ANTICANCER RESEARCH 33: 731-736 (2013)

Lumpectomy versus – A Post- Patient Survey

CHRISTIAN EICHLER1, MARIT KOLSCH1, AXEL SAUERWALD2, ALEXANDER BACH3, OLEG GLUZ4 and MATHIAS WARM5

1Department of Gynecology and Obstetrics, Holweide Hospital, Cologne, Germany; 2Department of Gynecology and Obstetrics, Hospital Düren GmbH, Germany; 3Department of Plastic Surgery, St. Antonius Hospital, Eschweiler, Germany; 4Department of Gynecology and Obstetrics, Bathesda Clinics, Moenchengladbach, Germany; 5Department of Health, University Witten/Herdecke, Cologne, Germany

Abstract. Background: In oncoplastic surgery, post-surgical did not differ significantly. MP may be offered as an option subjective outcome evaluation is usually performed for patients when simultaneous enhancement is desired at little cost with breast-conserving surgery and patients with . to post-surgical patient satisfaction. This study attempts to broaden the spectrum by comparing mastopexy (MP) and lumpectomy (BCS). Evaluating this aspect An optimal surgical approach for any given oncoplastic is important, since performing a mastopexy along with tumor surgery is the basis for patient satisfaction, follow-up patient removal offers a chance for simultaneous breast enhancement, morbidity and patient mortality. If at all possible, a clean- thus possibly offering a more beneficial subjective outcome. margin surgical approach should be combined with the Both procedures were used to remove single-locus tumors. A esthetically most satisfying oncoplastic option (1). While it is total of 143 patients, 71 of which answered a questionnaire important to compare surgical outcomes by way of, for regarding post-surgical body image, were evaluated. Results: example, clean-margin rates, required revision and Post-surgical patient evaluation showed the following results: A complication rates, it is also important to determine patient “very satisfactory” or “satisfactory” outcome was achieved in satisfaction and the impact of a surgical procedure on a 87% of BCS cases and 86% of MP cases. No significant patient’s self-esteem, psychological health and body image difference was established here (p=0.48). Evaluation of overall (2-8). The most common comparisons are performed between cosmetic outcome, scar tissue formation, shape and size of the breast-conserving surgery (BCS) and mastectomy (2, 9). breast and overall quality of life were answered positively in This study attempted to quantify patient evaluation of the both groups. Regarding the remaining superficial scar tissue, surgery outcome and thus compare two fundamentally patients answered as being satisfied with the result in 85% of different surgical approaches. The commonly used BCS BCS cases and 79% of MP cases. A significant difference was approach is the gold standard for single-locus tumor established between the very satisfied (77% BCS/44% MP) and resection of smaller neoplastic formations in the breast. satisfied (8% BCS/35% MP) group (p=0.013). Post-surgical While attempts are made to conserve the previous shape of swelling, nipple sensitivity and overall quality of life did not the breast, no further augmentation or plastic improvement differ significantly. Conclusion: Simple lumpectomy, i.e. classic is performed during this type of surgery. BCS, leads to less scar tissue and involves a shorter surgical Mastopexy (MP) on the other hand, is a more intricate procedure, both of which may be considered as arguments for procedure which allows simultaneous tumor removal and performing BCS. Scar tissue formation was more positively plastic improvement of the breast (10-13). While the obvious evaluated in the BCS group, where 77% of patients were “very advantage of a simple BCS lies in the shorter surgical time, satisfied” and 8% “satisfied”. The other evaluated parameters lower cost and absence of opposite side treatment, clinical experience shows that some patients appreciate the notion of a combined tumor removal and surgical enhancement (8). In order to support this notion however, the surgical outcome Correspondence to: Dr. med. Christian Eichler, Brustzentrum, must first be quantitatively evaluated. Krankenhaus Holweide, Neufelder Str. 32, 51067 Köln, Germany. Tel: +49 1635050614, e-mail: [email protected], eichlerc@kliniken- Patients and Methods koeln.de This study evaluated 143 patients who underwent either a Key Words: Mastopexy, breast-conserving surgery, lumpectomy, lumpectomy (71) or a mastopexy (72) in 2007, at the University of . Cologne, Department of Senology. A selection of patient groups

0250-7005/2013 $2.00+.40 731 ANTICANCER RESEARCH 33: 731-736 (2013)

