Psychosocial Adaptation during and after Breast Cancer

Kimberley L. Miller

Julia H. Rowland

Mary Jane Massie

INTRODUCTION

Breast cancer is the most common form of cancer among American women, with advances in detection and treatment leading to increases in disease-free survival. However, unlike treatment for other chronic diseases, many treatments for cancer are toxic and intensive, adversely affecting patients’ physical, psychological, and social resources, both short and long term.

Because of improvements in screening technology that allow the diagnosis of breast cancer at earlier stages; new developments in treatment approaches; the greater use of preoperative systemic therapy, and increased awareness about potential late effects of chemotherapy and radiation, more women are confronted with a variety of treatment choices, emphasizing her role in the decision-making process and the critical role of patient-doctor and family communication in breast cancer care. The identification of genetic markers of breast cancer risk and the evaluation of chemopreventive agents adds to the psychological toll on unaffected women who are at increased risk for this disease. With the publication in 2008 of the Institute of Medicine’s report, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, a new standard has been set for oncology practice, one that acknowledges that the patient herselfis as important as, and at times more important than, the tumor in planning and delivering optimal care (1).

Although breast cancer is a major stressor for any woman, there is great variability in women’s psychological responses. This chapter outlines the range of women’s psychosocial responses to breast cancer and factors that may increase a woman’s risk for poor adaptation. In addition, the role of family supports in adaptation, and concerns related to sexual functioning and posttreatment survivorship are addressed.

Although very little research has been done in male, compared to female, breast cancer, male breast cancer survivors have been found to have long-term deficits in physical and mental health status, compared to noncancer controls (2). There may be similarities in the challenges men and women face in coping with their cancers, however, there is a clear difference in that compared to women, men likely experience their cancer within the context of lower social awareness and higher social isolation. Male breast cancer is reviewed more fully in Chapter 61.

FACTORS THAT AFFECT PSYCHOLOGICAL IMPACT

A patient’s psychological response to her disease is affected by her surrounding sociocultural environment, her underlying psychological characteristics, and medical factors (Table 89-1). Comprehensive care requires individualized attention to, and assessment of, each of these areas, as needed, throughout the illness trajectory.

Sociocultural Context and Psychosocial Issues in Decision-Making

The national visibility afforded to cancer has resulted in increasing attention to the patient’s role in medical decision-making. As a result, women today have more information about, understanding of, and resources to manage their breast cancer illness and recovery than ever before. Although increasing patient awareness and understanding continues to be the goal, it is important to note that some women may feel they have “too much” responsibility in treatment decisions, up to 21% in one study (3), which was associated with poor baseline knowledge and 6-month decision regret. Thus, the need for physicians to tailor their communication and information-sharing with patients, especially those with low health literacy, is significant.

TABLE 89-1 Factors That Contribute to the Psychological Responses of Women to Breast Cancer

1. Current sociocultural context, treatment options, and decision-making
	a. Changes in surgical and medical management from a uniform approach, e.g., breast-conserving management; introduction of sentinel node biopsies and neoadjuvant therapy; more therapeutic options and acknowledged uncertainty
	b. Social attitudes
	c. Public figures openly sharing their breast cancer experience
	d. Autobiographic accounts of and “how to” guides for dealing with and surviving breast cancer in the popular press
	e. Ethical imperative for patient participation in treatment issues; legal imperative for knowledge of treatment options
	f. Variations in care by ethnicity, location, age
	g. Public awareness of treatment and research controversies; advocacy for more funding and lay oversight
2. Psychological and psychosocial factors
	a. Type and degree of disruption in life-cycle tasks caused by breast cancer (e.g., marital, childbearing, work)
	b. Psychological stability and ability to cope with stress
	c. Prior psychiatric history
	d. Availability of psychological and social support (partner, family, friends)
3. Medical factors
	a. Stage of cancer at diagnosis
	b. Treatment(s) received: mastectomy/lumpectomy and radiation (plus/minus immediate/delayed reconstruction), adjuvant chemotherapy, hormonal therapy
	c. Availability of rehabilitation
	d. Psychological (partner, support groups)
	e. Physical (reconstruction; arm mobility and lymphedema prevention)
	f. Psychological support provided by physicians and staff

