Psychological, sociodemographic, and clinicopathological predictors of breast cancer patients' decision to undergo breast reconstruction after mastectomy.
Breast cancer patients experience psychological morbidities, primarily mood disorders, after receiving and when living with the diagnosis. The untreated anxiety and depression are important factors that render the QOL of these patients low, not merely the physical aspect of the patients' presentation. (17,18) These morbidities in women with breast cancer are often overlooked and left untreated because they can have unclear presentations. (17)
According to the findings of a Polish study, deciding to undergo BR after breast removal is correlated with personality traits among women. Specifically, introverts rarely opted to undergo BR. (19) Another important personality type is the narcissistic personality. Specifically, narcissists tend to demand perfectionism as it is a sentinel feature of their personality type; hence, they seek to have an extremely attractive body. (20-22)
Despite recommendations to undergo BR, the rates at which the procedure is performed are low, ranging from 11% to less than 40% (in some tertiary care centers in the US). (23,24) The decision to undergo BR is complicated by a variety of procedures. (12) Women are asked to choose from an array of procedures, and the problem has become more strenuous with the development of the perforator flap technique, which minimizes the risk of hernia albeit requires longer operation time. (12) Additionally, the burden that the surgical procedure places on the patient and her relatives makes the decision-making process even more difficult. (25) Two studies that were conducted in Europe found that the patient's age influences her decision to undergo BR and the possession of information about the procedure. (26,27)
Only a small proportion of treated breast cancer patients decide to undergo BR. (15,28) Therefore, it is important to examine which mood states and social aspects influence this decision-making process. In this study, we aimed to examine the influence of socioeconomic factors, anxiety, depression, and personality traits on the decision to undergo BR after a mastectomy in one center in Jeddah, Saudi Arabia.
Methods. This cross-sectional study was conducted between March and July 2019, using an interview-based questionnaire. This interview was conducted among female patients who were diagnosed with breast cancer at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia.
Women aged 18 years and older who had undergone mastectomy for breast cancer between January 2017 and 2019 were included. The exclusion criteria were as follows: a) undergone bilateral mastectomy, contralateral mastectomy for prophylactic purposes, or a reoperation and b) breast cancer recurrence. All contributors were knowledgeable before participation, and those who agreed to contribute were registered. Approximately 400 randomly chosen patients were identified from the hospital records, and 241 of them who met the study's inclusion criteria were contacted; only 196 patients agreed to participate (Figure 1). Patients were divided into 2 subgroups: Group A, which consisted of women who had opted for BR and Group B, which consisted of women who chose to not undergo BR.
Study variables. We reviewed the literature and developed a valid questionnaire based on the findings of several published studies. (19,29-32) The questionnaire consisted of 46 questions that were divided into 5 sections: demographic data, personality traits, (19) the Narcissism Index (NI), (29,30) and the Hospital Anxiety and Depression Scale (HADS). (31,32) The NI is a reliable tool for predicting the degree of narcissism. (29,30) The reliability and validity of HADS on similar populations (breast cancer patients) has been studied, and it has been shown to have a good predictive value. Furthermore, the Arabic translation used in this study has been shown to be both valid and reliable. (31-33) The study was conducted after ethical approval was granted by the Research Ethics Committee at the King Abdulaziz University Hospital. Patients participated in this study on an entirely voluntary basis.
Statistical analysis. Data were checked for completeness, and errors were corrected. The normality of the distributions of continuous variables were checked by conducting the Shapiro-Wilk and Kolmogorov Smirnov tests. Their results indicated that all variables were none normally distributed. The sociodemographic variables and clinicopathological features (namely, tumor size, lymph node involvement, and metastasisTNM) of the 2 participant groups were compared using the Chi-squared test. Respondents' scores on the NI and HADS were calculated by counting the responses. The mean scores of the 2 participant groups were compared using the Mann-Whitney U test. The relationship between TNM and anxiety and depression scores were examined using the Kruskal-Wallis test. The extroversion/introversion personality continuum of the 2 participant groups were compared using Chi-squared and fisher exact tests. Binary logistic regression analysis was conducted to identify the predictors of the decision to undergo BR. The results have been presented using tables and figures.
All analyses were conducted using the Statistical Package for Social Sciences version 23.0 (IBM, Armonk, NY, USA), and 95% confidence intervals were computed to interpret the results.