Table I. List of questions regarding all evaluated parameters referred to publication. This was procured in all cases. Additional Ethics side of surgery only. Committee approval was not required as this was a retrospective data analysis. Evaluated parameters (side of surgery only) Surgical method. Obviously, not every patient qualifies for a BCS 1 Evaluate the overall cosmetic outcome of your breast. or MP. The decision process by which patients were offered the 2 Are your satisfied with the appearance and amount of scar tissue? surgical procedure was lead by an experienced senelogical surgeon. 3 Do you like the current shape of the breast? Both approaches were explained to the patients and they were given 4 Are you currently satisfied with the appearance of the breast? a choice of which was to be performed. Scar patterns for inverted- 5 Are you currently satisfied with the size of the breast? T MP and areolar incision options for lumpectomies were clarified 6 Evaluate your current quality of life. during these pre-surgical sessions. Consequences, differences and 7 Has sensitivity changed in the nipple/areola complex, possible side-effect were also addressed. increased/decreased? 8 Was there a significant amount of swelling in and around the breast area? Neoadjuvant therapy. Pre-operative treatment was either 9 Are you less likely to show yourself in public? , according to the Cologne protocol, with four cycles 10 Has your self confidence level changed due to the surgery? of epirubicin (90 mg/m2) and cyclophosphamide (600 mg/m2) and four cycles of Taxotere (docetaxel at 100 mg/m2) or antihormone therapy with Letrozol (Femara), the latter as part of an ongoing study (14-16). with similar tumor characteristics was attempted. Tumor quality was . Post-surgical radiation treatment was similar between the two compared groups, so as to minimize administered according to the gold standard, whenever appropriate. skewing of patient evaluation through, for instance, advanced tumor Since the vast majority of our patients underwent post-surgical stage within one of the two groups. The first part of this analysis radiotherapy, this aspect was not taken into account in a separate thus demonstrated patient subgroup comparability, maintaining that subgroup analysis. identical groups are rarely achieved in clinical studies. Naturally, a plethora of factors play a vital role in the treatment of breast cancer Statistics. Statistical analysis was performed using the VassarStats® apart from those addressed in this study, such as radiation, chemo, (Vassar College, Poughkeepsie, NY, USA) statistics program. antihormone and antibody therapy. Nodal status, metastases and Clinical, tumor-biological and histo-pathological factors were opposite side treatment (MP) are also a commonly addressed issues. analyzed. Pearson’s chi-squared tests and t-tests were used in order Nonetheless, a specific excursion into the details of these aspects is to evaluate significance, when appropriate. beyond the scope of this study.

Questionnaire. Several options are available to evaluate the post- Results surgical patient satisfaction. These include the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire The analysis of the study may be sectioned into two parts. (EORTC QLQ-C30), the FACIT.org-based FACT-B questionnaire and First a subgroup comparison must be attempted in order to the Breast-Q (7). While the authors are aware of these instruments, it establish initial group comparability. Thus, five parameters was felt that these issues could be more adequately addressed by a have been chosen in order to show representative tumor new questionnaire designed specifically for this study group. A total characteristics in the two patient subgroups. These were of 52 parameters were evaluated, including all of the relevant tumor stage/classification, tumor histology, grading, questions addressed in the above mentioned tools. As it is not the point of this study to introduce yet another device for post-surgical chemotherapy and resection margins. Other parameters, such patient evaluation, only the central aspects are presented here. as radiation therapy and psychooncological support are also The questionnaire was completed by 71 patients: 40 patients involved in patient group homogeneity. It is, however, the undergoing BCS chose to answer the questionnaire as well as 31 intention of this analysis to provide only an approximate women who underwent a MP. Ten parameters are presented. The picture of cancer property distribution in the analyzed intra-collective oncological character remained similar. The subgroups, thus establishing comparability. Providing every questionnaire was distributed to the patients via mail, after the detail in the patient history would not be helpful to the surgery had been performed, so as to allow time for the post- surgical rehabilitation and evaluation of the final outcome only. subsequent analysis. Radiation therapy, as well as chemotherapy, had been concluded at Subgroups are herein referred to as the BCS (lumpectomy) the time of patient evaluation. A minimum of six months was group and the MP (mastopexy) group. The average age of allowed for this process. In order to maintain comparability between the BCS group was 52.5 (standard deviation ±9.8) years and the two groups, patients who underwent MP were asked to comment that of the MP group was 53.3 (±8.8) years (p=0.14). on the outcome of the side that they had received oncoplastic surgery only. Table I shows a list of the questions. Tumor characteristics. The stage subgroup analysis indicated Patient consent and ethics. In accordance with the University’s that the MP group included slightly larger tumors. T1 versus standard operating procedures, this retrospective evaluation required T2 tumors were distributed as follows: BCS included 45 written and informed patient consent regarding data analysis and (63.4%) patients with T1, while the MP group contained 28

