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PubMed1997

Mastectomy without malignancy after carcinoma diagnosed by large-core stereotactic breast biopsy.

Mammary carcinoma diagnosed by large-core stereotactic biopsy (LCSBB) is often followed by definitive surgery. We report on positive (malignant) LCSBB followed by definitive surgery that failed to demonstrate malignancy. Between January 1993 and August 1996, 206 women in our institution underwent LCSBB. Carcinoma was diagnosed in 45 patients (22%) of the 206 (ductal carcinoma in situ (DCIS), n = 12; invasive carcinoma, n = 33). Twenty-nine of the 45 patients subsequently underwent mastectomy, and 8 of 45 underwent lumpectomy. In 34 (92%) of these 37 patients, carcinoma was demonstrated at follow-up surgery, but in 3 patients (8%), mastectomy failed to reveal carcinoma. The characteristics of these three patients are as follows: Patient 1 was a 58-year-old woman with a nonpalpable 6- to 8-mm nodule revealed by a screening mammogram. Three of 8 LCSBBs showed colloid carcinoma, but histologic examination of 50 paraffin blocks and radiographic examination of the mastectomy sample failed to reveal carcinoma. Patient 2 was a 64-year-old woman with a nonpalpable 6- to 9-mm nodule revealed by mammogram. Six of 12 LCSBBs showed tubular carcinoma, but histologic examination of 30 paraffin blocks from her mastectomy sample failed to reveal carcinoma. Patient 3 was a 72-year-old woman with a history of DCIS. She had undergone a lumpectomy and radiotherapy, and she had suspicious ipsilateral microcalcifications. Two of 8 LCSBBs showed comedo DCIS, but histologic examination of 26 paraffin blocks and radiographic examination of the mastectomy sample failed to reveal carcinoma. Possible explanations for a mastectomy without malignancy after carcinoma was diagnosed by LCSBB include removal of the entire lesion by LCSBB, inflammatory response obliterating remaining tumor, false-positive core biopsy result, patient misidentification, inadequate sampling of the surgical specimen, and failure to remove the tumor. We outline a series of steps for the pathologists to follow when confronted with such a case.

Adenocarcinoma↗
PubMed1999

Predictors of Mastectomy for Women with Breast Cancer in the Greater Western Region of Sydney.

This population-based study examined predictors of mastectomy for women with breast cancer in the greater western region of Sydney (GWRS) in New South Wales (NSW), Australia in 1992. Patients with a first diagnosis of breast cancer in 1992, the year prior to population-based mammographic screening in the region, were identified through the NSW state cancer registry. Data on stage, treatment, and demographic and health service characteristics were obtained from hospital records for patients treated within the region. The 282 patients who received surgical treatment for operable disease were considered in this analysis. Logistic regression was used to determine the odds ratio (OR) for mastectomy in relation to predictor variables with adjustment for confounding where appropriate. Age was included in all regressions even though it was not statistically significant. The tumor characteristics that were significant predictors (age adjusted) of mastectomy were stage [I (referent); IIA: OR = 1.5 (ns); IIB / IIIA-B: OR = 6.3, p < 0.05] and tumor size [T0-1 (referent); T2: OR = 1.8, p < 0.05; T3: OR = 12.9, p < 0.05]. There was a significant linear trend (p < 0.05) for lower ORs for mastectomy in women treated by surgeons with a higher breast cancer caseload (adjusted for age and stage). Women from municipalities with high socioeconomic status had lower mastectomy rates than others (OR = 0.5, p < 0.05), adjusted for age, stage, and surgeon activity level. Distance of residence from the main referral hospital and radiotherapy unit did not affect mastectomy rates. This study documents factors, in addition to stage at diagnosis, that play an important part in decisions about surgery for women with operable breast cancer. The experience of the surgeon, measured by the number of breast cancer patients, had an effect, as did the socioeconomic status of the woman. The latter may act through educational characteristics and participation of women in decisions concerning surgery.

Journal Article↗
PubMed2005

Invasive breast cancer following bilateral subcutaneous mastectomy in a BRCA2 mutation carrier: a case report and review of the literature.