Over the course of care, women face three major decisionmaking periods. The first is encountered at the time of initial discovery of a lump or symptom suspicious for breast cancer, at which time a woman must decide if further evaluation is needed. A woman’s decision is informed by her access to, and cost of, specialized care; her age, her level of education or knowledge, her attitudes and beliefs about cancer; her personality and coping style; and the nature of the existing doctor-patient relationship (4). Delays in seeking care have been attributed to age (>65 years), a symptom other than a breast lump, not sharing the symptom with others, negative attitudes toward, or a poor relationship with, the healthcare professional, fear of cancer and related treatments, low perception of risk, less spirituality, and a willful ignorance of symptoms (4, 5). Independent of health insurance, stage of diagnosis, and age, black and Hispanic patients have been shown to have higher risks of 30-, 60-, and 90-day treatment delay than white patients (6, 7). Medicare beneficiaries may be at increased risk for delay in definitive treatment in particular (8). Language barriers, inadequate resources, and inaccurate beliefs may disproportionately affect Latina and African American women (9, 10). In at least one study, treatment delays experienced among low-income women led to worse survival outcomes (11). If a delay in early detection has occurred, personal guilt or anger at her physician can interfere with a woman’s adaptation to treatment. Reinforcing the value of care she is receiving may be important in her engagement in the recovery process.

The second major set of decisions is set in motion at the time of consultation with a surgeon about local treatment options, which may be followed by multiple consultations with other cancer specialists. Women may choose between mastectomy versus limited resection and irradiation, plus or minus immediate reconstruction. If systemic therapy is indicated, an additional cascade of decisions must be made. Differences in the types of breast cancer treatment received by a woman exist, based on geography, age, socioeconomic status, and race. For example, African American women with less education are at risk for receipt of non-guidelineconcordant adjuvant chemotherapy regimens, potentially contributing to worse outcomes (12). Women living in rural areas, particularly those who are older, may be less likely to receive recommended radiation therapy in association with their breast cancer treatment (13). Breast-conserving therapy is more likely to be performed in academic settings, in the Northeast, and among younger women (14).

The time between diagnosis and initiation of treatment is one of the most stressful periods in the breast cancer experience. The emphasis on informed decision-making places a responsibility on the physician to be cognizant of the individual woman’s physical and psychological needs and to tailor accordingly the discussion and recommendations made. At times, it may mean addressing a woman’s demands for unrealistic treatment, acquiescing to another woman’s desire to defer a final decision to her physician or significant other, or in some cases reassuring a woman that she need not reach a decision immediately but can research her options and come to an appropriate choice. During this time, she may opt to seek a second opinion to aid in her decision-making. As desire for information and preference about decision-making roles can change over time, asking about them periodically is important. Treatment information can be provided as printed or videotaped materials, and reputable websites may be recommended to patients and families. For women feeling overwhelmed or pressured to make a surgical decision, it may be helpful to postpone surgery and meet with a member of a psychosocial support team who could facilitate a discussion about underlying concerns and fears.

Psychological Variables in Adaptation

In 1980, Meyerowitz (15) delineated three broad areas of psychosocial impact of breast cancer: (a) psychological discomfort (anxiety, depression, and anger); (b) behavioral changes due to physical discomfort, marital or sexual disruption,
and altered activity level; and (c) fears and concerns related to body image, recurrence, or death. Although women diagnosed today have many more treatment options and resources for support, the psychological concerns remain the same (16). In addition to these variables, the life stage at which the cancer occurs, previous emotional stability (personality and coping style), and presence of interpersonal support also affect adaptation (see Table 89-2).

