Abstract
Background:
The effect of lumpectomy defect repair (a level 1 oncoplastic technique) on patient-reported breast satisfaction among patients undergoing lumpectomy has not yet been investigated.
Methods:
Patients undergoing lumpectomy at our institution between 2018 and 2020 with or without repair of their lumpectomy defect during index operation, comprised our study population. The BREAST-Q quality-of-life questionnaire was administered preoperatively, and at 6 months, 1 year, and 2 years postoperatively. Satisfaction and quality-of-life domains were compared between those who did and did not have closure of their lumpectomy defect, and compared to surgeon-reported outcomes.
Results:
487 patients met eligibility criteria, 206 (42%) had their partial mastectomy defect repaired by glandular displacement. Median breast volume, as calculated from the mammogram, was smaller in patients undergoing defect closure (826 cm3 vs. 895 cm3, p=0.006). There were no statistically significant differences in satisfaction with breasts (SABTR), physical well-being of the chest (PWB-CHEST), or psychosocial well-being (PsychWB) scores between the 2 cohorts at any time point. While patients undergoing defect closure had significantly higher sexual well-being (SexWB) scores compared to no closure (66 vs. 59, p=0.021), there were no predictors of improvement in SexWB scores over time on multivariable analysis. Patients’ self-reported scores positively correlated with physician-reported outcomes.
Conclusion:
Despite a larger lumpectomy-to-breast volume ratio among patients undergoing defect repair, satisfaction was equivalent among those whose defects were or were not repaired at 2 years post-surgery. Defect repair was associated with clinically relevant improvement in patient-reported sexual well-being.
Keywords: breast cancer, patient-reported outcomes, partial mastectomy, lumpectomy, breast satisfaction
INTRODUCTION
Breast-conservation surgery (BCS) with the addition of radiation has been shown to be oncologically safe and equivalent to mastectomy for the local control of early breast cancer.1-3 Prior studies have demonstrated increased patient satisfaction with BCS compared to mastectomy with immediate reconstruction.4-5 Often, patients with larger tumors or smaller breasts are not recommended for BCS given the concern for poor aesthetic outcomes.
Some of these limitations have been overcome through the introduction of oncoplastic techniques, allowing larger volumes of tissue to be removed without compromising cosmetic outcomes.6 There are a growing range of oncoplastic techniques in BCS ranging from simple tissue transfers to more complex procedures involving a mastopexy breast reduction. Limited data suggest improved patient satisfaction with oncoplastic techniques compared to mastectomy.7 More extensive or level 2 oncoplastic surgery often requires plastic surgery involvement either at initial surgery or in a staged fashion, although many breast surgeons are becoming more comfortable with this approach. This may involve a larger operation or 2 procedures, which can lead to a prolonged recovery for the patient. Conversely, local tissue displacement and closure of the lumpectomy defect, also known as level 1 oncoplastic techniques, can be performed by the breast surgeon at the time of index operation.
An increasingly widely used tool for measuring patient satisfaction with treatment among women with breast cancer are patient-reported outcome measurements (PROMs). The BREAST-Q questionnaire is a PROM that has been validated as a measure of satisfaction and quality of life after breast surgery.8-10 There are limited patient-reported outcomes data regarding breast satisfaction after lumpectomy with and without closure of the defect by the breast surgeon. The aims of this study were to determine if closure of the partial mastectomy defect (CoD) leads to improved patient satisfaction 2 years postoperatively compared to no closure of defect (NCoD), and if patient-reported levels of satisfaction align with surgeon-reported cosmetic outcomes.