732 Eichler et al: Lympectomy versus Mastopexy - A Post-surgery Survey

Table II. Tumor stage distribution. Table IV. Tumor grading distribution.

Lumpectomy (BCS) Mastopexy (MP) Lumpectomy (BCS) Mastopexy (MP)

Stage Number of % Number of % Grading Number of % Number of % patients patients patients patients

Tis 6 8.5 9 12.5 G1 9 12.7 5 6.9 T1 45 63.4 28 38.9 G2 50 70.4 51 70.8 T2 18 25.4 32 44.4 G3 7 9.9 7 9.7 T3 0 0 3 4.2 Unknown 5 7 9 12.5 T4 1 1.4 0 0 TX 1 1.4 0 0 Total 71 100 72 100

Total 71 100 72 100

Table V. Chemotherapy therapy regiments.

Table III. Tumor histological distribution. Lumpectomy (BCS) Mastopexy (MP)

Lumpectomy (BCS) Mastopexy (MP) Chemotherapy Number of % Number of % patients patients Histology Number of % Number of % patients patients Neoadjuvant 15 21.1 22 30.6 Adjuvant 28 39.4 29 40.3 DCIS 5 7 9 12.5 None 20 28.2 21 29.2 Invasive ductal 26 36.6 30 41.7 Unknown 8 11.3 0 0 DCIS + invasive ductal 26 36.6 22 30.6 Invasive lobular 4 5.6 5 6.9 Total 71 100 72 100 Invasive lobular + ductal 1 1.4 1 1.4 Invasive lobular CLIS 4 5.6 3 4.2 Rest 4 5.6 2 2.8

Total 71 100 72 100 Table VI. Resection summary.

Lumpectomy (BCS) Mastopexy (MP)

R0 Number of % Number of % (38.9%) such patients. T2 tumors were found in 18 (25.4%) patients patients BCS patients, whereas 32 (44.4%) patients had T2 tumors in Yes 49 69 51 70.8 the MP group. Table II shows tumor stage distributions in No 22 31 21 29.2 detail. As the surgical procedures were explained to the patients beforehand, having a larger tumor may lead to a more Total 71 100 72 100 prominent defect when simple lumpectomy is chosen. Thus patients may have opted for MP in order to avoid this possibility. This fact introduced an unfortunate, but unavoidable bias into this study which needs to be kept in mind. Chemotherapy, both neoadjuvant and adjuvant, was also Table III shows tumor histology distributions for both similarly distributed in both patient subgroups. Neoadjuvant subgroups. Again, distributions are similar, but not equal. therapy was given to 15 (21.1%) patients in the BCS group, Both groups show invasive ductal components to be the in comparison to 22 (30.6%) in the MP group. Adjuvant major histological contributor. A combined total of 52 therapy was administered to 28 (39.4%) patients in the BCS (73.2%) patients in the BCS group and 52 (72.3%) patients group and 29 (40.3%) patients in the MP group. The in the MP group presented with an invasive ductal remaining distributions are shown in Table V. carcinoma, although the DCIS components varied. Clean margins were achieved in 49 (69%) patients in the Tumor grading is addressed in Table IV. Most patients BCS group, while 51 (70.8%) patients in the MP group also presented with a G2 tumor. The BCS group included 50 profited from them. A summary is given in Table VI. While (70.4%) patients and the MP one included 51 (70.8%) these resection rates are not optimal, literature reports patients with a G2 tumor. involved margins in up to 60% of cases. (17) These results

733 ANTICANCER RESEARCH 33: 731-736 (2013)

Table VII. Subjective parameters as evaluated by patients 6 months after surgery.