Age at time of diagnosis is important in considering a breast cancer patient’s distress (17, 18). Concerns about the threat to life and future health, as well as fears of potential disfigurement, disability, and distress associated with treatment, are common for women of all ages but may be heightened in younger women with breast cancer. In younger patients, beyond disruption to multiple active roles, there is the perception that they have more to lose due to the threat to their future, including the potential loss or delay in having or building a nascent career or family. Worse outcomes in quality of life and depressive symptoms have been shown to be more frequent and severe in breast cancer survivors aged 50 years or younger when compared with the general age-matched population of women without cancer and to older women (aged >50 years) with breast cancer (19). Concerns about premature menopause, menopausal symptoms, and infertility were common in younger women and have a role in the level of posttreatment distress. Additionally, the younger breast cancer patient often presents with more advanced disease and typically is treated more “aggressively” surgically, which further affects psychological adjustment. (See Chapter 85 on Breast Cancer in Younger Women.) Research has not focused as much on women older than 65, despite their representing almost half of current breast cancer survivors (20). Although one may assume an older woman’s distress regarding her breast cancer may be buffered by her greater life experience and familiarity with medical settings, she may experience the diagnosis in the presence of other major losses and concurrent chronic medical conditions. Older women with breast cancer experience poorer health-related quality of life and lower psychosocial well-being than unaffected peers (21) and are at risk for significantly higher rates of decline in upper body function (22). This pattern, coupled with the observation that older women are significantly less likely to receive appropriate surgical care or rehabilitation (23, 24), suggests that patients at both ends of the age continuum are at increased risk for problems in adaptation. Finally, although threats to body image, sense of femininity, and self-esteem may be greatest in younger women, particularly those who are single or without a partner, these threats are concerns of many older women as well (25). (See Chapter 84 on Breast Cancer in Older Women.)

TABLE 89-2 Risk Factors for Poor Adaptation

1. Medical
	▪ More advanced disease
	▪ More intense or aggressive treatment
	▪ Other/multiple co-morbid medical conditions
	▪ Fewer rehabilitative options
	▪ Poor doctor/patient relationship
2. Personal
	▪ Prior psychiatric history
	▪ Past trauma history (especially physical or sexual abuse)
	▪ Rigid or limited coping capacity
	▪ Helpless/hopeless outlook
	▪ Low income/education
	▪ Multiple competing demands (e.g., work, child or other family care, economic)
	▪ Poor marital/interpersonal relationship
	▪ Younger age (<40) or older age (>80)
3. Social
	▪ Lack of social support (and/or religious affiliation)
	▪ Limited access to service resources
	▪ Cultural biases
	▪ Social stigma or illness taboo
4. Breast cancer specific
	▪ Prior breast cancer experience
	Recurrence or second breast cancer Loss of family or friends to breast cancer
	▪ High investment in body image, in particular breasts
Adapted from Weisman D. Early diagnosis of vulnerability in cancer patients. Am J Med Sci 1976;271:187.

Personality and coping styles affect adaptation to breast cancer. Women who are flexible and employ active problemsolving approaches have better moods and adaptation (26). Women who are able to draw on and use available social resources and support adapt better and may even live longer than women who do not (27). In contrast, women who are passive, helpless, hopeless, or pessimistic in the face of illness; are rigid in their coping style; and isolate themselves or reject help when it is offered adapt more poorly. Women who manifest persistent depressive symptoms in the face of cancer may be at risk not only for poor quality of life but also premature death (28, 29) and should be considered promptly for professional psychological assessment and support. Women with a history of resolved major depression have been found to be at increased risk of developing greater depressive symptoms during treatment, which in turn predicts declines in physical functioning during chemotherapy, compared to those with no history of depression (30), highlighting the importance of identifying such women as early as possible and ensuring that adequate resources are in place for them. The relationship between attitude and cancer risk and/or survival remains an area of public interest and active research. Because breast cancer is so prevalent, is associated with significant negative psychological impact, and has inadequately defined causative factors, the possible role of psychological variables in vulnerability to breast cancer and its progression has been explored in medical studies. It also has received considerable attention from patients and the media. Stewart et al. (31) found that 42.2% of the 378 breast cancer survivors surveyed believed that stress caused cancer and 27.9% felt that stress reduction could prevent a recurrence, confirming work done 20 years earlier. Such beliefs can become an added psychological burden and lead some women to pursue unproven therapies. Although epidemiologic studies have failed to find an association between stress and breast cancer development (32) or survival (33), it is nonetheless important to mitigate chronic stress when it is identified. Education regarding the lack of evidence of stress causing cancer is an important component of integrated oncological care. Other important factors in adaptation are a patient’s prior experiences with breast cancer and body image. Levels of psychological distress can be affected by the memory of a friend’s or family member’s suffering with breast cancer. Some women cannot tolerate the idea of loss or damage to a breast and may delay seeking consultation for a symptom, especially if their community views cancer as stigmatizing.