METHODS
Following Memorial Sloan Kettering Cancer Center (New York, NY, USA) institutional review board approval, we queried our prospective database for female patients undergoing lumpectomy between 2018-2020 with or without closure of their lumpectomy defect. As of 2018, all operative reports included a field to specify the repair of the lumpectomy defect and its technique. All patients were requested to complete the BREAST-Q preoperatively and at 6 months, 1 year, and 2 years postoperatively. The BREAST-Q was administered via an electronic portal as well as offered in clinic using an institutionally approved electronic tablet. For inclusion in the study, patients had to have completed a BREAST-Q survey at both the preoperative time point and at 2 years postoperatively. Complete BREAST-Q data were obtained from an institutional database. Domains of the BREAST-Q examined included Satisfaction with Breasts (SABTR), Physical Well-Being of the Chest (PWB-CHEST), Psychosocial Well-Being (PsychWB), and Sexual Well-Being (SexWB). Each domain was scored on a scale of 0–100. Higher scores on a 0–100 scale indicated superior satisfaction, with differences of ≥ 4 being considered clinically meaningful.11
Exclusion criteria included plastic surgery involvement at initial operation, including implant reconstruction, reduction mammoplasty, or flap closure. Additionally, patients with plastic surgery involved in a delayed manner for staged oncoplastic breast reduction were excluded. Finally, patients who underwent mastectomy within 2 years of initial lumpectomy were also excluded.
Clinicopathologic and treatment data were collected from an institutional tumor registry and from medical records. Demographic and clinicopathologic data, including age at surgery, histology, receptor status, clinical and pathologic tumor and nodal stage, and receipt of radiotherapy were collected. Whether the defect was surgically closed and the technique used for closure were collected from surgeon operative reports. The decision to close the lumpectomy defect was at the discretion of the operating surgeon. Surgeon-reported aesthetic outcomes were collected from follow-up clinic notes. Volume of tissue removed during BCS was calculated from the summation of pathology-reported excised tissue dimension measurements. Preoperative breast volume of the affected breast was calculated quantitively from full-field digital mammograms (FFDMs) using the Volpara TruDensity® system (Volpara Health, Lynnwood, WA, USA).12
Characteristics were compared between CoD and NCoD groups using Fisher’s exact test for categorical variables and the Wilcoxon rank-sum test for continuous variables. Median (interquartile range [IQR]) scores on the BREAST-Q were reported and compared between the CoD and NCoD groups at baseline, 6 months, 1 year, and 2 years. Univariate analysis was conducted to assess the significance of association of clinicopathologic features with closure of defect. Univariate analysis to assess the factors determining the difference in BREAST-Q scores between the 2-year and preoperative time points was conducted using simple linear regression. Factors that were significant at a type I error rate of 0.05 were then included in the multivariable analysis (MVA), in which the type I error rate after multiple comparison correction for the 4 domains was set to 0.0125. All analysis was done using R v4.2 (R Foundation for Statistical Computing, Vienna, Austria).
RESULTS
Of the eligible 2991 patients undergoing lumpectomy from 2018-2020 at our institution, a total of 487 patients completed the BREAST-Q pre-operatively and at 2 years, and were included in the study. The surgical procedure was performed by one of the 15 designated breast surgeons at our institution. The partial mastectomy defect was closed in 206 (42%) (CoD) and was not in the remaining 281 (58%) (NCoD). The majority of the closures were performed through glandular rearrangement techniques including level 1 oncoplastic procedures. There were no statistically significant differences in patient age (median 59 years) or clinical or pathologic tumor characteristics between the 2 cohorts. The proportion of patients receiving neoadjuvant chemotherapy was higher in the CoD cohort (16% vs. 7.4%, p=0.009). There was no difference in the size of lumpectomy volume excised between the 2 cohorts (43 cm3 vs. 41 cm3, p=0.5). However, average preoperative breast volume was smaller in patients undergoing CoD compared to NCoD (826 cm3 vs. 895 cm3, p=0.006) (Table 1). The lumpectomy-to-breast volume ratio remained significantly larger in the CoD cohort as compared to NCoD (0.04 vs 0.03, p<0.001).
TABLE 1.
