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Health Related Quality of Life in Breast Cancer Patients after Breast Reconstructive Surgery
Rika Ohkuma, M.D., Marcelo J. Lacayo Baez, MD, Pablo A. Baltodano, MD, Anne Tong Jia Wei, MD, Eric B. Schneider, PhD, Carisa M. Cooney, MPH, Eric Wan, Miceile Barrett, Justin M. Sacks, MD, Damon S. Cooney, MD, PhD, Michele A. Manahan, MD, Gedge D. Rosson, MD.
Johns Hopkins Hospital, Baltimore, MD, USA.

BACKGROUND:
Breast reconstruction following mastectomy has been shown to improve quality of life (QoL). The goal of this study is to quantify and compare QoL scores for breast cancer patients undergoing different surgical procedures.
METHODS:We performed an IRB-approved prospective study of patients undergoing breast reconstruction at the Johns Hopkins Hospital between November 2010 and April 2013. Two validated questionnaires, the RAND-36 and BREAST-Q©, were administered at four time points: preoperatively, after tissue expander (TE) placement in staged cases), and at 6 and 12 months post-reconstruction. Patient QoL scores were compared at each time points and between the groups of autologous vs. implant reconstruction and staged vs. non-staged reconstruction. Responses were analyzed using the paired t-test. Multivariate logistic regression model was performed in the 6 month follow up questionnaire outcomes.
RESULTS:Of 122 female patients eligible for study [mean age: 48.6±9.0 (range 26-72), mean BMI: 25.3±4.6 (range 15-37)], 93 patients (76%) underwent staged reconstruction.
93 staged reconstruction patients were found to have significantly lower scores for satisfaction with breasts, physical well-being on the chest, sexual well-being (all p<0.001), and pain (p=0.015) by TE placement.
Of 122 eligible patients, 66 patients completed 6 month follow-up questionnaires (mean length of follow up: 9.0±6.2 month); 49 autologous flap reconstructions (2 DIEP, 3 SGAP, 4 msTRAM) and 17 implant reconstructions. Overall patients were found to have significant lower satisfaction scores for physical well-being on the abdomen (p=0.040) at 6 month after the major reconstruction surgery comparing to the baseline. However, 6 month follow up scores showed significant improvement in satisfaction with breasts, psychosocial well-being, and sexual well-being compared to the scores when TEs were in place (all p<0.01). At 12 month follow up, satisfaction with physical well-being on the chest and the abdomen returned to the baseline level with significant improvement between postoperative 6-12 months (both p<0.03). There was no significant difference at both postoperative time points between cohorts; staged vs. non-staged or flap vs. implant.
Multivariate logistic regression model showed extended adjuvant chemotherapy after major reconstruction surgery was associated with lower satisfaction with breasts, overall outcomes, psychosocial well-being and sexual well-being (all p<0.05), and complications were related to lower satisfaction with overall outcome (p=0.047).
CONCLUSIONS:Patients’ post-operative QoL is worsened after TE placement, however, significantly improved following reconstruction with a positive psychological impact on patients’ psychosocial well-being. The role of QoL is an important concept when counseling and planning breast reconstruction.
TE follow up QoL Score: BREAST-Q
QoL Score: Mean±SD (Min-Max)
BREAST-Q SubScale (93 Patients)BaselineAfter TE PlacementΔ TE-BaseP
Satisfaction with Breasts58.6±21.5 (0-100)48.6±13.6 (24-91)-9.0±25.0<0.001
Psychosocial Well-being72.3±18.2 (38-100)66.3±20.8 (30-100)-6.0±24.50.472
Physical Well-being : Chest80.5±14.9 (39-100)69.6±15.5 (31-100)-11.1±19.3<0.001
Sexual Well-being57.1±18.2 (0-100)47.6±23.4 (0-100)-10.1±26.6<0.001

TE follow up QoL Score: RAND36
QoL Score: Mean±SD (Min-Max)
RAND36 (65 Patients: 69.8% response)BaselineAfter TE PlacementΔP
Physical Functioning57.5±11.5 (50-93)57.2±8.3 (50-90)-0.3±11.30.830
Role Limitations due to Physical Health80.3±9.2 (75-100)83.3±10.7 (75-100)-2.1±27.20.056
Role Limitations due to Emotional Problems81.4±9.5 (75-100)79.3±8.7 (75-100)-6.9±26.20.170
Energy/Fatigue40.5±11.1 (13-75)41.4±10.1 (25-69)0.9±12.00.550
Emotional well-being35.9±8.4 (15-55)35.7±8.6 (15-65)-0.3±10.80.852
Social functioning49.4±11.4 (0-100)50.0±16.1 (0-100)0.6±17.50.791
Pain78.1±24.3 (13-100)69.0±28.1 (0-100)-9.0±29.10.015
General Health51.0±14.2 (25-100)49.9±12.0 (20-75)-1.0±14.70.571

6 month follow up QoL Score: BREAST-Q©
QoL Score: Mean±SD (Min-Max)
BREAST-Q SubScale (66 Patients)BaselineAt 6 month follow upΔ TE-Base (34Patients)PΔ 6m-TE (34Patients)PΔ 6m-BaseP
Satisfaction with Breasts55.6±23.2 (0-100)68.4±21.0 (23-100)-10.5±24.90.01921.1±20.2<0.00112.8±29.20.057
Satisfaction with Outcomen/a75.7±22.3 (0-100)n/an/a-5.4±30.50.385n/an/a
sychoSocial Well-being69.6±19.9 (23-100)78.2±20.2 (37-100)-5.7±23.90.17111.6±23.70.0088.6±21.60.123
Sexual Well-being53.3±19.3 (0-100)56.7±24.1 (0-100)-10.8±24.00.01512.5±21.80.0024.1±26.40.874
Physical Well-being : Chest77.2±14.9 (36-100)74.6±17.8 (21-100)-6.8±15.70.0174.0±15.40.143-2.5±18.90.424
Physical Well-being : Abdomen (46 Abd Flap Patient)89.9±14.8 (35-100)76.9±20.1 (21-100)n/an/an/an/a-13.1±19.90.040

12 month follow up QoL score:BREAST-Q©
QoL Score: Mean±SD (Min-Max)
BREAST-Q SubScale (30 Patients)BaselineAt 12 month follow upΔ 6m-BasePΔ 12m-BasePΔ 12m-6mP
Satisfaction with Breasts56.4±22.7 (22-100)69.3±16.6 (35-100)11.4±27.20.03012.9±27.90.0171.6±12.30.490
Satisfaction with Outcomen/a81.7±16.7 (43-100)n/an/an/an/a-0.6±11.70.834
PsychoSocial Well-being66.7.6±16.0 (32-100)77.1±18.1 (43-100)1.6±18.70.00410.4±17.90.003-0.1±17.30.967
Sexual Well-being54.6±17.1 (18-100)60.4±23.7 (20-100)1.3±23.30.7585.1±25.00.2925.7±20.10.138
Physical Well-being : Chest75.2±12.6 (57-100)77.1±18.1 (39-100)-2.3±17.80.4921.9±17.60.5584.2±9.60.024
Physical Well-being : Abdomen (23 Abd Flap Patient)89.6±14.3 (46-100)81.5±17.0 (47-100)-17.7±22.00.001-8.1±21.90.0909.6±12.60.001


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