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Preventive mastectomy leaves mark on sexuality: breasts 'didn't feel like my own'.

SAN ANTONIO -- Long-term satisfaction with the decision to undergo bilateral prophylactic mastectomy with immediate breast reconstruction is often diminished by unanticipated changes in body image and the sexual relationship, Paula J.C. Bresser, Ph.D., reported.

This is an aspect of preoperative patient counseling that clearly warrants far greater emphasis. As part of the decision-making process, women contemplating this radical preventive surgery need to fully understand that there is a good chance that changes in sexual functioning are in store, Dr. Bresser said at a breast cancer symposium sponsored by the Cancer Therapy and Research Center.

She reported on 114 women who completed a detailed questionnaire on the effects of bilateral prophylactic mastectomy with immediate breast reconstruction via subpectoral implants a median of 3 years after undergoing the surgery at Erasmus Medical Center, Rotterdam, the Netherlands.

All of the women were genetically predisposed to breast cancer; one-third had already been diagnosed with it. Overall, 57% also underwent bilateral prophylactic salpingo-oophorectomy, and 27% were on hormone therapy for at least part of the follow-up period.

The practice at Erasmus is to provide women at high genetic risk for breast or ovarian cancer with nondirective counseling regarding prevention options.

"A woman's decision is a personal decision," explained Dr. Bresser of the medical center.

This nondirective counseling approach requires that patients receive comprehensive information so they make an informed choice. In this regard, Dr. Bresser and her colleagues were gratified to find that 95% of survey participants said they would opt for bilateral prophylactic mastectomy if they had it to decide over again, and 79% would chose the same type of immediate breast reconstruction.

On the downside, nearly one-third of women indicated they weren't completely satisfied with the results of the surgery, that the surgery didn't meet their expectations, and that they hadn't been fully informed as to the possible adverse consequences.

Overall, 43% of women experienced perioperative complications. A total of 32% reported ongoing physical complaints a median of 3 years later, and 25% indicated they were experiencing limitations in daily life they attributed to their surgery.

Women singled out changes in their sexuality as a particular problem: 44% of survey respondents said prophylactic mastectomy had adversely affected their sexual relationship, and 50% of all women indicated the reconstituted breasts "didn't feel like my own." Also, 29% reported altered feelings of femininity.

On the other hand, 13% of women declared that the surgery had positive effects upon their sexual relationship.

In a multivariate analysis, women who reported adverse changes in their sexual relationship were significantly more likely to fall into the group who said they wouldn't opt for the surgery again.

Prophylactic salpingo-oophorectomy had no impact upon the sexual relationship. Neither did being on hormone therapy during follow-up.

A British surgeon in the audience said that he and his colleagues have also found adverse effects upon sexuality to be "a very, very important complication" of bilateral prophylactic mastectomy but have been unable to identify in advance those women or couples most likely to be affected.

Dr. Bresser said that the Dutch group has not had success in making such predictions, either. For now, the best that can be done is to use the opportunity for comprehensive counseling to make the patient aware of these possible adverse effects.


Denver Bureau
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Title Annotation:Clinical Rounds
Author:Jancin, Bruce
Publication:Internal Medicine News
Geographic Code:1USA
Date:Feb 1, 2004
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