A woman’s sociocultural background can further influence her breast cancer experience. Although the interpretation of between-group differences in ethnicity often is confounded by variables such as income, education, and treatment (34), it is worth noting two historically understudied minority groups: lesbian breast cancer survivors and survivors living in rural communities. (For a full discussion of this topic, see also Chapter 86, Breast Cancer in Minority Women.)

Sexual orientation appears to have little effect on quality of life among breast cancer survivors (35). Some data suggest that lesbian breast cancer survivors may be more comfortable with body image and perceive greater social support than their heterosexual peers. However, they also may tend to experience more difficulty interacting with physicians (36). Survivors in rural areas are at greater risk for relationship problems, lack of support, and feelings of isolation (37). Finally, adjustment depends on the actual and perceived level of support, as well as the patient’s ability to rely on that support (e.g., attachment security). For example, women who recalled childhood abuse were more likely to experience their surgeon as unsupportive (38).

Prolonged anxiety or depression is not an expected reaction to a cancer diagnosis (39).The common stress reactions around the time of diagnosis and onset of treatment usually can be evaluated and managed by the patient’s physicians, nurses, or social worker. However, some women have greater problems and can benefit from psychological management by psychiatrists and psychologists, who often are collaborating members of the treatment team (Table 89-3).

If a patient’s anxiety or insomnia interferes with functioning, low-dose anxiolytic medication (e.g., lorazepam [0.25 to 1.0 mg orally two to four times a day] or clonazepam [0.25 to 1.0 mg orally twice daily]) or a hypnotic (e.g., zolpidem [5 to 10 mg]) usually are effective. When anxiety and insomnia cannot be controlled with these medications or when surgical or medical staff observe symptoms of depression—such as frequent crying episodes, loss of interest and/or motivation, irritability, inability to concentrate, or remarks indicating hopelessness, helplessness, or suicidal thoughts—psychiatric consultation is indicated. Psychiatric consultants assess all of the factors contributing to a woman’s distress, including any family or relational issues, combining psychopharmacological interventions with psychosocial support for the patient and family. The selective serotonin reuptake inhibitors (SSRIs; e.g., fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram, escitalopram) and novel or mixed action antidepressants (venlafaxine, duloxetine, bupropion, mirtazapine) are considered first-line treatment because they are better tolerated in patients with comorbid depression and medical conditions. Venlafaxine currently is believed to be the antidepressant that should be prescribed to the depressed woman (or the woman with hot flashes) who is taking tamoxifen, due to its relative lack of impact on tamoxifen metabolism. (See Chapter 51 for information on management of hot flashes.)

TABLE 89-3 Women with Breast Cancer Who Should Be Considered for Psychiatric Evaluation

1. Those who present with current symptoms or a history of the following:
	▪ Depression or anxiety
	▪ Suicidal thinking (attempt)
	▪ Substance or alcohol abuse
	▪ Confusional state (delirium or encephalopathy)
	▪ Mood swings, insomnia, or irritability from steroids
2. Those who:
	▪ Have a family history of breast cancer
	▪ Are very young, old, pregnant, nursing, single, or alone
	▪ Are adjusting to multiple losses and managing multiple life stresses
	▪ Seem paralyzed with cancer treatment decisions
	▪ Fear death during surgery or are terrified by loss of control under anesthesia
	▪ Request euthanasia
	▪ Seem unable to provide informed consent

Medical Variables in Adaptation

The stage of breast cancer at diagnosis, treatment required, prognosis, and available rehabilitative opportunities constitute important medical variables that influence psychological adjustment. However, central to successful adaptation is a woman’s relationship to her treating physicians and the degree to which they are sensitive to her individual concerns, communicate clearly, and monitor emotional and physical well-being. The length and intensity of current treatments and the recognition that women treated for breast cancer must be followed for extended periods of time have placed an added burden on healthcare providers. Depending on the setting, nurse clinicians or psychosocial clinicians may provide supportive care. Preliminary guidelines for psychosocial care across the cancer continuum have been developed, albeit for highly resourced comprehensive cancer centers, with adherence to, or adaptation of, these guidelines known to be quite low (40, 41). Further, concerns about the cost of providing the recommended psychosocial and supportive care and who should pay for this continue to be significant barriers to optimal service delivery.