Patient, tumor, and treatment characteristics in the closure and no closure of defect cohorts
1Wilcoxon rank sum test; Pearson's chi-squared test; Fisher's exact test
Abbreviations: DCIS ductal carcinoma in situ, HER2 human epidermal growth factor receptor 2
| Characteristic | Overall, n = 487 |
Closure of defect n = 281 |
No closure of defect n = 206 |
p-value1 |
|---|---|---|---|---|
| Median age, years | 59 (51–66) | 58 (50–66) | 60 (52–66) | 0.3 |
| Histology | 0.5 | |||
| Benign | 25 (5.1%) | 18 (6.4%) | 7 (3.4%) | |
| DCIS | 84 (17%) | 47 (17%) | 37 (18%) | |
| Invasive carcinoma | 378 (77.6%) | 216 (77%) | 162 (78.6%) | |
| Estrogen receptor positive | 367 (87%) | 209 (86%) | 158 (88%) | 0.7 |
| Progesterone receptor positive | 262 (75%) | 151 (74%) | 111 (76%) | 0.7 |
| HER2 positive | 44 (11%) | 31 (14%) | 13 (7.8%) | 0.07 |
| Clinical T | 0.2 | |||
| Tis | 84 (19%) | 45 (18%) | 39 (21%) | |
| T1 | 282 (64.5%) | 157 (56%) | 125 (61%) | |
| T2 | 71 (16%) | 47 (19%) | 24 (13%) | |
| Clinical N | 0.14 | |||
| N0 | 416 (94%) | 232 (92%) | 184 (97%) | |
| N1 | 24 (5.4%) | 18 (7.2%) | 6 (3.2%) | |
| N2 | 1 (0.2%) | 1 (0.4%) | 0 (0%) | |
| Pathologic T | 0.043 | |||
| T0 | 10 (2.3%) | 10 (4.1%) | 0 (0%) | |
| Tis | 68 (16%) | 34 (14%) | 34 (18%) | |
| T1 | 290 (67%) | 160 (66%) | 130 (69%) | |
| T2 | 63 (15%) | 40 (16%) | 23 (12%) | |
| T3 | 3 (0.7%) | 1 (0.4%) | 2 (1.1%) | |
| Pathologic N | 0.5 | |||
| N0 | 335 (86%) | 194 (86%) | 141 (85%) | |
| N1 | 55 (14%) | 30 (13%) | 25 (15%) | |
| N2 | 2 (0.5%) | 2 (0.9%) | 0 (0%) | |
| Chemotherapy | ||||
| Neoadjuvant | 48 (13%) | 36 (16%) | 12 (7.4%) | 0.009 |
| Adjuvant | 158 (55%) | 97 (55%) | 61 (54%) | 0.9 |
| Radiation | 397 (82%) | 228 (82%) | 169 (82%) | > 0.9 |
| Median defect size (cm3) | 42 | 43 | 41 | 0.5 |
| Mean breast volume (cm3) | 842 | 826 | 895 | 0.006 |
There was no statistically significant difference in SABTR scores between the CoD and NCoD cohorts at any time point. In both cohorts, SABTR scores increased from preoperative to 2 years postoperative (64 to 75, CoD cohort; 64 to 74, NCoD cohort) (Fig. 1A). At 6 months postoperative, SABTR scores were higher in the CoD cohort compared to NCoD, although this difference was not statistically significant (82 vs. 75, p=0.06) (Table 2). On MVA comparing preoperative and 2-year postoperative scores, the only significant factor associated with SABTR scores was receiving radiation therapy (RT). SABTR score improvements were 13 points lower in patients receiving RT as comparted to no RT (p<0.001).
Fig. 1. Comparison of domain-specific BREAST-Q scores between patients who did and did not undergo closure of lumpectomy defect.
A) Satisfaction with breasts. B) Physical well-being of the chest. C) Psychosocial well-being. D) Sexual well-being.
TABLE 2.