BACKGROUND: Primary prevention of breast cancer through prophylactic mastectomy can reduce the risk of malignancy in high-risk individuals. No type of mastectomy completely removes all breast tissue, but a subcutaneous mastectomy leaves more tissue in situ than does a simple mastectomy. CASE PRESENTATION: We report a case of invasive breast cancer in a BRCA2-positive woman 33 years after bilateral subcutaneous mastectomy. To our knowledge, only one case of primary breast cancer after prophylactic mastectomy in a BRCA1-positive patient has been reported in the literature and none in BRCA2-positive individuals. CONCLUSION: Careful documentation and long follow-up is essential to fully assess the benefits and risks of preventive surgical procedures in BRCA1 and BRCA2 mutation carriers.

Journal Article↗
PubMedDate not supplied

[Reconstruction of a breast following mastectomy].

Breast reconstruction has become an available option for most patients undergoing mastectomy. Breast reconstruction has been shown to lessen the psychological disturbances associated with mastectomy. Reconstruction with a silicone breast prosthesis is selected when the preserved tissues after subcutaneous mastectomy, total mastectomy or modified radical mastectomy, have an adequate quantity and quality for insertion of the prosthesis. Frequently these tissues are quantitatively deficient. In these cases the use of tissue expanders allows the expansion of deficient soft tissues. Anatomically shaped expanders produce breasts with a natural appearance, adequate ptosis and a well-defined submammary fold. When the skin has poor quality or has been irradiated, or when a radical mastectomy has been performed, additional autogenous tissue needs to be brought to the breast area with a flap. The two most commonly used musculocutaneous flaps are the latissimus dorsi and the transverse rectus abdominis flap (TRAM). To get a good result nipple-areola reconstruction is necessary, and it is often necessary to modify the contralateral breast.

English Abstract↗
PubMed1994

Mastectomy versus conservative surgery and radiation therapy. Psychosocial consequences.

BACKGROUND: Clinical trials comparing mastectomy to conservative surgery plus radiation therapy in the treatment of breast cancer have provided an opportunity to increase understanding of the biology of this disease and the psychological adaptation of the breast cancer patient. Because these local treatments appear to be equal in terms of survival, the question remains as to whether conservative surgery plus radiation therapy confers a measure of psychological comfort superior to that of mastectomy for women diagnosed with early-stage breast cancer. METHODS: One hundred forty-two women participating in a clinical trial randomizing patients to mastectomy or lumpectomy and radiation therapy were prospectively evaluated for psychological response to their respective local therapy. A baseline assessment before randomization and subsequent questionnaires at 6, 12, and 24 months after treatment were completed by patients entered in the clinical trial. RESULTS: At 6 months, mastectomy patients reported significantly less control over events in their lives (P = 0.003) and more problems with sexual relations (P = 0.021) than did their conservatively treated counterparts. In addition, there were marked differences between mastectomy patients and lumpectomy and radiation therapy patients in the degree of distress over their nude bodies, with P = 0.001 at 6 months, P = 0.019 at 12 months, and P = 0.057 at 24 months. CONCLUSIONS: From our findings, it appears that breast conservation therapy protects women's perception of their body but does not, over time, contribute to a more positive sexual adjustment.

Adaptation, Psychological↗
PubMed1993

Long-term results of post-operative radiation therapy following mastectomy with or without chemotherapy in stage I-III breast cancer.

PURPOSE: To determine the risk of local-regional failure following post-mastectomy radiotherapy and the incidence of complications associated with such treatment. METHODS AND MATERIALS: We retrospectively analyzed the results in 309 patients with Stage I-III invasive breast cancer treated with post-mastectomy radiation therapy between 1975 and 1985. The median radiotherapy dose was 45 Gy in 1.8 to 2.25 Gy fractions. One hundred forty-seven (48%) of the patients received adjuvant systemic chemotherapy with 115 (78%) of these receiving a CMF-based or doxorubicin-containing regimen. The median follow-up time of surviving patients was 130 months (range, 28 to 191 months) after mastectomy. RESULTS: Seventeen patients (6%) developed a local-regional failure at an interval of 4 to 87 months after radiotherapy. Moderate or severe complications related to radiotherapy and requiring treatment were uncommon. Symptomatic radiation pneumonitis occurred in four patients (1.3%), arm edema in 18 (5.8%), and brachial plexopathy in 2 (0.6%). CONCLUSION: We conclude that post-operative radiotherapy is a safe and effective means of reducing local-regional failure following mastectomy. The efficacy of post-mastectomy radiotherapy in improving survival should be addressed in new large randomized controlled studies.