Surgery

Mastectomy Mastectomy is now performed in fewer than half of women diagnosed with early-stage breast cancer. Of late, however, there has been an increase in the number of women selecting ipsilateral mastectomy with contralateral prophylactic mastectomy (CPM), in part due to the greater use of pre-operative magnetic resonance imaging (MRI) (42, 43). Further, for women who do undergo mastectomy, more will undergo breast reconstruction than previously, although data suggest that many mastectomy patients are not made aware of their reconstruction options. Considerable research exists on the impact of loss of one or both breasts on women’s physical, social, and emotional functioning. Among the effects documented are feelings of mutilation and altered body image, diminished self-worth, loss of a sense of femininity, decreases in sexual attractiveness and function, anxiety, depression, hopelessness, guilt, shame, and fear of recurrence, abandonment, and death. Historic data indicate that women who are well adjusted before they have a mastectomy and whose disease is in an early stage can expect at 1 year to have a quality of life equal to that of unaffected peers. Today, a woman’s persistent issues generally have less to do with the type of surgery received and more to do with her personal and social characteristics and the adjuvant therapy given. Issues related to the latter are discussed in the treatment-specific chapters and in the section Breast Cancer Survivors, later in this chapter.

Research suggests that, in addition to a number of medical factors (e.g., tumor size, location, and aggressiveness), several other characteristics may distinguish women who have mastectomy from those who receive breast-sparing surgery. These include older age, fear of irradiation, preferring to have no therapy beyond surgery, being black or Hispanic (or possibly low income), and among older women, living with extended or nonfamily members or in an assistedliving setting (10).

Contralateral Prophylactic Mastectomy Rates of CPM have increased dramatically in the past two decades, mostly in patients without any identified risk factors, such as genetic predisposition (BRCA1/2 mutation) or a prior history of radiation (44). Independent predictors of CPM in a large retrospective analysis at a leading cancer center in the United States included white race, immediate reconstruction, family history of breast cancer, MRI at diagnosis, age younger than 50 years, noninvasive histology, and prior attempt at breast conservation (44).

Similar to all treatment decisions, the patient contemplating a CPM should be fully informed regarding her individual risk and given adequate time and information to make the decision, including the option to use a patient decision tool. An individualized approach includes incorporating a patient’s personal values regarding risk aversion and anticipated regret into the ultimate treatment decision (45). A Cochrane review has found that there is insufficient evidence that CPM improves survival (46). However, those who chose bilateral prophylactic mastectomy (BPM) had lower levels of anxiety after BPM, compared to their baseline worry and to those who chose surveillance (46).

Breast-Conserving Therapy or BCT (Lumpectomy and Irradiation) A significant factor in what type of surgery is performed is the nature of the care that is available, including the availability of high-quality irradiation therapy. Further, restricted access to plastic surgeons can limit the availability of reconstructive options. Another factor determining choice is the knowledge and availability of genetic testing for mutations in BRCA1 and 2; patients with mutations now generally undergo bilateral mastectomy. Cultural and ethnic values also may direct or even dictate choice, although their role is poorly understood. Physician recommendation continues to exert the most significant influence on treatment choice for most women. Early reports suggested that women in BCT groups manifest a somewhat better overall adjustment than those in mastectomy groups (47). However, longer-term follow-up of more current cohorts of breast cancer survivors has failed to show differences in overall quality of life based on type of surgery alone (48). A consistent finding is that psychosocial variables are, for the most part, much stronger predictors of psychosocial outcomes than are medical factors (49). These latter studies further suggest that benefits to sexual function associated with BCT may be less than previously believed. Because BCT often is selected because it is perceived as less disfiguring than mastectomy, it is problematic when the surgical results do not meet expectations. A significant confound to examining the impact of surgery on women’s quality-of-life outcomes is that younger women, known to be at increased risk for psychosocial problems in adapting to breast cancer, tend to elect to undergo BCT. These young patients also are more likely to receive adjuvant chemotherapy, which has a significant negative impact on sexual functioning. What we have learned is that BCT is not a psychosocial panacea; rather, it is a surgical and cosmetic option that may facilitate adaptation for many women. Two critical factors that continue to influence the surgical decision-making process are attitudes about cancer and irradiation. The thought of leaving tumor cells in the breast is intolerable for some women, who feel more secure with mastectomy. Other women fear irradiation or are unable to devote 6 weeks to daily irradiation treatments. Women undergoing irradiation are at risk for psychological distress, either related to treatmentassociated fatigue, or persistent fears about their disease and the risk of recurrence. Providing a reassuring environment, orientation to expected side effects, and strong support promotes optimal adaptation. Most women who undergo radiation therapy experience initial anxiety related to the treatment, which diminishes after a few treatments, only to return toward the conclusion of therapy because of fear of tumor re-growth without treatment, and the loss of close medical surveillance. To ease this transition, patients should be made aware of the paradoxical increase in feelings of distress. Staff should remain available by telephone and through follow-up appointments.