SATBR, PWB-CHEST, PsychWB, and SexWB scores by closure of defect. Data presented as median (interquartile range)
1Wilcoxon rank-sum test
Abbreviations: SABTR satisfaction with breasts, PWB-CHEST physical well-being of the chest, PsychWB psychosocial well-being, SexWB sexual well-being, IQR interquartile range
| Overall | Closure of defect | No closure of defect | p-value1 | |
|---|---|---|---|---|
| SATBR | ||||
| Preoperative | 64 (53–82) | 64 (53–82) | 64 (53–82) | 0.2 |
| 6 months | 78 (61–100) | 82 (65–100) | 75 (59–100) | 0.06 |
| 1 year | 75 (63–100) | 75 (65–100) | 75 (61–100) | 0.2 |
| 2 years | 75 (59–100) | 75 (59–100) | 74 (57,100) | 0.5 |
| PWB-CHEST | ||||
| Preoperative | 92 (76–100) | 92 (76–100) | 92 (76–100) | 0.7 |
| 6 months | 82 (66–89) | 79 (66– 89) | 82 (60–89) | 0.8 |
| 1 year | 76 (66–89) | 76 (66–89) | 82 (66–89) | 0.2 |
| 2 years | 82 (71–100) | 82 (71–100) | 89 (71–100) | 0.5 |
| PsychWB | ||||
| Preoperative | 74 (64–87) | 74 (64–88) | 74 (64–87) | 0.5 |
| 6 months | 87 (66–100) | 93 (66–100) | 77 (69–93) | 0.092 |
| 1 year | 83 (66–100) | 83 (66–100) | 80 (66–100) | 0.3 |
| 2 years | 83 (66–100) | 83 (66–100) | 83 (64–100) | 0.3 |
| SexWB (IQR) | ||||
| Preoperative | 62 (48–70) | 62 (48–70) | 62 (50–70) | >0.9 |
| 6 months | 66 (49–84) | 66 (50–91) | 64 (48–74) | 0.11 |
| 1 year | 66 (50–84) | 66 (53–84) | 62 (48–84) | 0.14 |
| 2 years | 66 (48–79) | 66 (53–84) | 59 (48–74) | 0.021 |
PWB-CHEST scores did not significantly differ between the CoD and NCoD cohorts at any time point. In both cohorts, these scores declined and almost recovered to baseline at 2 years postoperative (Fig. 1B). On MVA, nodal positivity and receiving RT were significantly associated with the change in PWB-CHEST scores between the preoperative and 2-year time points. Node-positive patients’ PWB-CHEST score improvements from pre-surgery to 2 years postoperative were 9.3 (p=0.016) points lower than N0 patients’, but this was not significant after multiple comparison correction. Patients receiving RT had a PWB-CHEST score improvement that was 8.9 (p=0.001) points smaller than among those not receiving RT.
PsychWB also did not significantly differ between the CoD and NCoD cohorts at any time point, but overall, both groups saw an improvement in PsychWB at 2 years postoperatively from their preoperative score (Fig. 1C). On MVA, receiving chemotherapy was the only factor significantly associated with change in PsychWB over time. Patients receiving chemotherapy had a PsychWB score improvement from preoperative to 2 years postoperative that was 6.2 (p=0.007) points lower than among patients who did not receive chemotherapy.
There was no difference in SexWB between CoD and NCoD cohorts at the preoperative time point. This score differed between the 2 groups at all 3 follow-up time points, but was only significantly higher in the CoD cohort at 2 years postoperative (66 vs. 59, p=0.021) (Fig. 1D). On MVA, there were no factors significantly associated with the change in SexWB scores from preoperative to 2 years postoperative.
Physicians reported better cosmesis at 6 months among patients who had CoD compared to NCoD (54% vs. 29% with excellent cosmesis, p<0.001). This difference was no longer evident at the 2-year postoperative time point (48% vs. 43% with excellent cosmesis, p=0.7) (Table 3). Patients’ self-reported breast satisfaction scores positively correlated with physician-reported cosmesis, with greater rates of physician-documented “excellent” and “good” cosmesis among patients with SABTR scores > 75 compared to patients with lower SABTR scores (Fig. 2).
