Sm. Sci. Med. Vol. 27, No. II, pp. 12574262, 1988 Printed in Great Britain. All rights reserved

0277-9536/88 53.013 + 0.00 Copyright C 1988 Pergamon Press plc

CHOICE OF SURGERY FOR EARLY BREAST CANCER: PSYCHOSOCIAL CONSIDERATIONS

JENNY MORRIS* and RIXER INGHAM

Department of Psychology, The University, Southampton SO9 SNH, England

Abstract-A prospective study was conducted with early breast cancer patients who had either been offered, or not been offered, a choice of surgery for treatment. The choice involved mastectomy or wide excision plus radiotherapy. Available evidence suggests that the medical outcome between these two options is similar; this study was designed to investigate selected psychosocial outcomes. It was found that whether or not patients were given a choice was of greater relevance to psychosocial outcomes than was the type of operation performed. Providing a choice led to improved reported adjustments with respect to the ability to undertake work, attitudes towards the future, beliefs about coping, and in physical and psychological functioning.

Key words-breast cancer, choice, surgery, psychosocial

INTRODUCTION

Breast cancer is the most common form of cancer in women, and is the leading cause of death in women aged 35-55 yr [I]. Approximately 1 in 12 women develop the disease at some stage during their life- times, and there are roughly 24,000 new cases and 12,000 deaths annually [2].

The main form of treatment for early breast cancer is surgery, either mastectomy or wide excision plus radiotherapy. It is generally recommended that axil- lary node clearance also be performed [3]. Which of these treatments is used depends upon the site and size of the tumour, the size of the breast, the partic- ular surgeon involved, and the patient.

Surgical research conducted over the past decade has indicated that simple mastectomy and wide ex- cision for early breast cancer produce similar out- comes in terms of 5 year survival, and disease free interval (41. Such research has led to alternative treatment possibilities.

Mastectomy may be the only real option because of the size and/or site of the tumour or the size of the breast. In other cases, however, the patient may be offered a choice between the different treatments. In such cases, the patient may decide for herself, or may prefer to ask the surgeon to make the decision on her behalf.

There is, however, a paucity of knowledge regard- ing the ps_vchological outcome in cases in which patients are offered a choice of surgery. Accordingly, a prospective study was undertaken to investigate whether there were differences in aspects of psycho- social adjustment between those patients offered a choice of surgery, and those not offered a choice. Data were also collected from the patients’ husbands.

Preliminary findings from this study [5,6] indicated that significantly more of the patients not offered a choice of surgery were clinically anxious and de- pressed pre- and post-operatively than those patients who had been offered a choice. Similar findings were

*Author for correspondence.

obtained for the husbands of the two groups. The purpose of this report is to present further results obtained from the semi-structured interviews and questionnaires.

METHOD

A description of the patient sample and the pro- cedure followed are provided elsewhere [5,6]. Briefly, there were two groups of breast cancer patients matched for stage of disease and age: those offered a choice of surgery, and those not offered a choice. The two groups arose because patients with centrally located tumours were not offered a choice of surgery-at the time of the study it was the policy of the surgeons at the hospital concerned to perform mastectomy for such patients.

All patients (breast cancer and controls) were managed by two consultant surgeons with a special interest in breast disease. It is, therefore, considered that there will have been sufficiently similar inter- actions between patients in the different groups, and consistency in the ways in which choice of treatment (where appropriate) was offered and discussed. Whether these surgeons are ‘representative’ of those dealing with breast cancer patients is difficult to ascertain-a national survey of surgeons found quite wide variation in approaches to treatment (71.

Using semi-structured interview schedules designed for this study, information was obtained about the perceptions of the process of diagnosis and treatment, and the reported impact of the disease on (a) social activities, (b) marital relationships, and (c) work carried out inside and outside the home. Levels of anxiety and depression were obtained from the Hospi- tal Anxiety and Depression Scale [8], self-esteem from the Rosenberg Self-Esteem Scale [9], and phys- ical and psychological symptoms from the Rotterdam Symptom Checklist [lo].