Evaluated parameters (side of surgery only) Very Satisfied Indifferent Unsatisfied Very p-Value+ satisfied (%) (%) (%) unsatisfied (%) (%)

BCS MP BCS MP BCS MP BCS MP BCS MP

1 Evaluate the overall cosmetic outcome of your breast. 59 62 28 24 3 10 5 3 5 0 0.480 2 Are your satisfied with the appearance and amount of scar tissue? 77 44 8 35 5 14 5 5 5 2 0.013 3 Do you like the current shape of the breast? 62 47 18 33 18 13 0 7 3 0 0.206 4 Are you currently satisfied with the appearance of the breast? 69 65 18 18 8 12 3 0 3 6 0.901 5 Are you currently satisfied with the size of the breast? 62 57 26 27 10 7 3 10 0 0 0.747 6 Evaluate your current quality of life. 49 50 41 37 8 10 3 0 0 3 0.688

+Pearson’s chi square test.

Table VIII. Subjective parameters as evaluated by patients 6 months after surgery.

Evaluated parameters (side of surgery only) on a scale from 1 to 5, 1 (No)++ 2 3 4 5 (Yes)++ p-Value+ (1: very little/least amount, 5: a lot/largest amount) (%) (%) (%) (%) (%)

BCS MP BCS MP BCS MP BCS MP BCS MP

7a Has sensitivity changed in the nipple/areola complex increased? 76 50 5 20 3 10 5 17 11 3 0.045 7b Has sensitivity changed in the nipple/areola complex decreased? 14 17 5 13 5 3 3 10 73 57 0.467 8 Was there a significant amount of swelling in and around the breast area? 60 48 15 29 8 16 10 6 8 0 0.215 9 Are you less likely to show yourself in public?++ 93 94 8 6 0.764 10 Has your self confidence level changed due to the surgery? 90 94 3 0 3 0 3 0 3 6 0.545

+Pearson’s chi square test.

are currently being improved by the use of intraoperative Post-surgical breast size was also evaluated as being frozen sections and intraoperative ultrasound. satisfactory or better by 87% (BCS) and 83% (MP) of the patients. Again, both procedures proved equally effective Patient evaluation. The central question of this study, both (p=0.747). Finally, a large percentage of patients noticed an in the quantitative analysis of subjective surgery outcome, as improvement in quality of life when comparing post- to pre- well as the difference between the two surgical approaches, surgical status: 90% of the BCS group patients stated being showed the following results: A “very satisfactory” or satisfied with their quality of life, while 87% in the MP group “satisfactory” outcome was produced at 87% (BCS) and 86% answered similarly (p=0.688). A detailed list of the post- (MP) of the time (p=0.48). surgical patient evaluation is given in Tables VII and VIII. The overall satisfaction with the remaining superficial The second part of the patient survey allowed patients to skin scar tissue showed at least a satisfactory result 85% answer each question on a sliding scale from 1 to 5, with 1 (BCS) and 79% (MP) of the time. A significant difference being “very little/the least amount possible” and 5 being “a was established between the very satisfied (77% BCS/44% lot/the largest amount possible”. Alternatively, for question MP) and satisfied (8% BCS/35% MP) groups (p=0.013). 9, 1 stood for “No” and 5 for “Yes”. Questions regarding the current breast shape were answered Sensitivity in the nipple/areola complex, as judged on a similarly, with 85% (BCS) and 80% (MP) of all patients scale from 1-10 by the patients, did generally not increase, being satisfied with their post-surgical breast shape. A although the distribution differed significantly. While 82% of slight trend towards patients being very satisfied may be the BCS group reported no increase in nipple/areola observed in the BCS group, but no significance was sensitivity, only 70% of the MP group agreed (p=0.045). established (p=0.206). Overall, post-surgical breast Similarly, 76% of the BCS patients complained of decreased appearance was generally evaluated positively, with 87% sensitivity, where as only 60% of the MP group did (p=0.467). (BCS) and 82% (MP) being satisfied with the surgical Regarding the post-surgical swelling, both groups agreed results (p=0.901). (75% BCS and 77% MP) that there was no significant

