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PubMed2005

Opinions of women with high inherited breast cancer risk about prophylactic mastectomy: an initial evaluation from a screening trial including magnetic resonance imaging and ductal lavage.

OBJECTIVE: Prophylactic mastectomy (PM) is often considered, but variably chosen by women at high inherited risk of breast cancer; few data exist on patient tolerance of intensive breast screening as an alternative to PM. We performed an evaluation of high-risk women's tolerance of a breast screening protocol using clinical breast examination, mammography, breast magnetic resonance imaging (MRI) and ductal lavage (DL), and of change in attitudes toward PM after screening. DESIGN: A questionnaire assessing tolerance of screening procedures and change in opinion towards PM was designed and administered to 43 study participants, after a median follow-up of 13 months. Responses were evaluated according to patient characteristics, including type of study-prompted interventions, BRCA mutation status, and prior history of cancer, via univariate analysis. RESULTS: Most patients [85.3% (68.9-95.1%)] were more opposed or unchanged in their attitudes towards PM after study participation, with only 14.7% (5.0-31.1%) less opposed (P = 0.017) despite a short-interval follow-up MRI rate of 71.7% and a biopsy rate of 37%. Lower rates of maximal discomfort were reported with mammogram [2.8% (0-14.5%)] and MRI [5.6% (0-18.7%)] than with DL [28.6% (14.6-46.3%)], with P = 0.035. CONCLUSIONS: Most high-risk women tolerated intensive breast screening well; they were not more inclined towards PM after participating. Future studies should prospectively evaluate larger numbers of high-risk women via multivariate analysis, to determine characteristics associated with preference for breast screening vs. PM.

Adult↗
PubMed1979

Subcutaneous mastectomy using an inferior nipple pedicle.

A technique for subcutaneous mastectomy is described which permits a reduction mammoplasty or mastopexy to be performed at the same time. The nipple is based on an inferior dermal pedicle. This appears to provide a safe blood supply to the nipple and safe cover for the prosthesis. The dermal pedicle for the nipple reinforces the submammary suture line and lessens the chance of extrusion of the prosthesis.

Breast↗
PubMed1979

The surgical pathology of breast cancer in relation to reconstruction after mastectomy.

Pathological features such as tumour type, tumour size and lymph node invasion have an important bearing on the prognosis of the patient with breast cancer. It is suggested that such prognostic factors should be considered in the selection of women for post-mastectomy breast reconstruction. The implications of pathological and other factors are reviewed and a summary of favourable prognostic factors is presented.

Breast↗
PubMed1982

Postoperative arm positioning after mastectomy and other procedures in the pectoral region.

Mastectomy is the commonest operative procedure in the pectoral region. Other procedures include raising of deltopectoral or pectoralis major myocutaneous flaps. Proper postoperative positioning allowing the least tension on the wound and a primary closure without a skin graft is desirable. An attempt was made to mathematically quantify the effect of various arm positions on skin tensions over the axilla, the chest wall and the cervico-thoracic region. It was found that the position of 90 degrees flexion at the shoulder with 90 degrees flexion of the elbow with the hand pointing across or cephalically, on alternate days, was the most suitable. This position does not compromise movements at the shoulder.

Arm↗
PubMed1985

Operative aid to combined synchronous mastectomy and latissimus dorsi breast reconstruction.

A special frame is described which has been designed to hold the upper trunk and arm of patients firmly in the lateral position during the operation of combined synchronous mastectomy and latissimus dorsi breast reconstruction. The frame has prevented movement at the shoulder joint and distraction on the brachial plexus which resulted in brachial plexus palsy in two out of 15 patients in whom the operation was performed with a conventional arm support.

Breast↗
PubMed1991

The free transverse rectus abdominis myocutaneous flap in breast reconstruction after mastectomy.

Breast reconstruction after mastectomy by the transverse rectus abdominis myocutaneous (TRAM) flap technique is a widely accepted method which allows reconstruction without the need for an implanted silicone prosthesis. Even in suitable patients, deficiencies of the traditional technique, where the blood supply is based on anastomotic vessels in the superior part of the rectus abdominis muscle, may lead to complications. These include flap failure, fat necrosis which may mimic recurrence of breast carcinoma or sub-optimal cosmetic results. By transferring the same abdominal tissue as a free flap based on the inferior epigastric vessels, a more reliable blood supply and better cosmetic results can be obtained. This article reports a series of 14 flaps in 13 patients in whom an entirely free flap technique was used. No flap losses were recorded and the results are judged to be superior to the traditional technique.

Abdominal Muscles↗
PubMed1977

Psychological implications of mastectomy.

The adjustment of a group of mastectomy patients to their operation was assessed at an interval of between 18 months and 5 years after surgery. They were found to be significantly more depressed and anxious than a control group of cholecystectomy patients; they tended to have lower self-esteem; and they described themselves as being more introverted in their behaviour. These differences were attributed to concern about both the loss of the breast and the possibility of recurrence of the cancer.

