Undergarment Needs After Breast Cancer Surgery: A Key Survivorship Consideration

Abstract

An important aspect of breast cancer survivorship is finding comfortable undergarments that work for women’s post-treatment bodies. Patients who undergo mastectomy, including both those who do and do not receive reconstruction, need bras that can accommodate new breast shape, size, and feel, as well as scarring and skin sensitivity. Our research with breast cancer patients and the literature reveal that ready-to-wear bras are inadequate for the variety of patients’ needs, and many women lack support and guidance to make decisions about undergarments after cancer. This commentary describes a major quality-of-life challenge for breast cancer survivors and makes recommendations for future research. Healthcare providers need more guidance and resources to be able to help their patients prepare for this aspect of survivorship. New technologies, such as biomechanical modeling, 3D body scanning, and manufacturing techniques, should be pursued in collaboration with patients, healthcare providers, and clothing designers to ease this burden for breast cancer patients.

A lasting challenge in breast cancer survivorship is finding a comfortable, supportive bra. There are many physical changes to the breast and torso after breast cancer treatment, such as painful surgical scars, swelling, sensitive skin after radiation, and new breast sizes, shapes, and locations on the torso [1]. The bra is intimately associated with a woman’s body image [2], and the struggle to find a well-fitting bra can cause both physical and psychological distress, hindering a patient’s sense of normalcy and well-being after cancer.

Even without breast cancer, women face challenges in selecting a properly fitting bra due to deficiencies in bra-sizing methods [3–6]. Up to 85% of women are reportedly wearing an incorrect bra size, with poor fit increasing with breast size [6, 7]. In addition, ready-to-wear bras are not designed to accommodate breast asymmetry, even though it occurs naturally in many women [8, 9]. Poor bra fit can cause pain, fatigue, and musculoskeletal problems, especially during physical activity [10, 11]. Bust prominence, back curvature, shoulder slope, age, and body mass index have all been shown to affect bra fit [12–14].

Women who receive different breast cancer treatments have different bra needs [1]. Women who undergo mastectomy, but not reconstruction, can either “go flat” or use an external breast prosthesis, ranging from a full silicone breast form to extra padding in a bra. Patients who choose to go flat have unique needs, as mastectomy can cause concavity of the chest wall and extra skin or fat tissue may remain on the chest wall. These patients may utilize a camisole or sports bra to even out the chest, but most women’s garments are constructed with extra room to accommodate breasts and, therefore, do not work well for those who “go flat.” External breast prostheses require special bras (“mastectomy bras”) with pockets that the prostheses fit into. The prosthetic’s fit is integral to women’s satisfaction with their appearance [1, 15]. Specialty bras can be significantly more expensive than ready-to-wear bras and are ideally purchased from a professional fitter.

Some women who undergo reconstruction choose not to wear bras because they do not feel they need the support or modesty after reconstruction or because bras are too uncomfortable. Others search for soft, wireless bras like bralettes or sports bras, and some find that they need expensive, custom-made bras. Patients with unilateral reconstructions have unique challenges in supporting both a reconstructed breast and a native breast. Breast asymmetry, scar location, restricted arm movement, and skin sensitivity all impact bra style choices. In previous studies on women’s satisfaction with undergarments after reconstruction, 87% reported changing their bra style owing to reconstruction [1]. Whether women undergo reconstruction or not, their bra needs change over time after breast surgery. Immediately after surgery, patients may have increased swelling, impaired blood flow, impaired sensation, drains, and pain, such that a post-surgical garment or compression wrap is necessary.

We conducted an online exploratory survey of women’s experiences with bras after total mastectomy in order to gather information about both undergarments worn immediately after surgery and undergarments purchased later in the recovery process. The qualitative survey was distributed in 2014 through electronic advertisements to breast cancer support groups in the Austin, Texas, area. Respondents must have been at least 18 years old and had breast cancer and surgical treatment. Fourteen closed- and open-ended questions asked about the type of undergarments worn after surgery and after healing, specific problems or dissatisfaction with undergarments, whether any advice was received, and general comments. Demographic questions were excluded. Of 68 eligible respondents, 17 had received reconstruction. We conducted a thematic analysis based on clinical experience, using information from the closed- and open-ended questions. Two main themes emerged from the survey: unsatisfactory bra choices after breast cancer treatment and lack of guidance in bra selection from medically trained professionals (Table 1).

Table 1.