Adult↗
PubMed2005

Determinants of mastectomy in breast conservation therapy candidates.

BACKGROUND: Although underused, breast conservation therapy (BCT) is an accepted method for treatment of noninvasive and early breast cancer. The purpose of this analysis was to identify factors associated with receiving mastectomy when eligible for BCT. METHODS: From a recent experience, 397 patients at the University of Texas M. D. Anderson Cancer Center presented with clinical stage 0, I, or II breast cancer. Demographics and tumor characteristics of patients who underwent BCT versus mastectomy were compared. RESULTS: Of 293 BCT candidates, 203 patients (69%) underwent BCT and 90 patients (31%) received a mastectomy. Of those 90 patients, 66 patients (73%) had documented concerns about receiving BCT. Multivariate analyses showed that widow status was a factor associated with receiving mastectomy at presentation (P = .04). CONCLUSIONS: The majority of BCT candidates with early stage breast cancer undergo BCT. In our study, widow status was a predictive factor of mastectomy in BCT candidates.

Breast Neoplasms↗
PubMed2006

Comparison of risk of local-regional recurrence after mastectomy or breast conservation therapy for patients treated with neoadjuvant chemotherapy and radiation stratified according to a prognostic index score.

PURPOSE: We previously developed a prognostic index that stratified patients treated with breast conservation therapy (BCT) after neoadjuvant chemotherapy into groups with different risks for local-regional recurrence (LRR). The purpose of this study was to compare the rates of LRR as a function of prognostic index score for patients treated with BCT or mastectomy plus radiation after neoadjuvant chemotherapy. METHODS: We retrospectively analyzed 815 patients treated with neoadjuvant chemotherapy, surgery, and radiation. Patients were assigned an index score from 0 to 4 and given 1 point for the presence of each factor: clinical N2 to N3 disease, lymphovascular invasion, pathologic size>2 cm, and multifocal residual disease. RESULTS: The 10-year LRR rates were very low and similar between the mastectomy and BCT groups for patients with an index score of 0 or 1. For patients with a score of 2, LRR trended lower for those treated with mastectomy vs. BCT (12% vs. 28%, p=0.28). For patients with a score of 3 to 4, LRR was significantly lower for those treated with mastectomy vs. BCT (19% vs. 61%, p=0.009). CONCLUSIONS: This analysis suggests that BCT can provide excellent local-regional treatment for the vast majority of patients after neoadjuvant chemotherapy. For the few patients with a score of 3 to 4, LRR was >60% after BCT and was <20% with mastectomy. If these findings are confirmed in larger randomized studies, the prognostic index may be useful in helping to select the type of surgical treatment for patients treated with neoadjuvant chemotherapy, surgery, and radiation.

Adult↗
PubMed2002

Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer.

BACKGROUND: We conducted 20 years of follow-up of women enrolled in a randomized trial to compare the efficacy of radical (Halsted) mastectomy with that of breast-conserving surgery. METHODS: From 1973 to 1980, 701 women with breast cancers measuring no more than 2 cm in diameter were randomly assigned to undergo radical mastectomy (349 patients) or breast-conserving surgery (quadrantectomy) followed by radiotherapy to the ipsilateral mammary tissue (352 patients). After 1976, patients in both groups who had positive axillary nodes also received adjuvant chemotherapy with cyclophosphamide, methotrexate, and fluorouracil. RESULTS: Thirty women in the group that underwent breast-conserving therapy had a recurrence of tumor in the same breast, whereas eight women in the radical-mastectomy group had local recurrences (P<0.001). The crude cumulative incidence of these events was 8.8 percent and 2.3 percent, respectively, after 20 years. In contrast, there was no significant difference between the two groups in the rates of contralateral-breast carcinomas, distant metastases, or second primary cancers. After a median follow-up of 20 years, the rate of death from all causes was 41.7 percent in the group that underwent breast-conserving surgery and 41.2 percent in the radical-mastectomy group (P=1.0). The respective rates of death from breast cancer were 26.1 percent and 24.3 percent (P=0.8). CONCLUSIONS: The long-term survival rate among women who undergo breast-conserving surgery is the same as that among women who undergo radical mastectomy. Breast-conserving surgery is therefore the treatment of choice for women with relatively small breast cancers.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2003

Recurrence following treatment of ductal carcinoma in situ with skin-sparing mastectomy and immediate breast reconstruction.