Results. A total of 196 patients were interviewed, and 118 (60.2%) of them had opted for BR; the remaining 78 (39.8%) patients had not opted for BR. The mean age of the participants was 48.44 ([+ or -] 9.87) years. Further, 86 (43.9%) patients were Saudi, the monthly income of 118 (60.2%) patients was <5000 Saudi Riyals (SR). One hundred and thirty (66.3%) patients were unemployed/housewives, 72 (36.7%) patients had chronic illnesses, and 76 (38.8%) patients had a family history of breast cancer (BC). Out of the 76 participants with a family history of BC, 71.1% had a relative who had BC and had undergone BR. The sociodemographic characteristics for each participant group are presented in Table 1.
The group of women who had opted for BR tended to have younger women (mean difference between the 2 groups was 7.53 years, p<0.001), fewer nonsmokers (p=0.015), and more women without chronic illnesses (p<0.001). Unemployed participants were less likely to have opted for BR (p=0.041). With regard to the TNM classification, a lymph node involvement was less prominent among those who had opted for BR (p=0.13) (Table 1).
Personality traits and mood status. The mean depression score for all participants was 5.78 ([+ or -] 4.65), anxiety score 7.72 ([+ or -] 4.88), and NI 4.17 ([+ or -] 2.81). Table 2 shows that anxiety (9.67 [+ or -] 5.07 versus 6.44 [+ or -] 4.31, p<0.001) and depression scores (7.74 [+ or -] 4.90 versus 4.49 [+ or -] 3.97, p<0.001) were significantly higher among participant who had opted to not undergo BR. However, scores on the NI were higher among those who had opted for BR (p=0.030) (Table 2).
The responses that the 2 participant groups provided to the extroversion/introversion personality questions (total: 5 questions) are summarized in Table 3. Group comparisons revealed that there was a statistically significant difference in the responses that were provided to questions 4 (p=0.0002) and 5 (p<0.001) (Table 3).
Disease stage and mood status. There was no statistically significant relationship between TNM classification and anxiety and depression scores (p>0.050).
Binary logistic regression. Binary logistic regression analysis was used to identify the predictors of the decision to undergo BR. Anxiety and depression scores, sociodemographic variables, TNM classification, and adjuvant treatment were included in the regression analysis. The results revealed that depression scores, age, and lymph node involvement were statistically significant predictors of BR decision. Other included variables were not statistically significant (p>0.050) (Table 4).
Discussion. Among breast cancer patients, undergoing mastectomy frequently has a negative impact on the QOL and psychological well-being. Undoubtedly, this body part entails important psychological implications. Consequently, patients who have undergone a mastectomy perceive a decline their sense of femininity and confidence levels. A mastectomy without BR can alter the mood and behaviors of patients in their workspaces. (34) Further, it can strongly impact their roles as a family member. Therefore, BR after breast removal can tremendously improve QOL and perceived body image. Accordingly, we aimed to examine the relationship that the decision to undergo BR shares with different personality traits, depression, anxiety and sociodemographic variables among breast cancer patients.
The existing literature suggests that age is a very important determinant on BR. (24,26,27) A similar result emerged in this study. This finding is attributable to surgeons' fear of postoperative complications, especially in a patient with other chronic illnesses. (27) There was a significant difference in BR status between Saudis and non-Saudis. This finding may be attributable to group differences in access to healthcare or the relatively higher mean depression (6.47 [+ or -] 4.96 versus 4.91 [+ or -] 4.04, p=0.035) and anxiety scores (8.93 [+ or -] 5.18 versus 6.19 [+ or -] 4.00, p<0.001) that non-Saudi participants obtained (the regression analysis presented in Table 4 yielded no significant predictor).
Another interesting finding was that the patients who were willing to undergo BR were healthier and did not have any chronic illnesses or comorbidities, when compared to the other group. Being healthy is closely related to happiness, and deciding to undergo such a procedure can tremendously improves a patient's QOL. (4-7,35) This is similar to the findings of 2 studies that were conducted in the US (36) and Australia, (37) whereby patients with fewer comorbidities were found to be more likely to undergo BR.