When discussing women’s reactions to irradiation, one additional factor that is important to consider is the risk for upper extremity lymphedema. Women who develop lymphedema are at high risk for problems in both psychological and social functioning (50). Fortunately, the proportion of women affected by this problem has decreased with the use of sentinel node biopsy. (See Chapters 40 and 42 for more details regarding lymphedema and radiation, respectively.)

Reconstruction Postmastectomy breast reconstruction is an important rehabilitative option pursued by a significant subset of women undergoing mastectomy. However, there is some evidence that reconstruction is not being routinely addressed in the surgical decision-making process. In their SEER-based sample, Alderman and colleagues found that only a third of patients reported that their general surgeon discussed this option with them during the decision-making process (51). Younger, more educated women with larger tumors were more likely to report that this discussion took place. Further, patients whose surgeon did cover this option were four times more likely to have a mastectomy. Relatively few studies have systematically examined the psychosocial impact of mastectomy alone compared with mastectomy plus reconstruction. Contemporary studies seek to evaluate psychosocial and sexual outcomes for women selecting each of the three different surgical options (lumpectomy vs. mastectomy alone vs. mastectomy with reconstruction). Parker and colleagues describe similar subtle differences in early adaptation among women undergoing each of the three different procedures, but note that few differences could be seen among groups 2 years after treatment (48). In general, aspects of quality of life other than body image are not better in women who have undergone BCT or mastectomy with reconstruction. In what remains the largest three-way comparison study, investigators found no differences in women’s emotional, social, or role functions by type of surgery (52). Consistent with others’ findings, women in the mastectomy with reconstruction group were most likely to report that breast cancer had a negative impact on their sex lives (45.4% vs. 41.3% for mastectomy alone, and 29.8% for lumpectomy). An important factor in women’s sexual outcomes is that mastectomy with or without reconstruction results in permanent loss of sensation in the area. Further, as discussed in Chapter 42, the use of postmastectomy radiation therapy generally decreases the cosmetic results with reconstruction, particularly with implants. At the same time, the use of immediate breast reconstruction can compromise effective and safe delivery of postmastectomy radiation therapy.

Research suggests there are sociodemographic differences between women who do and do not undergo postmastectomy reconstruction. Women undergoing mastectomy with reconstruction generally are younger, better educated, have higher incomes, are more likely to be partnered, and have an earlier stage of disease (52, 53). Women who are older, Hispanic, or born outside of the United States appear less likely to have reconstruction (54). Fewer African American women undergo reconstruction; this often may be due to economic and access barriers, but also potentially is related to lower interest in having reconstruction (55). Asian women also are less likely than white women to undergo reconstruction. There is some data to suggest that among sexual minority women (self-identified as lesbian or bisexual), there may be more decisional regrets among those who choose reconstruction versus mastectomy alone, leading to more adjustment problems (56). Regrettably, few efforts have been made to understand the psychological variables associated with who does and does not seek reconstruction, in particular in the present era in which autologous tissue procedures and immediate reconstruction represent standard options for care. Further, additional research is needed on the impact on women’s satisfaction and functioning related to the extent of surgery performed and procedures used to achieve good symmetry.

In addition to local treatment choice (e.g., BCT vs. mastectomy with or without reconstruction), the impact on psychosocial function of the timing and type of reconstruction performed has been examined.