734 Eichler et al: Lympectomy versus Mastopexy - A Post-surgery Survey swelling during their post-surgical period (p=0.215). Interestingly, when asked to evaluate sensitivity in the Additionally, a general consensus regarding the appearance nipple/areola complex most patients suggested that sensitivity in public during the post-surgical period was established. had decreased. Given the traumatic nature of these surgical Opinions did not differ significantly and both groups approaches this may not be surprising and has previously suggested that they had no problem with appearing in public been shown in literature (18). A significant difference was (93% BCS and 94% MP) (p=0.764). Similarly, overall post- established however, when patients were asked whether or not surgical self confidence loss seemed to be minimal, since sensitivity had increased: 76% of the BCS patients answered 93% (BCS) and 94% (MP) evaluated self confidence loss as with “no increase” in sensitivity, whereas only 50% of MP very small (p=0.545). patients reported increased nipple sensitivity. A definite reason for this fact could not be established. Discussion Self-worth and post-surgical swelling did not differ significantly between procedures and were answered This retrospective analysis evaluated a patient pool of 143 positively, i.e. very little swelling, and both groups suggested patients, 71 of which answered a questionnaire regarding that more than 90% did not experience any self worth post-surgical body image and patient satisfaction. Although deficiency during the post surgical period. not exactly equal, tumor characteristics were similar in both Some shortcomings should also be addressed: Several groups regarding tumor stage, histology, grading, different types of formal evaluation system have been chemotherapy regiments. Resection rates, although not established over the years (for example: Breast Q, EQ 5D optimal, did not significantly differ. A plethora of studies etc.). It might be useful to re-investigate some aspects using have been performed to evaluate self worth, and subjective formal and better-established questionnaires (19). The core evaluation of post-surgical outcome in patients with breast questions, however, will remain the same. In addition, cancer that underwent post-tumor removal reconstruction. radiation therapy, sometimes having a severe effect on Literature also states that most patients that undergo surgical outcome and patient satisfaction, was not taken into lumpectomy do not actually require reconstruction unless account in this analysis. severe damage has been done to the breast during surgery. Thus, with MP being somewhat of a half-way point between Conclusion actual reconstruction and simple lump removal, this procedure should be analyzed as well with respect to its This retrospective study quantitatively evaluated the post- subjective post-surgical outcome. surgical patient satisfaction after BCS and MP. In general, This study showed that both patients who underwent both surgical procedures achieved a satisfactory or better lumpectomy or mastopexy are generally satisfied with the outcome over 80% of the time. MP patients were less surgical outcome. Evaluation of overall cosmetic outcome, satisfied with the amount of scarring, although this did not superficial scar tissue formation, shape, appearance and size significantly influence the other evaluated parameters. of the breast and overall quality of life were Nipple/areola complex sensitivity loss was acknowledged for overwhelmingly answered positively. In general, one may both surgical procedures, more so for the BCS group. Over suggest that every investigated aspect had a satisfactory or 90% of all patients did not report loss in self confidence. better result, in 80-90% of the time. Neither method was Both surgical options may be considered, although BCS established as being significantly superior to the other from seems to be advantageous due to shorter surgeries and less the patient point of view. Since MP displays aspects of early scar tissue formation. , and BCS has been thoroughly investigated in literature, these findings agree with data References reported in literature (9). 1 Urban C, Lima R, Schunemann E, Spautz C, Rabinovich I and Naturally, a simple BCS procedure leads to less scar tissue Anselmi K: Oncoplastic principles in breast conserving surgery. and involves a shorter surgical procedure, both of which may Breast 20(3): 92-95, 2011. be considered as arguments for performing a BCS. MP 2 Harcourt DM, Rumsey NJ, Ambler NR, Cawthorn SJ, Reid CD, yields more scar tissue since more incisions are needed, Maddox PR, Kenealy, JM, Rainsbury RM and Umpleby HC: The although this aspect had little impact on the other parameters psychological effect of mastectomy with or without breast in this section. Scar tissue formation was evaluated more reconstruction: a prospective, multicenter study. Plast Reconstr positively in the BCS group, where 77% of patients were Surg 111(3): 1060-1068, 2003. 3 Hopwood P and Maguire GP: Body image problems in cancer “very satisfied” and 8% answered with “satisfied”. This was patients. Br J Psychiatry 2: 47-50, 1988. significantly different from the MP group, where these 4 Joslyn SA: Patterns of care for immediate and early delayed questions were answered at 44% and 35% respectively breast reconstruction following mastectomy. Plast Reconstr Surg (p=0.013). 115(5): 1289-1296, 2005.