Past findings suggest that patients with early-stage BC are more likely to undergo BR. Similarly, in the present study, the percentage of node negative patients was higher in the BR group. It is noteworthy that many of these early stage BC patients do not require postmastectomy chemotherapy and radiotherapy. (24)
It is noteworthy that, in the present study, patients with a family member who had undergone BR were more likely to have opted for BR than their counterparts. This may be the case because BC survivors prefer to receive information about BR from their friends and peers. Further, they feel less isolated after they receive such information from patients who have undergone BR. (38)
In this study, the HADS was used to assess the affective states of the participants. The Center for Epidemiological Studies Depression (CES-D) Scale was not used owing to 2 primary reasons: a) it does not screen for anxiety and b) its performance and reliability has been examined primarily mostly on young population. (39,40) In comparison, the HADS is a simpler assessment, and its reliability has been examined across different contexts (including among BC patients and cancer patients in general) and age groups. (31-33) Our results suggest that women with depression and anxiety are not prepared to undergo another nonvital procedure as most of the focus is on monitoring BC recurrence with anxiety and depression being vaguely present. (17) Satisfactory doctor-patient communication regarding patient concerns and the provision of crucial information to the patient are important factors that can improve the detection of psychological problems and mitigate depressive symptoms and anxiety among BC patients. (18)
The responses that the 2 groups provided to the 5 personality questions, which were adapted from the assessment that was used in a Polish study, were compared using Chi-squared and fisher exact tests (Table 3). Interestingly, 2 questions for which significant group differences had emerged in the original study had also evidenced significant group differences in the current study. (19) In both the studies, patients who had opted for BR were more likely to be extroverted, as extrovert individuals are mainly outgoing and like to be with others. In the present study, the NI scores were higher among those who had opted for BR.
Study limitations. Although our sample size was moderate, and the study's objectives were addressed, the study has a few limitations. First, our article was cross-sectional in nature and covered a short time period. Therefore, the participants may not have been representative of the entire population of Saudi Arabia. Second, this study was conducted in a single center, thereby limiting the generalizability of the results. Third, the reliability of the 5 personality questions has not been studied. In the future, studies must include a larger number of hospitals that represent different regions within the country. This study offers insights into the prevalence of depression and anxiety among breast cancer patients after mastectomy. It also uncovers the variability in personality traits within this population. More importantly, it indicates that depression single handedly plays a significant role in the decision to not undergo BR, after potential confounds are controlled for. It is important to screen and detect undiagnosed depression and anxiety among patients who have undergone a mastectomy. This is necessary to effectively treat these conditions through prompt referral to a psychiatrist, improve their QOL, restore at least a moderate level of functioning, and provide assistance during this difficult postmastectomy decision-making period. Patients of all ages should receive counseling about BR after a mastectomy.
In conclusion, undergoing BR is a difficult, yet important decision for a woman who survived BC to make. Age and depression significantly influenced this decision among our study participants. Women who opted to undergo BR tend to be younger, report lower levels of depression, and were characterized by less nodal involvement. Certain personality traits can also influence the decision to undergo BR. Diagnosing and treating depressed patients is an important aspect of caring for BC patients. A patient's age should not deter physicians from counseling patients about BR.
Acknowledgment. The authors would like to thank Randa Abushanab and Renad Alnemari for their help in data collection. Also, we would like to acknowledge www.Editage.com for English language editing.
Disclosure. Authors have no conflict of interests, and the work was not supported or funded by any drug company.
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[Please note: Some non-Latin characters were omitted from this article.]
Azmi Marouf, Medical Student, Hatan Mortada, MBBS, Mahmoud G. Fakiha, MD, DESC.
From the Faculty of Medicine (Marouf), King Abdulaziz University; from the Department of Plastic Surgery & Burn Unit (Mortada), King Saud Medical City; and from the Division of Plastic & Reconstructive Surgery (Fakiha), Department of Surgery, University of Jeddah, Jeddah, Kingdom of Saudi Arabia.
Received 1st November 2019. Accepted 16th January 2020.
Address correspondence and reprint request to: Dr. Hatan Mortada, Department of Plastic Surgery & Burn Unit, King Saud Medical City Riyadh, Kingdom of Saudi Arabia. E-mail: firstname.lastname@example.org ORCID ID: https://orcid.org/0000-0003-1283-4136
Caption: Figure 1--Flowchart depicting the inclusion and exclusion of the study participants.
