The equivalence and safety of BCS was proved in several studies by the 1990’s and established the procedure as an alternative to mastectomy for early-stage breast cancer. Since then, BCS rates have increased considerably . However, there is evidence that this trend is reversing with an increase in mastectomy rates in the last years, especially due to the enhanced number of contralateral prophylactic mastectomy. Some possible explanations for this trend are the greater awareness of breast cancer risk, the availability of genetic testing and the possibility of satisfactory aesthetic outcomes and oncological safety since the widespread of NSM . A recent study from Galimberti et al including 1989 women who had a NSM, with a median follow-up of 94 months, indicate that NSM is oncologically safe for selected patients, with acceptable local recurrence and low complication rates .
The overall safety of BCS and reconstruction surgery, as well as improvements in long term outcomes of breast cancer treatment, have enhanced concerns about quality of life and aesthetic results . QoL comprises aspects including body image, cosmetic results, breast satisfaction, attractiveness, sexual problems, post-surgical complications and worrying about the future. These aspects are influenced by type of surgery as well by additional treatments, like chemotherapy, endocrinotherapy and radiotherapy . Despite the importance of this concept, most of the studies on QoL originate only from the last 2 decades and we still have lack of information .
In our study, there was no statistical difference in global QoL and patient satisfaction among women who underwent BCS and NSM for breast cancer treatment. A study by Kim et al administered QoL questionnaires to 485 patients who underwent BCS and 46 patients who underwent mastectomy with immediate reconstruction at least 1 year after surgery and adjuvant therapy, showed no difference in global QoL and cosmetic results for both surgery groups. Similar results were described in a Polish study that included 82 breast reconstructions in 79 patients and 226 BCS, with high levels of global QoL between the two groups, not differing significantly from one another. Jagsi et al conducted a SEER population-based survey with 1450 respondents, 9 months and 4 years after diagnosis, to evaluate QoL and patterns and correlates of satisfaction with overall cosmetic outcomes. Among 963 patients receiving BCS and 222 receiving mastectomies with reconstruction, there was no difference related to the cosmetic satisfaction. The authors suggest that in patients undergoing post-mastectomy radiation, the use of autologous reconstruction may mitigate radiation's deleterious impact on cosmetic outcomes. A metanalysis from Sadaf Zehra et al published in 2020 compared QoL outcomes among breast cancer surgery groups and suggest that QoL outcomes in breast reconstruction and BCS groups are better than the mastectomy group. All these studies, except for the metanalysis, however, applied other questionnaires than the BREAST-Q [3, 16, 19].
Regarding the specific domains of QoL and patient satisfaction analyzed in the present study, we found significantly higher physical wellbeing scores in BCS group compared to NSM. Howes et al performed a case-controlled study to evaluate QoL following breast cancer surgery to compare outcomes following BCS versus total mastectomy with or without reconstruction. The BREAST-Q were completed by 400 women (123 controls, 97 breast conservations, 93 mastectomies without reconstruction, 87 mastectomies with reconstruction) and the results showed that women who underwent BCS scored the lowest in the physical well-being chest domain and the majority reported breast asymmetry. In the study, higher scores of satisfaction and sexual well-being was found among women who underwent mastectomy with reconstruction, compared to women who had BCS .
Satisfaction with the breasts in our analysis were significantly higher for patients who had undergone BCS, and this difference remained significant after adjusting for variables. Flanagan et al published the results of a study including 3233 women (2026 patients had BCS, 123 had NSM, and 1084 had skin-sparing or total mastectomy) to compare patient satisfaction following BCS and mastectomy with implant reconstruction (M-iR), utilizing the BREAST-Q. Breast satisfaction, psychosocial well-being and sexual well-being were higher for BCS compared with M-iR in early-stage invasive breast cancer. The satisfaction with the breasts decreased over time in all women of the study, highlighting the need for further evaluation with longer follow-up .
A study including 7619 patients recruited from the Army of Women with a history of breast cancer surgery, administered surgery-specific questionnaires, including the BREAST-Q, to evaluate the effect of procedure type on breast satisfaction scores. The authors reported that women who underwent implant-based reconstruction were less satisfied with their breasts compared to women that underwent BCS. These findings emphasize the value of PROMs as an important guide to decision making in breast surgery and underscore the importance of multidisciplinarity in the decision-making process .
The satisfaction with care in our study, related to the Surgeon, Medical Team and Office Staff, was extremely high in both groups. This domain addresses issues related to the professionalism, knowledge, respect and empathy of the team, as well as the patient's involvement in decision making and understanding of the process. Of our knowledge, this is the first study comparing patients operated on by the same surgeon, which considerably reduces the bias of different techniques of operation and practice, which we know has a profound influence on QoL and patient satisfaction. We correlated the high levels of satisfaction in both groups with the fact that patients were operated on by the same senior surgeon and, mainly, with the patient's involvement in decision-making regarding surgical treatment. Studies about satisfaction with breast cancer procedures have shown that women who report active roles in their decision-making process were twice as likely to be satisfied with their decision compared with those who reported more passive roles . Additionally, literature suggests that other aspects of care during consultation are more important than the type of surgery alone, including patient involvement in the decision for surgery, surgeon specialization in breast surgery, and access to informational materials. Patient satisfaction is highly dependent on the extent to which postoperative outcomes match preoperative expectations, which is deeply influenced by the support offered by the surgeon and his medical and office staff [21, 22].
One of the limitations of the study was the inclusion of the patients that made themselves available to answer, what could be a selection bias. Additionally, the median follow-up was short, less than 30 months, and we were unable to adjust for preoperative BREAST-Q scores, since the preoperative version of the questionary was not applied. Based on previous studies, we know that time from surgery is an important factor associated with satisfaction with breasts and QoL .