735 ANTICANCER RESEARCH 33: 731-736 (2013)

5 Roth RS, Lowery JC, Davis J and Wilkins EG: Quality of life 14 Ellis MJ, Coop A, Singh B, Mauriac L, Llombert-Cussac A, and affective distress in women seeking immediate versus Janicke F, Miller WR, Evans DB, Dugan M, Brady C, Quebe- delayed breast reconstruction after mastectomy for breast cancer. Fehling E and Borgs M: Letrozole is more effective neoadjuvant Plast Reconstr Surg 116(4): 993-1002, 2005. endocrine therapy than tamoxifen for ErbB-1- and/or ErbB-2- 6 Collins KK, Liu Y, Schootman M, Aft R, Yan Y, Dean G, Eilers positive, estrogen receptor-positive primary breast cancer: M and Jeffe DB: Effects of breast cancer surgery and surgical evidence from a phase III randomized trial. J Clin Oncol 19(18): side effects on body image over time. Breast Cancer Res Treat 3808-3816, 2001. 126(1): 167-176, 2010. 15 Ellis MJ and Ma C: Letrozole in the neoadjuvant setting: the 7 Chen CM, Cano SJ, Klassen AF, King T, McCarthy C, Cordeiro P024 trial. Breast Cancer Res Treat 105(Suppl 1): 33-43, 2007. PG Morrow M and Pusic AL: Measuring quality of life in 16 Marcom PK, Isaacs C, Harris L, Wong ZW, Kommarreddy A, oncologic : a systematic review of patient-reported Novielli N, Mann G, Tao Y and Ellis MJ: The combination of outcome measures. Breast J 16(6): 587-597, 2010. letrozole and trastuzumab as first or second-line biological 8 Metcalfe KA, Semple J, Quan ML, Vadaparampil ST, Holloway therapy produces durable responses in a subset of HER2 positive C, Brown M Bower, B, Sun P and Narod SA: Changes in and ER positive advanced breast cancers. Breast Cancer Res psychosocial functioning 1 year after mastectomy alone, delayed Treat 102(1): 43-49, 2007. breast reconstruction, or immediate breast reconstruction. Ann 17 Waljee JF, Hu ES, Newman LA and Alderman AK: Predictors Surg Oncol 19(1): 233-241, 2011. of re-excision among women undergoing breast-conserving 9 Han J, Grothuesmann D, Neises M, Hille U and Hillemanns P: surgery for cancer. Ann Surg Oncol 15(5): 1297-1303, 2008. Quality of life and satisfaction after breast cancer operation. 18 Araco A, Araco F, Sorge R and Gravante G: Sensitivity of the Arch Gynecol Obstet 282(1): 75-82, 2009. nipple-areola complex and areolar pain following aesthetic breast 10 Swanson E: A retrospective photometric study of 82 published augmentation in a retrospective series of 1200 patients: reports of mastopexy and . Plast Reconstr Surg periareolar versus submammary incision. Plast Reconstr Surg 128(6): 1282-1301, 2011. 128(4): 984-989, 2011. 11 Rivolin A, Kubatzki F, Marocco F, Martincich L, Renditore S, 19 Falk Dahl CA, Reinertsen KV, Nesvold IL, Fossa SD and Dahl Maggiorotto F, Magistris A and Ponzone R: Nipple-areola AA: A study of body image in long-term breast cancer survivors. complex sparing mastectomy with periareolar pexy for breast Cancer 116(15): 3549-3557, 2010. cancer patients with moderately ptotic . J Plast Reconstr Aesthet Surg 65(3): 296-303, 2012. 12 Bong J, Parker J, Clapper R and Dooley W: Clinical series of oncoplastic mastopexy to optimize cosmesis of large-volume resections for breast conservation. Ann Surg Oncol 17(12): 3247-3251, 2010. 13 Reefy S, Patani N, Anderson A, Burgoyne G, Osman H and Mokbel K: Oncological outcome and patient satisfaction with Received November 27, 2012 skin-sparing mastectomy and immediate breast reconstruction: a Revised January 2, 2013 prospective observational study. BMC Cancer 10: 171, 2010. Accepted January 4, 2013

736