Skin-sparing mastectomy with immediate breast reconstruction can provide an excellent cosmetic result. Despite its increasing popularity, few studies have assessed the risk of recurrence when the procedure is used for the treatment of ductal carcinoma in situ. To evaluate the oncologic safety of skin-sparing mastectomy used for the treatment of ductal carcinoma in situ, the recurrence rate was analyzed. Patients with ductal carcinoma in situ or invasive carcinoma or both who underwent skin-sparing mastectomy with immediate breast reconstruction between 1985 and 1994 and had a follow-up period of at least 6 years were included in this retrospective analysis. The recurrence rates were determined for invasive carcinoma (with or without foci of ductal carcinoma in situ) and ductal carcinoma in situ alone. A total of 221 patients were included, 177 patients with invasive carcinoma and 44 patients with ductal carcinoma in situ alone. The immediate breast reconstructions were performed with transverse rectus abdominis muscle (TRAM) flaps in 62 percent of patients, implants in 34 percent of patients, and latissimus dorsi myocutaneous flaps (with or without implants) in 4 percent of patients. The local recurrence rate was zero of 44 for patients with ductal carcinoma in situ and 5.6 percent (10 of 177) for patients with invasive carcinoma during a mean follow-up period of 9.8 years. There was a 6.8 percent (12 of 177) metastatic recurrence rate in the invasive carcinoma group. All recurrences were invasive ductal carcinoma. Of the patients with ductal carcinoma in situ alone, none developed metastatic disease. The combined metastatic and local recurrence rates for the invasive carcinoma group (n = 177) with each type of reconstruction were 13 percent (14 of 110), 12 percent (seven of 60), and 14 percent (one of seven) for TRAM flaps, implants, and latissimus dorsi flaps, respectively. The risk of recurrence following skin-sparing mastectomy and immediate breast reconstruction for ductal carcinoma in situ is low during this follow-up period. Therefore, skin-sparing mastectomy with immediate breast reconstruction seems to be a safe oncologic treatment option for ductal carcinoma in situ; however, a longer follow-up period is important to determine the long-term risk of recurrence.

Adult↗
PubMed1988

Mastectomy or conservation: the patient's choice.

STUDY OBJECTIVE: To determine whether, if given the choice, patients with breast cancer would prefer mastectomy or conservation treatment, neither treatment having been shown to be preferable. DESIGN: Non-randomised case series with 28 patients interviewed after two years and all followed up. SETTING: Secondary care referral centre. PATIENTS: 153 women, aged less than 65, with T1, T2, N1, and N0 tumours of the breast given the choice of treatment (that is, all eligible patients from December 1979). INTERVENTIONS: Patients were asked, after information and counselling, which treatment they would prefer. The chosen treatment was given without further question. Mastectomy included node sampling and local radiotherapy if indicated. Conservation treatment comprised excision of the lump, external radiotherapy, and irridium wire implant to tumour bed. MAIN RESULTS: Conservation treatment was chosen by 54 women and mastectomy by 99. Reasons for preferring mastectomy included desire for rapid treatment for domestic or employment reasons and fear of possibility of future mastectomy. Only two of the sample interviewed regretted their choice. During limited follow up no advantages to either form of treatment were seen in terms of recurrence or survival. CONCLUSIONS: Patients with breast cancer are capable of choosing treatment and should play a part in deciding which treatment to have. They do not automatically choose to retain the breast.

Adult↗
PubMed2001

Differences in risk factors for local and distant recurrence after breast-conserving therapy or mastectomy for stage I and II breast cancer: pooled results of two large European randomized trials.