Timing of Reconstruction: Immediate versus Delayed Research with women undergoing immediate reconstruction has shown high levels of patient satisfaction with surgical results and less psychosocial morbidity than in those who undergo mastectomy alone, although as noted in earlier discussions, these differences diminish over time (57). Patients undergoing immediate reconstruction report being less depressed and anxious and experience less impairment of their sense of femininity, self-esteem, and sexual attractiveness than their peers who delay or do not seek reconstruction, but these initial differences in adjustment may be minimal and disappear over time. At least one study has suggested that satisfaction with technical aspects of the reconstructive outcome may be slightly lower among women undergoing immediate versus delayed reconstruction (59). This may reflect the fact that women with immediate reconstruction compare the result with their original breast, whereas those undergoing delayed surgery use the mastectomy site as their basis for comparison.

Type of Reconstruction: Implant versus Transverse Rectus Abdominus Myocutaneous Flap (TRAM) The research evaluating psychosocial outcomes for women undergoing reconstruction using TRAM surgery also has been an area of interest. No differences were seen between groups undergoing implant versus TRAM surgery in satisfaction with the appearance or feel of their breasts or the overall impact of breast cancer on their sex lives, although there was a consistent tendency for the women with TRAM reconstructions to report greater comfort and satisfaction (59). This pattern is consistent with others’ findings and the observation that timing of reconstruction may be more influential than type of procedure on women’s long-term adaptation (57). However, women who had an implant were significantly more worried about having a problem with their reconstruction (59). Longer-term follow-up of cosmetic outcomes for implant recipients would appear to confirm these fears. Clough et al. (60) report that overall cosmetic outcome was rated as acceptable in 86% at 2 years but had declined to 54% by 5 years in their study sample. Further, 23% of the 334 women in their study underwent implant exchange (excluding those with expanders). A similar pattern was not observed among TRAM reconstructions, in which assessment of cosmetic outcome remained stable over time (60).

Regardless of the type of reconstructive surgery proposed or selected, women need to be well informed about what to expect, including the cost of the surgery, length of time under anesthesia, number of procedures required, cosmetic results achievable, and safety of the techniques used. This may be accomplished through providing patients written materials, including images of reconstructed breasts, as well as referring them to a previously reconstructed patient for more details. Wider availability of video and online tools for decision-making is beginning to provide a unique way to educate women about choices that allows them to tailor the information they receive.

Adjuvant Chemotherapy

A recent systematic review has shown that, of the three breast cancer treatments (surgery, radiation, or chemotherapy), chemotherapy-treated patients have the highest level of anxiety, reaching its peak just before the first infusion, mediated by age and trait anxiety (61). Anticipation of chemotherapy can be difficult, highlighting the importance of patient education by the medical team. Women fear the transient acute sequelae of chemotherapy (e.g., nausea and hair loss). With greater public awareness, fear of chemotherapy’s persistent effects (e.g., fatigue, pain, memory problems, sexual dysfunction, sleep disturbance, depression) also can cause major concern (62). Clinical experience suggests that most women cope with the short-term adverse psychological effects by focusing on delayed benefits (e.g., reassurance that they have done everything possible to eradicate their disease). However, clinicians need to be aware that, for some women, declines in health-related quality of life during treatment increase risk for discontinuation of chemotherapy (63). Monitoring for problems and addressing them promptly are important in ensuring adherence to the planned course of care.

Nausea and vomiting, once common side effects of adjuvant chemotherapy and feared and dreaded by patients, now are well controlled with pharmacologic and behavioral interventions (64, 65). However, other side effects such as hair loss, weight gain, poor concentration, premature menopause, and fatigue affect psychological adjustment and warrant special attention and early discussions with patients. Information about wigs, the cost of which often is covered by insurers, along with referral to the American Cancer Society’s Look Good… Feel Better program can help reduce appearance-related distress.

The cause of weight gain with chemotherapy remains unclear. Because of the added insult to self-esteem posed by significant weight gain, as well as data suggesting that obesity leads to worse prognosis (66), greater attention is being paid to diet and exercise. The introduction of exercise programs during chemotherapy is feasible, well tolerated (67), and of benefit in controlling weight gain, improving functional and cardiac status, and potentially enhancing quality of life. (See Chapter 50 for a broader discussion of lifestyle interventions.)

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