Table 1--Sociodemographic characteristics and clinicopathological features of the respondents split by participant group. Breast reconstruction Characteristics Attributes (n=118) Age (years) Mean [+ or -] SD 45.44 [+ or -] 8.66 Median 45.0 Nationality Saudi 62 (52.5) Non-Saudi 56 (47.5) Marital status Single 9 (7.6) Married 93 (78.8) Divorced 8 (6.8) Widowed 8 (6.8) Educational Below high school 29 (24.6) level High school 37 (31.4) Bachelor's degree 41 (34.7) Master 6 (5.1) PHD 5 (4.2) Monthly income <5000 68 (57.6) (Saudi Riyals) 5000-10,000 18 (15.3) 10,000-20,000 24 (20.3) >20,000 8 (6.8) Occupation Works in Jeddah 26 (22.0) Works outside 14 (11.9) Jeddah Unemployed 78 (66.1) Smoking No 104 (88.1) Yes 14 (11.9) Chronic illness No 88 (74.6) Yes 30 (25.4) Family history No 70 (59.3) of breast Yes 48 (40.7) cancer Family member No 4 (8.3) underwent BR Yes 36 (75) postmastectomy Don't know 8 (16.7) Tumor size Ductal carcinoma 27 (22.9) in situ Breast cancer 33 (28.0) T1a-c ([less than or equal to] 2cm) Breast cancer T2 34 (28.8) Breast cancer T3 10 (8.5) Breast cancer T4 14 (11.9) Lymph node N0 56 (47.5) involved N1 25 (21.1) N2 20 (16.8) N3 17 (14.4) Distant No 110 (93.2) metastasis Yes 8 (6.8) Adjuvant None 29 (24.6) therapy Chemotherapy 54 (45.8) Chemo + endocrine 6 (5.1) therapy Chemo + radio 16 (13.6) therapy Chemo + radio + 13 (11.0) endocrine No breast reconstruction Characteristics Attributes (n=78) Age (years) Mean [+ or -] SD 52.97 [+ or -] 9.90 Median 53.0 Nationality Saudi 24 (30.8) Non-Saudi 54 (69.2) Marital status Single 9 (11.5) Married 57 (73.1) Divorced 6 (7.7) Widowed 6 (7.7) Educational Below high school 19 (24.4) level High school 29 (37.2) Bachelor's degree 25 (32.1) Master 4 (5.1) PHD 1 (1.3) Monthly income <5000 50 (64.1) (Saudi Riyals) 5000-10,000 14 (17.9) 10,000-20,000 10 (12.8) >20,000 4 (5.1) Occupation Works in Jeddah 24 (30.8) Works outside 2 (2.6) Jeddah Unemployed 52 (66.7) Smoking No 76 (97.4) Yes 2 (2.6) Chronic illness No 36 (46.2) Yes 42 (53.8) Family history No 50 (64.1) of breast Yes 28 (35.9) cancer Family member No 8 (28.6) underwent BR Yes 18 (64.3) postmastectomy Don't know 2 (7.1) Tumor size Ductal carcinoma 10 (12.8) in situ Breast cancer 31 (39.7) T1a-c ([less than or equal to] 2cm) Breast cancer T2 23 (29.5) Breast cancer T3 8 (10.3) Breast cancer T4 6 (7.7) Lymph node N0 35 (44.9) involved N1 30 (38.5) N2 10 (12.8) N3 3 (3.8) Distant No 70 (89.7) metastasis Yes 8 (10.3) Adjuvant None 7 (9.0) therapy Chemotherapy 47 (60.3) Chemo + endocrine 8 (10.3) therapy Chemo + radio 8 (10.3) therapy Chemo + radio + 8 (10.3) endocrine Odds ratio Characteristics Attributes (95% CI) P-value Age (years) Mean [+ or -] SD <0.001 Median Nationality Saudi 2.491 0.003 Non-Saudi (1.365-4.546) Marital status Single 0.779 Married Divorced Widowed Educational Below high school 0.721 level High school Bachelor's degree Master PHD Monthly income <5000 0.506 (Saudi Riyals) 5000-10,000 10,000-20,000 >20,000 Occupation Works in Jeddah 0.041 Works outside Jeddah Unemployed Smoking No 0.195 0.015 Yes (0.043-0.886) Chronic illness No 3.422 <0.001 Yes (1.863-6.287) Family history No 0.817 0.501 of breast Yes (0.452-1.474) cancer Family member No 0.046 underwent BR Yes postmastectomy Don't know Tumor size Ductal carcinoma 0.241 in situ Breast cancer T1a-c ([less than or equal to] 2cm) Breast cancer T2 Breast cancer T3 Breast cancer T4 Lymph node N0 0.013 involved N1 N2 N3 Distant No 0.636 0.430 metastasis Yes (0.228-1.773) Adjuvant None 0.291 therapy Chemotherapy Chemo + endocrine therapy Chemo + radio therapy Chemo + radio + endocrine * odds ratio were presented for dichotomous sociodemographic variables. BR: breast reconstruction. 