Adjustment Disorders↗
PubMed1983

Locus of control and cognitive behaviour therapy with mastectomy patients: a pilot study.

A cognitive behaviour therapy programme was designed for use with mastectomy patients, and a pilot study performed to test the efficacy of the programme. This article reports the locus of control data collected during the pilot study and the relationship between these data and the clinical assessment measures. Lower chance scores at pre-treatment are associated with greater clinical improvement as predicted. Surprisingly, however, there is an increase in chance scores over treatment although this disappears at follow-up. Patients who also received medication scored higher on internal control than those who did not. These results are discussed and it was concluded that antidepressant medication may assist the cognitive therapy programme.

Adjustment Disorders↗
PubMed2005

Investigation into dosimetric effect of a MAGNA-SITE tissue expander on post-mastectomy radiotherapy.

It is increasingly common for radiotherapy departments to encounter high density objects in patients being planned for radiotherapy. Many cases, such as artificial hip prostheses, are well documented. In our cancer center we have recently come across a new type of implant--a McGhan Style 133 Tissue Expander--implanted in patients who have undergone a mastectomy and will in future have breast reconstruction. This type of implant contains a small rare earth magnet encased in a titanium body, which induces significant perturbations in the dose distribution. These perturbations have been measured using a p-type semiconductor diode. Attenuation of up to 30% of local dose has been observed for a single beam. However, in more realistic clinical situations using tangential parallel opposed beams, it is estimated that part of the planning target volume maybe be underdosed by approximately 10%. Comparisons have been made between measured attenuation and that calculated by a treatment planning system, which demonstrates inadequate modeling of the dose perturbation caused by the implant in this case.

Breast Implants↗
PubMed1982

Cost of counselling women who undergo mastectomy.

The psychiatric morbidity associated with mastectomy and brest cancer was substantially reduced by a specialist nurse who counselled women before and after surgery and monitored their progress. A controlled study was, therefore, carried out to determine what this cost. National Health Service costs were almost wholly covered by savings made because counselled subjects who developed psychiatric problems were recognised and treated much earlier than control patients. Counselled and control subjects suffered considerable financial losses, but these were offset in the counselled group by their relatives' earlier return to work. Such counselling schemes are necessary and effective and may be implemented at little extra cost.

Community Health Services↗
PubMed1986

Psychological impact of adjuvant chemotherapy in the first two years after mastectomy.

Psychological symptoms were assessed over two years in a randomised trial of three forms of treatment given to women after mastectomy for stage II breast cancer. The treatments were: three weeks' radiotherapy; one year's adjuvant chemotherapy with cyclophosphamide, methotrexate, and 5-fluorouracil; and radiotherapy followed by chemotherapy. Analysis of the results on an intention to treat basis showed no substantial differences in depression or anxiety among groups at one, three, or six months after the operation. At 13 months, however, patients who had been allocated chemotherapy had significantly more symptoms, especially depression, than control patients treated with radiotherapy alone. Conditioned reflex nausea and vomiting increased considerably during the second six months of chemotherapy and persisted for up to a year afterwards. The psychological morbidity of adjuvant chemotherapy could be substantially reduced if courses of treatment were restricted to about six months.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1987

Psychosocial effects of radiotherapy after mastectomy.

Psychosocial morbidity was measured in 47 patients who received postoperative radiotherapy and in 38 who received no further treatment after mastectomy. Roughly one third of all patients experienced depression or anxiety. One month after operation, before radiotherapy, there were no significant differences between the two groups in any of the measures of psychosocial morbidity. Knowledge of impending treatment did not seem to influence morbidity. At three months patients who had completed radiotherapy had significantly more somatic symptoms and social dysfunction than those not so treated. At six months the radiotherapy group continued to show more somatic symptoms, but a year after operation there were no significant differences between the groups. Although several patients who received radiotherapy were upset by their treatment, the study failed to confirm that depression and anxiety were commoner among those given radiotherapy than among patients given no further treatment.

Anxiety↗
PubMed2003

Recurrence in autogenous myocutaneous flap reconstruction after mastectomy for primary breast cancer: US diagnosis.

PURPOSE: To assess the value of ultrasonography (US) and US-guided fine-needle aspiration biopsy (FNAB) in the detection and diagnosis of recurrent cancer in breasts reconstructed with autogenous myocutaneous flaps after mastectomy for primary breast cancer and to describe the US appearances of recurrence in the reconstructed breast. MATERIALS AND METHODS: Between July 1994 and March 2001, US of the reconstructed breast was performed in 20 women with autogenous myocutaneous flap reconstruction. US findings were correlated with clinical and mammographic findings. US-guided FNAB of 25 (64%) of the 39 recurrent cancers depicted at US was performed. RESULTS: Twenty-one (54%) of the 39 recurrent cancers depicted at US were clinically occult. Mammography performed in 12 of the 20 patients with reconstructed breasts depicted 14 (56%) of the 25 recurrent cancers that were detected at US in these patients. US-guided FNAB helped to establish a definitive diagnosis of recurrent breast carcinoma in 24 (96%) of the 25 tumor specimens sampled. CONCLUSION: US and US-guided FNAB are valuable for the assessment of both palpable and clinically occult recurrent breast cancers in autogenous myocutaneous flap breast reconstructions.