PURPOSE: Risk factors for local and distant recurrence after breast-conserving therapy and mastectomy were compared to define guidelines for the decision making between both treatments. PATIENTS AND METHODS: The data of two randomized clinical trials for stage I and II breast cancer patients were pooled. The total number of patients in the study was 1,772, of whom 879 underwent breast conservation, and 893, modified radical mastectomy. Representative slides of the primary tumor were available for histopathologic review in 1,610 cases (91%). RESULTS: There were 79 patients with local recurrence after breast-conservation and 80 after mastectomy, the 10-year rates being 10% (95% confidence interval [CI], 8% to 13%) and 9% (95% CI, 7% to 12%), respectively. Age no more than 35 years (compared with age >60: hazard ratio [HR], 9.24; 95% CI, 3.74 to 22.81) and an extensive intraductal component (HR, 2.52; 95% CI, 1.26 to 5.00) were significantly associated with an increased risk of local recurrence after breast-conserving therapy. Vascular invasion was predictive of the risk of local recurrence, irrespective of the type of primary treatment (P <.01). Tumor size, nodal status, high histologic grade, and vascular invasion were all highly significant predictors of distant disease after breast-conserving therapy and mastectomy (P <.01). Age no more than 35 years and microscopic involvement of the excision margin were additional independent predictors of distant disease after breast-conserving therapy (P <.01). CONCLUSION: Age no more than 35 years and the presence of an extensive intraductal component are associated with an increased risk of local recurrence after breast-conserving therapy. Vascular invasion causes a higher risk of local recurrence after mastectomy as well as after breast-conserving therapy and should therefore not be used for deciding between the two treatments.

Adult↗
PubMed2006

Breast-conserving surgery versus mastectomy for survival from breast cancer: the Western Australian experience.

BACKGROUND: The focus of this study was the relative survival rates of breast cancer patients whose treatment was breast-conserving surgery compared with that of mastectomy, adjusting for tumor size and nodal status because these factors may be intrinsically associated with mastectomy being the treatment of choice. Patient age was also accounted for in the model. By adjusting for these factors, we mitigate them as confounders of treatment choice in assessing effects on survival rates. METHODS: Data were sourced from linked administrative data from the Western Australian Department of Health Record Linkage Unit. The data consisted of linked records containing the diagnosis, subsequent hospital admission, and death records of about 3000 women diagnosed with cancer in Western Australia between 1 January 1995 and 31 December 1999. Cox proportional hazards regression was used to investigate survival outcomes of breast-conserving surgery compared with that of mastectomy, adjusting for tumor size, nodal status, and subject age. RESULTS: The hazard of death is reduced by a factor of about one half for subjects whose treatment was breast-conserving surgery over treatment by mastectomy. Furthermore, the hazard of death increases substantially for subjects with nodal involvement over subjects for whom there has been no identified spread to regional lymph nodes. Hazard of death increases as both age and tumor size increase. CONCLUSIONS: Western Australian breast cancer patients treated with breast-conserving surgery have improved survival outcomes over those treated with mastectomy, after allowing for tumor size, patient age, and lymph node involvement.

Aged↗
PubMed1991

Comparison of mastectomy and lumpectomy for medial carcinoma of the breast.

The recurrence and five year disease-free survival rates of 86 patients with carcinoma of the breast located in the medial quadrants who had either lumpectomy and radiotherapy or mastectomy were compared. Patients who had lumpectomy and mastectomy were comparable with respect to variables reflecting extent of the disease. One of 54 patients who had lumpectomy had a local recurrence and five had a recurrence regionally or at distant sites. In the group of 32 patients who had a mastectomy, one patient had a local recurrence and an additional four patients had a recurrence at other sites. The five year study disease-free survival rate was 83 per cent for the lumpectomy group and 78 per cent for the mastectomy group. These data suggest that, for medial quadrant lesions, there may be a disease-free survival advantage associated with lumpectomy and radiotherapy over mastectomy. Further study of this treatment modality for this subset of patients seems indicated.

Breast Neoplasms↗
PubMed1988

Total mastectomy: indications and techniques.

Total mastectomy is an effective operation for patients who are candidates for a prophylactic mastectomy. This operation removes a larger percentage of breast tissue than subcutaneous mastectomy. The cosmetic results of total mastectomy with immediate reconstruction compare favorably with those of subcutaneous mastectomy.

Adult↗
PubMed1991

Results of mastectomy and postoperative irradiation in the management of locoregionally advanced carcinoma of the breast.