Comments illustrating the main themes of bra choice and guidance

Insufficient Bra Choices		Insufficient Guidance
Comfort and Fit	Variety and Accessibility	Care Team Support	Bra Fitter Support
“I’ve tried many bras since surgery & all are very uncomfortable. The bras sent home with me from the hospital were very uncomfortable around my midsection.”	“Nothing seemed to fit my needs…Nothing out there for those who choose no recon. Everything has cups.”	“Was not given any information on bra or potential bra choices post op.”	“[Bras] Did not fit well. Needed a prosthetic breast but had no idea about where to start.”
“Something that fits like a hug would be nice. Soft fabric, front closure that is easy on / off, something protective between the closure and skin so as not to irritate with zippers and Velcro rubbing, and available in sizes that accommodate women who were [formerly] not only A cups but F cups and larger.”	“I did not go to the 2 fitters that were recommended. I looked them up online and didn’t see anything I liked that I wanted to pay the huge cost for, even though it would have been covered by insurance. I found what worked for me through trial and error at a fraction of the cost. It was the same with prosthesis. I found the [transgender] sites online had better options for cheaper costs.”	“Surgeon did not properly size me for the bra.”	“No one helped me, but why wear a bra -I have nothing there.”
		“My surgeon gave me Rx prior to surgery for compression bras so I could go home in comfort. All surgeons should provide [prescription] for bra best suited for their respective patient needs.”	“I was fitted for my bra and breast forms and the fitter did an EXCELLENT JOB at helping me look and feel normal!”
“The sides were either too low allowing spillage over the top [that] was both unsightly and very uncomfortable. Or on the other hand was too high causing tremendous discomfort.”	“I would love sexy bras for bilaterally flat and gorgeous women. I would also love to see sexy, pretty bras for unilaterally flat women.”	“Just that it would be good to get advice about compression for scar / seroma reduction and also for lymphedema prevention.”	“I don’t think the assumption should be that women want to have fake breasts - especially immediately after surgery. I needed something flat with light compression and that was not easy to find and is not covered by insurance while all the fake boobs stuff is. I find that annoying.”

According to the survey respondents, ready-to-wear bras are not sufficient for this population’s needs. Fifty-two percent of the participants reported problems with the bra they purchased after surgery (e.g., itchy or uncomfortable, poor fit or support, difficult to put on or take off). Some reported that because of nerve damage after surgery they could not feel when the bra was damaging their skin. Others needed multiple bra sizes to accommodate swelling. Bras were reported to be heavy or to cause too much pressure on sensitive skin. Forty-two percent reported being dissatisfied with their bra choices. Multiple comments were related to parts of the bra rubbing on incisions or sensitive skin, not enough options for flat-chested women, and lack of sizes, attractiveness, and affordability (Table 1). The most common bras that the respondents were currently wearing were mastectomy bras, nonmedical sports bras, and nonmedical soft, leisure bras purchased from nonmedical retailers. Reconstruction participants reported more difficulties with bra design components such as closures and straps and with general comfort, than non-reconstruction participants. Our results are similar to those of LaBat et al. with regard to difficulties in finding bras that offer comfort and support after mastectomy and the use of nonmedical bras [1].

The survey respondents lacked guidance in finding a bra: 55% of respondents were not given a prescription by their surgeon, 90% were not given a fabric-type recommendation, and 57% were not given any advice about purchasing an undergarment. Women who reported being fitted by a professional fitter expressed greater satisfaction, while those who searched for a bra on their own reported needing to buy multiple types of bras from multiple retailers before finding a satisfactory bra or deciding to not wear a bra. Others desired more support for and acceptance of their decision to forego “fake” breasts (prostheses) and bras. Patients reported that a well-fitting bra or an empowered choice to not wear bras benefitted their sense of well-being after breast cancer treatment. Limitations of our survey include a small percentage of reconstruction patients and possible self-selection bias.

Bra fit can significantly impact breast cancer patients’ quality of life. From the literature and our own research and clinical experience, it is clear that current products are not meeting the needs of breast cancer patients. Clothing designers and retailers can improve available bras by incorporating changes that will address breast cancer patients’ needs, such as fabric choice and bra construction that will not irritate scars or irradiated skin. They can also utilize new technology and research such as 3D body scanning, 3D printing, and computational biomechanical modeling to develop custom undergarment designs [16–19]. LaBat et al. suggest including patients as co-designers to capture their specific needs for undergarments [1].

Further studies can address these issues and also investigate how psychological distress is connected to the physical discomfort of wearing and purchasing undergarments for post-mastectomy women. In addition, it would be valuable for patient care teams to be educated about the difficulties and importance of finding supportive, comfortable undergarments and have access to resources to better support this patient need.