TABLE 3.
Physician-reported cosmesis by closure of defect.
1Fisher's exact test; Pearson's Chi-squared test
| Overall | No closure of defect | Closure of defect | p-value1 | |
|---|---|---|---|---|
| 6 months | <0.001 | |||
| Excellent | 111 (44%) | 31 (29%) | 80 (54%) | |
| Good | 128 (51%) | 69 (65%) | 59 (40%) | |
| Fair | 12 (4.7%) | 6 (5.7%) | 6 (4.1%) | |
| Poor | 2 (0.8%) | 0 (0%) | 2 (1.4%) | |
| 1 year | 0.6 | |||
| Excellent | 121 (54%) | 54 (57%) | 67 (52%) | |
| Good | 89 (40%) | 34 (36%) | 55 (42%) | |
| Fair | 15 (6.7%) | 7 (7.4%) | 8 (6.2%) | |
| Poor | 0 (0%) | 0 (0%) | 0 (0%) | |
| 2 years | 0.7 | |||
| Excellent | 111 (45%) | 47 (43%) | 64 (48%) | |
| Good | 114 (47%) | 54 (49%) | 60 (45%) | |
| Fair | 18 (7.4%) | 8 (7.3%) | 10 (7.5%) | |
| Poor | 1 (0.4%) | 1 (0.9%) | 0 (0%) | |
Fig. 2.
Physician-reported cosmesis according to patient-reported satisfaction with breasts.
DISCUSSION
In this study evaluating BREAST-Q scores in patients undergoing lumpectomy, closure of the lumpectomy defect did not alter patient-reported SABTR, PWB-CHEST, or PsychWB scores at any time point up to 2 years postoperative. The only significant improvement with defect closure was seen in patient-reported SexWB scores at 2 years postoperative, although defect closure was not significantly associated with improvement in these scores over time on MVA.
Patients who had closure of their lumpectomy defect had smaller average breast volumes than those whose defect was not closed, but equivalent lumpectomy volumes were removed. This suggests that despite a larger lumpectomy-to-breast volume ratio, closure of the defect in these patients led to equivalent breast satisfaction compared to patients who had smaller lumpectomy-to-total breast volume ratio without closure of the defect. Historically a large tumor-to-breast volume ratio was considered a contraindication to BCS or to lead to worse cosmetic outcomes. In a cohort of 151 women, those with a larger estimated percentage of breast volume excised during BCS reported lower satisfaction.13 Among patients with ≤ 10% of their breast volume removed, 83.5% were very satisfied, compared to 37% of patients who had > 10% removed. Our data suggest that in women with smaller breast volumes, some of these less optimal cosmetic results may be mitigated by closure of the lumpectomy defect.
At 2 years postoperative, SexWB scores in patients who underwent defect closure were 7 points higher than in those who did not. On MVA, there were no significant predictors of SexWB score, including defect closure. Voineskos and colleagues have reported that a difference in BREAST-Q SexWB scores of 4 is clinically relevant.11 The defect closure-associated improvement in SexWB scores we observed may reflect patients’ greater comfort with their appearance and ease in being a sexual partner, as the SexWB scale includes questions about feelings of sexual attractiveness when clothed and unclothed, sexual confidence relating to the breasts, and how comfortable a woman feels during sexual activity.14 Sexual well-being is an under-reported patient outcome in the breast cancer literature. In a recent study from Spain of 34 women undergoing mastectomy with reconstruction, patient-reported sexual well-being was highly and positively associated with both physical and psychosocial well-being as well as breast satisfaction.15 This may indicate that sexual well-being is a comprehensive measure of multiple factors that influence the patient’s satisfaction.