Adult↗
PubMed1999

Utilisation of prophylactic mastectomy in 10 European centres.

Increasingly women at high risk of breast cancer are opting for prophylactic surgery to reduce their risks. Data from 10 European centres that offer a risk counselling and screening service to women at risk show different approaches to the option of preventive surgery, although most centres adhere to a protocol including at least two risk counselling sessions and a psychological assessment. Thus far the combined centres have data on 174 women who have undergone prophylactic mastectomy with in excess of 400 women years of follow up. Operations were carried out on women with lifetime risks of 25-80%, with an average annual expected incidence rate of 1% per women. No breast cancers have occurred in this cohort. Long term follow up on an extended group of women will be necessary to truly address the risk of subsequent breast cancer and the psychological sequelae.

Adult↗
PubMedDate not supplied

Prophylactic mastectomy or screening in women suspected to have the BRCA1/2 mutation: a prospective pilot study of women's treatment choices and medical and decision-analytic recommendations.

BACKGROUND: Women suspected to have the BRCA1/2 mutation may choose between two management options: breast cancer screening and prophylactic mastectomy (PM). OBJECTIVES: To compare women's treatment choices with medical and decision-analytic recommendations and to explore variables related to the women's choices. METHODS: After provision of information, individual time-tradeoff values for the health outcome "living after PM" were assessed and incorporated into a decision-analytic model, which compared the management options PM and screening with respect to their effects on quality-adjusted life expectancy. RESULTS: Of the 54 women suspected to have the mutation, 51 completed the shared-decision-making procedure. Quality-adjusted life expectancy after PM management was longer for 67% of proven carriers and for 58% of women awaiting the DNA-test result. Twelve proven carriers made definitive treatment choices: eight (67%) chose PM and four (33%) chose screening. All carriers' treatment choices agreed with the normative decision-analytic recommendations. Four (33%) disagreed with the medical recommendations. Of the 36 women awaiting DNA-test results, 32 made hypothetical treatment choices. The agreement between these hypothetical treatment choices and the decision-analytic recommendations was good (78%). Combining data from all 48 women, being married (OR = 14.00, p = 0.006), having children (OR = 4.71, p = 0.02), low desire to participate (OR = 0.14, p = 0.004), high decisional stress (OR = 5.22, p = 0.01), a lower estimate of the "probability of cure for screen-detected breast cancer" (OR = 0.13, p = 0.004), and higher time-tradeoff values for PM (OR = 182, p < 0.0001) made a choice for PM more likely. CONCLUSIONS: The complete agreement between the decision-analytic recommendations and the carriers' choices suggests that women act in accordance with normative decision theory. The disagreement between the carriers' choices and the medical recommendations suggests that women's choices and physicians' recommendations were guided by different arguments. The strong association between time-tradeoff value and treatment choice suggests that the time-tradeoff is a valid method to assess preferences.

Adult↗
PubMedDate not supplied

Assessment of the time-tradeoff values for prophylactic mastectomy of women with a suspected genetic predisposition to breast cancer.

BACKGROUND: Female carriers of the breast-cancer-susceptibility genes BRCA1 and BRCA2 are at high risk for breast cancer (85%). They face the choice between prophylactic mastectomy (PM) and breast cancer screening. For this treatment choice, a shared-decision-making program was developed. In this program, the time tradeoff (TTO) was used to assess preferences for PM. PURPOSE: Assessment of the feasibility, constant proportional tradeoff, and reliability of using the TTO for this purpose. METHODS: Fifty-four women suspected to carry the BRCA1/2 mutation were provided with comprehensive relevant information. Their preferences for PM were assessed on two occasions. Discrepancies between preferences indicated by the two tests were resolved by testing a third time. The preferences assessed on the last occasion were used for individual decision analyses. In order to test constant proportional tradeoff, the TTO consisted of four items with different numbers of life years. RESULTS: Forty-two women (78%) completed the TTO twice and nine women (17%) performed the test a third time. Three women (5%) completed the TTO only once. The mean TTO value for PM at the last replication was 0.69 (SD=0.30). Violations of constant proportional tradeoff were significant: the largest tradeoffs were recorded for the shortest durations. Pearson's correlation coefficient between the TTO values for the two last sessions was 0.96. CONCLUSION: Assessment of individual preferences by the TTO in this patient group is feasible and reliable. Therefore, the TTO can be used in clinical settings to elicit treatment preferences of women proven or suspected to have a genetic predisposition to breast cancer.

Adult↗