95% CI: 95% conference interval Table 2--Distribution of respondents' mean NI score, anxiety score and depression score split by participant group. Breast No breast Scores reconstruction reconstruction P-value (n=118) (n=78) Narcissism Index 4.53 [+ or -] 2.84 3.64 [+ or -] 2.70 0.030 Score Anxiety score 6.44 [+ or -] 4.31 9.67 [+ or -] 5.07 <0.001 Depression score 4.49 [+ or -] 3.97 7.74 [+ or -] 4.90 <0.001 Values are presented as mean [+ or -] SD. * Mann-Whitney U test was carried out Table 3--Extroversion/introversion personality continuum in the 2 study groups. Breast No breast Personality questions/ reconstruction reconstruction P-value answers (n=118) (n=78) 1) Do you seek success 0.254 in life? ([double Definitely yes 100 (84.7) 68 (87.2) dagger]) Rather yes 12 (10.2) 4 (5.1) Hard to say 4 (3.4) 6 (7.7) Rather no 2 (1.7) 0 (0.0) Definitely no 0 (0.0) 0 (0.0) 2) Do you have the ability 0.216 to motivate other people? ([double Definitely yes 80 (67.8) 50 (64.1) dagger]) Rather yes 26 (22.0) 20 (25.6) Hard to say 8 (6.8) 6 (7.7) Rather no 4 (3.4) 0 (0.0) Definitely no 0 (0.0) 2 (2.6) 3) Are you open to other 0.119 people? ([double Definitely yes 74 (62.7) 50 (64.1) dagger]) Rather yes 30 (25.4) 12 (15.4) Hard to say 10 (8.5) 8 (10.3) Rather no 4 (3.4) 8 (10.3) Definitely no 0 (0.0) 0 (0.0) 4) Does belonging to a 0.002 * social group have an impact of your feeling of safety? Definitely yes 52 (44.1) 40 (51.3) Rather yes 22 (18.6) 16 (20.5) Hard to say 4 (3.4) 14 (17.9) Rather no 20 (16.9) 6 (7.7) Definitely no 20 (16.9) 2 (2.6) 5) Is the opinion of other <0.001 * people about you important for you? Definitely yes 38 (32.2) 36 (46.2) Rather yes 30 (25.4) 20 (25.6) Hard to say 8 (6.8) 8 (10.3) Rather no 12 (10.2) 12 (15.4) Definitely no 30 (25.4) 2 (2.6) ([double dagger]) Fisher-Freemen-Halton test. * Chi-square test Table 4--Logistic regression of the predictors of the decision to undergo breast reconstruction postmastectomy. Variables Odds ratio 95% CI P-value Anxiety score 0.897 0.786-1.024 0.108 Depression score 0.794 0.695-0.907 0.001 Age (years) 0.870 0.813-0.930 0.001 Nationality Saudi Ref. Non-Saudi 2.082 0.722-6.005 0.175 Occupation Unemployed Ref. Works outside Jeddah 0.006 0.000032-1.138 0.056 Works in Jeddah 0.101 0.000435-23.453 0.410 Monthly income (SR) <5000 Ref. 5000-10000 0.514 0.057-4.607 0.552 10000-20000 0.355 0.033-3.816 0.392 >20000 1.030 0.104-10.243 0.980 Educational level PHD Ref. Master 0.643 0.076-5.491 0.687 Bachelor degree 0.880 0.104-7.450 0.907 High school 1.567 0.044-55.619 0.805 Below high school 0.520 0.058-4.676 0.560 Marital status Married Ref. Single 0.731 0.068-7.903 0.797 Divorced 0.918 0.166-5.084 0.922 Widowed 0.349 0.041-2.929 0.332 Smoking No Ref. Yes 7.045 0.085-582.244 0.386 Chronic illness No Ref. Yes 0.983 0.342-2.826 0.975 Tumor size Ductal carcinoma in situ Ref. Breast cancer Tla-c 1.776 0.298-10.595 0.528 Breast cancer T2 0.632 0.121-3.304 0.587 Breast cancer T3 2.461 0.421-14.399 0.318 Breast cancer T4 1.309 0.156-10.955 0.804 Lymph node involved N0 Ref. N1 0.217 0.021-2.255 0.201 N2 0.041 0.003-0.540 0.015 N3 0.090 0.007-1.156 0.064 Distal metastasis No Ref. Yes 0.756 0.165-3.464 0.719 Adjuvant treatment None Ref. Chemotherapy 2.475 0.221-27.750 0.462 Chemo+endocrine therapy 0.657 0.086-5.008 0.685 Chemo+radiotherapy 2.711 0.149-49.222 0.500 Chemo+radio+endocrine 1.424 0.129-15.732 0.773 Family history of BR Yes Ref. 0.063 No 0.194 0.034-1.095 Ref.: reference, SR: Saudi Riyals, BR: breast reconstruction
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|Title Annotation:||Original Article|
|Author:||Marouf, Azmi; Mortada, Hatan; Fakiha, Mahmoud G.|
|Publication:||Saudi Medical Journal|
|Date:||Mar 1, 2020|
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