic some twelve months after completing adjuvant treatment.
She had a unilateral mastectomy of her left breast, opted not to have immediate reconstruction and currently wears a breast prosthesis.
Here, the patient's desire for a breast reconstruction is made relevant by the surgeon's reference to a prior discussion (lines 1-2). The surgeon makes asymmetry explicit by asking the patient how she is currently 'coping' with being flat on one side (lines 4-6). The use of the word 'coping' suggests that the surgeon is treating breast asymmetry as something negative that requires management.
The patient: 1. Builds her postoperative breast asymmetry as a concern by responding that she is not coping 'at all' (line 7); 2. Accounts for her response, and works to persuade the surgeon of the validity of her subjective experience, by building a contrast between the views of her partner, who reportedly tells her 'I love The remaining instances represent a significant minority of cases. Here, we see evidence for misalignment between clinician and patient, as clinicians prioritize a symmetry agenda, or treat symmetry as normative, while patients are more accepting of asymmetry.

| Set Two: Patients appear more accepting of their treatment outcome, but clinicians prioritize symmetry or treat symmetry with the presence of breast tissue as normative
Extract 4 (see Table 5) is from a follow-up consultation with a patient who has had surgery to replace a temporary implant with a permanent one.
The sequence opens with an examination of the patient's breasts. Despite evidence that both nurse and patient appear more positive about the treatment outcome, and status quo, the surgeon nonetheless maintains and progresses her symmetry agenda by describing ways in which the asymmetry may be surgically addressed (lines 21-48).
We note similar misalignment between a different surgeon and patient in Extract 5 (see Table 6). This patient is attending a follow-up clinic after a unilateral mastectomy with immediate reconstruction using an expander implant.
The surgeon asks the patient how she is 'coping' with her post-operative breast appearance (line 5), and she responds that she is 'fine' (line 8) and has 'had no issues with it' (line 10). Clinician and patient are aligned over the patient's positive outcome in terms of wound healing (lines 11-18).
However, the surgeon's later announcement that the patient's breasts are going to be 'very symmetrical' (line 20) is built for an approving response in which the assessment is treated as good news (e.g. 'oh, that's great!'). 71 However, the patient's response does not align.
Instead, she actively challenges the fundamental basis of the surgeon's assessment, on the grounds that achieving very symmetrical breasts is not her concern, and does not reflect the reality of our bodies, where symmetry is non-normative: 'I'm ↑not bothered if they're not? because that's-our bodies aren't ↑are they' (lines [22][23]. The patient's response may be heard as resistance to medical authority. 63,72 Indeed, her challenge is a delicate one to bring off interactionally, and something she manages by grammatically composing her turn for agreement: 'our bod- The final extract (see Table 7

| Discussion
Our  Here, it is clinicians who pursue an agenda that focuses on achieving better symmetry, or treat symmetry with the presence of breast tissue as normative. This agenda is in line with clinical guidelines that emphasize the cosmetic quality of surgery, 15,77 and the importance of ensuring patient satisfaction with post-operative outcomes 3,14 : There is a positive correlation between optimal post-operative cosmesis, breast symmetry, high-quality survivorship and overall psychological adjustment. 15,78 In this respect, our data reflect a certain pressure placed on clinicians to maximize patients' quality of life with and beyond the disease. However, this symmetry agenda also strongly reflects normative ideas relating to feminine appearance, which subscribe to the presence of full, ample and symmetrical breasts. 33  Patients counter clinician concerns relating to asymmetry by outlining their satisfaction with their post-operative appearance (Extract 4), questioning the achievability of perfectly symmetrical breasts (Extract 5) and implicitly resisting the idea that they need breast tissue to achieve an acceptable kind of symmetry (Extract 6). In so doing, these patients challenge discourses that pathologize bodies that fall outside of these parameters as physically deformed and incomplete. 34,35 Findings suggest that clinicians and medical educators may benefit from remaining alert to the possibility that patients possess stances towards breast symmetry that differ from normative constructs of ideal feminine appearance, and to actively work to treat those perspectives as valid.

| Limitations
Data were collected from a single site, which restricts the claims that can be made about the generality of the interactional practices identified. The specific nature of this topic meant that breast surgeons predominate in our analysis. Future research may benefit from considering how expectations relating to post-operative appearance are managed within pre-operative appointments. Finally, our patient sample is predominantly white, heterosexual and post-menopausal: a more diverse demographic may produce different results.

| Conclusion
This study offers a snapshot of current practice in a breast cancer clinic.
Post-operative breast asymmetry is a common outcome for many women with breast cancer. 11 However, current clinical communication guidelines and practices reflect the health-care context in which they are situated and may inadvertently reproduce culturally normative assumptions regarding the desirability of full, symmetrical breasts that are not held by all women. Data point to the potential benefits of a fine-grained consideration in clinical training and practice of individual patient interpretations of post-operative appearance, and of being attuned to the possibility that for some women, asymmetrical breasts, or even no breasts, can be an acceptable surgical outcome.
Clinicians and medical educators may therefore benefit from detailed engagement with recordings of clinical communication like those analysed here, to reflect on which communicative practices work best to attend to a patient's individual stance on post-operative appearance and breast symmetry, and optimize doctor-patient alignment.

ACK N OWLED G EM ENTS
The authors would like to thank the patients and clinicians who took part in this study, and the breast unit's clinical lead and administrative team for their time and unwavering support. We also thank anonymous reviewers for their insightful comments and suggestions.

CO N FLI C T O F I NTE R E S T
There are no conflicts of interest to disclose.

AUTH O R CO NTR I B UTI O N S
The design of the study was conceived by Speer in conjunction All authors commented on and contributed to successive drafts.

DATA AVA I L A B I L I T Y S TAT E M E N T
Raw research data are not shared, given the sensitivity of patient data and the ethical requirements governing this study.