In both cohorts in our study, SABTR and PsychWB scores improved from the preoperative time point to 2 years postoperative. This may be secondary to the resolution of some dissatisfaction with the breast as well as stress related to the diagnosis of breast cancer requiring a surgical intervention. Furthermore, the subtle decline in PWB-CHEST scores at the 6-month and 1-year time points may be explained by post-surgical discomfort as well as discomfort related to other treatments, such as chemotherapy and radiation. In accordance with most of these treatments concluding by 2 years postoperative, both cohorts reported near-baseline scores for PWB-CHEST at that time point.
Physicians reported improved cosmesis at 6 months for patients who underwent defect closure compared to those who did not, although this difference was no longer evident at 2 years postoperative. This finding contrasts with that of a recent study from England, in which 233 patients undergoing BCS were randomized to simple oncoplastic closure of their lumpectomy defect or no closure.16 In that study, physician-reported cosmetic outcomes were better in those undergoing oncoplastic closure: 75% of patients undergoing oncoplastic closure were given a good or excellent score compared to 48% in the no-closure cohort at the 1-year assessment, and this difference persisted at the 5-year follow-up. Conversely, patient-reported body image questionnaires demonstrated no difference at the 1-year assessment between the two cohorts, but at the 5-year follow-up revealed better scores in those undergoing closure of the defect. This suggests that some aspects of patient-reported satisfaction with breasts may evolve over time and require longer follow-up.
The present study is, to our knowledge, the first to assess the effect of lumpectomy defect closure on patient-reported quality of life. Its limitations include the retrospective design and the potential for selection bias, as the decision for closure of the lumpectomy defect was at the discretion of the surgeon. Additionally, there could be variability between the 15 surgeons on closure of defect technique that may affect patient- and surgeon-reported satisfaction and cosmetic outcome. Furthermore, the study only included patients who had completed the BREAST-Q at the preoperative visit and 2-year follow-up. It is unknown if the decision not to complete the BREAST-Q correlates in either direction with overall satisfaction. As BCS with radiation has been shown to be oncologically safe and equivalent to mastectomy1-3, and to yield better patient-reported outcomes as compared to mastectomy4-5, it is essential to continue to evaluate methods to improve outcomes and reported satisfaction.
Conclusions
Our results suggest that defect closure compensates for the greater lumpectomy-to-total breast volume ratio among patients in whom this procedure was pursued in terms of patient satisfaction. Furthermore, defect closure is associated with clinically relevant improvement in SexWB scores, although it was not a predictor of improvement in these scores on MVA. Improved sexual well-being satisfaction scores may reflect the patient’s acceptance of the final cosmetic result and reflect their comfort of being a sexual partner. Our results support the continued use of level 1 oncoplastic techniques and raise questions for future research regarding the factors influencing the decision to pursue defect closure and its relationship with patient-reported outcomes, particularly sexual well-being, over the long term.
Synopsis:
Here we determined if partial mastectomy defect repair improved patient satisfaction 2 years postoperatively. Despite a larger lumpectomy-to-breast volume ratio, patients whose defects were repaired had equivalent satisfaction to those whose defects were not. Defect closure was associated with clinically relevant improvement in sexual well-being.
ACKNOWLEDGEMENTS
This study was presented in poster format at the 24th Annual Meeting of the American Society of Breast Surgeons, April 26-30, 2023, Boston, MA, and the preparation of this study was supported in part by NIH/NCI Cancer Center Support Grant P30CA008748 to Memorial Sloan Kettering Cancer Center. Sixth author Dr. Katja Pinker-Domenig has served on speaker bureaus for Bayer, Siemens Healthineers, Olea Medical, and Roche, and has provided consulting/advisory services for Genentech, Merantix Healthcare, AURA Health Technologies GmbH, and Guerbet. No other authors have relationships with outside entities to disclose. We thank Jessica Moore of Memorial Sloan Kettering Cancer Center for provision of editorial support.
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