BACKGROUND: Bilateral prophylactic mastectomy can significantly reduce the risk of breast cancer in women at increased risk, but little is known about the psychological impact of this surgery. The authors of this study designed a prospective analysis of the psychosocial implications of prophylactic surgery for breast cancer.
POPULATION STUDIED: Women at increased risk for developing breast cancer who had been offered bilateral prophylactic mastectomy were referred to the researchers from 20 centers throughout the United Kingdom. A total of 168 women were referred after meeting the eligibility criteria consisting of family history of breast cancer or high risk of developing breast cancer. The researchers did not know the risk level used by the referring clinicians to select patients. More than 73% of both groups were employed, and more than 75% had children. Ethnicity and education level were not reported.
STUDY DESIGN AND VALIDITY: The authors conducted a prospective nonrandomized controlled trial using 6 validated questionnaires to assess the psychological morbidity, anxiety state, sexual activity, coping strategies, risk perception, and body image of the study participants. Women accepting surgery were interviewed at the time of referral and at 6 and 18 months postoperatively. Those declining surgery were interviewed at referral and 18 months later. Of the 168 women, 11 were lost to contact before completing the assessment. Of the 154 remaining participants, 79 (51%) chose surgery; 64 (42%) declined; and 11 (7%) chose to defer their decision making and were not included in the analysis.
OUTCOMES MEASURED: This study involved a comparison of the psychological and sexual morbidity in women having prophylactic mastectomy with those who were offered the surgery but declined.
RESULTS: Psychological morbidity decreased significantly (P <.001) over time in the group accepting surgery, as measured by the “General health questionnaire 30,” a tool used to determine psychiatric morbidity in outpatients. Those who declined showed no change in psychiatric morbidity over the 18 months. Anxiety scores declined significantly over this time period for those who accepted (P=.001) but remained unchanged for those who declined. A significantly higher proportion of those who declined had high baseline anxiety (P=.006), and their anxiety levels remained high at the 18-month follow-up. Those who accepted tended to use a problem-focused approach to coping, while those who declined tended to use a detached style of coping. Sexual activity and sexual discomfort did not change significantly over time in either group, and it did not differ between the groups. Body image was not different in either group (most women who had surgery had immediate breast reconstruction). A risk perception questionnaire revealed that those who accepted had a significantly higher (32% vs 10%, P=.001) belief that it was inevitable that they would develop breast cancer. More than half of those who accepted felt they had at least a 50-50 chance of developing cancer (their actual likelihood was much lower).
Psychological morbidity and anxiety are significantly reduced in women at high risk for developing breast cancer who undergo bilateral prophylactic mastectomy. The women having surgery had less anxiety without an impact on their body image or sexual functioning. Women at high risk for developing breast cancer who are contemplating this radical surgical intervention should be made aware of the results of this study to assist them in their decision-making process.