Between 1955 and 1984, 376 patients with locoregionally advanced breast carcinoma were treated at The University of Texas M. D. Anderson Cancer Center with mastectomy and irradiation and without adjuvant chemotherapy. Patients with inflammatory carcinoma or synchronous bilateral primary tumors were excluded. There were 202 patients with Stage IIIA disease and 174 patients with Stage IIIB disease (AJC Staging--1983). In 124 patients the surgical management was confined to the breast only--total mastectomy (BR) and in 252 dissection of the axilla was performed--extended total, modified radical, or classic radical mastectomy (BR + AX). All patients had postoperative irradiation. The follow-up period ranged between 8 and 34 years. At 10 years, the actuarial disease-specific, relapse-free survival (DSRFS) rate for the entire group was 40%, and the actuarial locoregional control rate was 82%. For patients with Stage IIIA disease the DSRFS was 48% and locoregional control rate was 88%. For those with Stage IIIB disease, the figures were 30% and 74%, respectively. Most of the failures occurred within 5 years of the mastectomy and essentially all occurred within 10 years. When analyzed by type of surgery, both the locoregional control and DSRFS rates were improved by the axillary dissection, the difference being largely caused by fewer axillary node recurrences after dissection of both the breast and axilla than after removal of the breast alone. In the 252 patients in whom the axilla was assessed, the number of positive nodes was a powerful predictor of both locoregional control and survival. The DSRFS rates at 10 years for patients with 0, 1-3, and greater than or equal to 4 positive nodes were 63%, 48%, and 30%, respectively. The actuarial locoregional control rates at 10 years exceeded 95% for patients with 0-3 positive nodes and 75% for those with greater than or equal to 4 nodes. These results show that locoregionally advanced breast cancer is not a uniformly fatal disease when treated without chemotherapy and provide a baseline upon which to assess the value of adjuvant systemic therapy for this stage of disease.

Adult↗
PubMed1990

Seroma prevention using fibrin glue in a rat mastectomy model.

Seromas are a frequent complication of mastectomy (17% to 53%) in humans and are correlated to skin flap elevation, lymphovascular interruption, and drainage into surgically created potential spaces. The use of intraoperative topical fibrin glue to reduce morbidity in rats undergoing radical mastectomies has been evaluated. A model consistently producing seromas was developed by radical mastectomy and lymphadenectomy in the Sprague-Dawley rat. A fibrin glue application procedure was tested using this model. The double-blinded protocol called for spray application of saline or fibrin glue to mastectomy wounds followed by sequential inspection and necropsy on postoperative days 5, 8, 11, and 14. Topical fibrin glue was shown to be statistically significant in decreasing the presentation of seromas following a radical mastectomy in the Sprague-Dawley rat.

Animals↗
PubMed2000

Long-term satisfaction and psychological and social function following bilateral prophylactic mastectomy.

CONTEXT: Prophylactic mastectomy is a preventive option for women who wish to reduce their risk of breast cancer. There has been concern about possible negative psychological sequelae following this procedure. However, few data are available regarding long-term satisfaction and psychological and social function following this procedure. OBJECTIVE: To evaluate patients' long-term satisfaction and psychological and social function following prophylactic mastectomy. DESIGN, SETTING, AND PARTICIPANTS: Descriptive study of all women known to be alive (n = 609) who had a family history of breast cancer and elected to undergo bilateral prophylactic mastectomy at a large, tertiary US health care clinic between 1960 and 1993, 94% (n = 572) of whom completed a study questionnaire. MAIN OUTCOME MEASURES: Satisfaction with procedure and effects on psychological and social function, based on responses to the study-specific questionnaire. RESULTS: Mean time from prophylactic mastectomy to last follow-up was 14.5 years. Most women (70%) were satisfied with the procedure; 11% were neutral; and 19% were dissatisfied. Among the psychological and social variables, the most striking finding was that 74% reported a diminished level of emotional concern about developing breast cancer. The majority of women reported no change/favorable effects in levels of emotional stability (68%/23%), level of stress (58%/28%), self-esteem (69%/13%), sexual relationships (73%/4%), and feelings of femininity (67%/8%). Forty-eight percent reported no change in their level of satisfaction with body appearance; 16% reported favorable effects. However, 9%, 14%, 18%, 23%, 25%, and 36% reported negative effects in these 6 variables, respectively. CONCLUSIONS: This study suggests that positive outcomes following prophylactic mastectomy include decreased emotional concern about developing breast cancer and generally favorable psychological and social outcomes. These must be weighed against the irreversibility of the decision, potential problems with implants and reconstructive surgery, and occurrence of adverse psychological and social outcomes in some women. JAMA. 2000;284:319-324

Adaptation, Psychological↗