The breast cancer (all T1/2NOMO) patients were interviewed on the day prior to surgery, thereafter at 2-monthly intervals for the first IO-12 months post- operatively. Data were collected from patients’ hus-

1257

1258 JENNY MORRIS and Rocm INGHAM

Table 1. Sample size of each group

Post-operatively

TWO Tell

Group Pre-operatively months months

Patient choice 20 19 16

Patient no choice IO 9 8 Husband choice 12 II 8 Husband no choice 7 7 5

bands pre-operatively, 2, 6 and 10 months post- operatively. (Data were also collected from a benign breast disease group, and from a general surgical group, at various times pre- and post-operatively, although results from these groups are not reported in the present paper.)

There were 20 patients and 12 husbands in the choice group; 10 patients and 7 husbands in the no choice group. Results from independent t-tests dem- onstrated that the patients who chose mastectomy were significantly older than the other patients, as were their husbands.

Of the 20 patients offered a choice of surgery, 13 chose wide excision plus radiotherapy and 7 chose mastectomy. Patients who chose mastectomy largely did so because they wanted the whole area containing the cancer removed, or to avoid radiotherapy. Those who chose wide excision did so to preserve the breast and undergo a less drastic surgical procedure; radio- therapy for these patients was commenced approxi- mately 4 weeks post-operatively and given on 5 days a week for 5 weeks. The 10 who were not offered a choice underwent mastectomy. The sample size of each group is shown in Table 1; a variety of reasons led to the subject drop-out but it is not thought that these affected the between-group comparisons.

Of those husbands available to respond, only one from each group (choice and no-choice) refused to participate. However, three of the choice patients, and one of the no-choice patients did not want their husbands to participate-there are no strong grounds for believing that these refusals adversely affected the comparability of the samples.

RESULTS

The data were analysed using an unified analysis of variance for ranks test [I I].

El Choice

0 NO choice

60

% t

IntertGew data

There were no significant differences in the results on any of the measures between those who chose mastectomy, and those who chose wide excision plus radiotherapy. The only significant differences ob- tained were between the patients offered a choice of surgery, independent cf the type of operation under - gone, and those not offered a choice. The results from the husband groups mirrored the results from the patient groups. Results are presented from the data obtained pre-operatively, 2 and 10 months post- operatively.

Disease recurrence. At 2 months post-operatively there was little difference between groups, with ap- proximately 20% of patients in both groups reporting concern about disease recurrence. However, at 10 months there was an increase in the percentage of no choice patients (to 37%), and a decrease in the

percentage of choice patients (to 6%) concerned about disease recurrence. More husbands of the patients not offered a choice of surgery were con- cerned about disease recurrence than were those of the patients offered a choice at 2 months (H = 3.76, d.f. = 1, P -C 0.05) and at 10 months (H = 5.47, d.f. = 1, P < 0.01) post-operatively (see Fig. 1).

It is of interest to mention here, although the data are not presented, that the patients who chose mas- tectomy were the least concerned about disease recur- rence. This suggests that, with regard to concerns about disease recurrence, the type of surgery may not be as influential as beliefs about cancer and beliefs about the optimum form of treatment.

Social activities. There was little change in social activities over time for the majority of the patients; differences between both patient and husband groups were insignificant. However, more husbands than patients in both groups felt that their social activities had changed (see Fig. 2).

The pre-operative changes reported by the patients were largely due to tiredness, restlessness and not wanting to mix with others. Post-operative changes were more positive in nature and reflected a return to pre-diagnosis levels of social functioning.

There were no significant differences between groups with regard to changes in the nature of relationships with either family or friends. The major- ity of patients in both groups felt that relationships were the same or closer than they had been pre- diagnosis. Similarly. the majority of patients in both

0 2 months 10 months 2 months 10 months

pas? - operatively pcl*t - operatlva~y

Patients Husbands

Fig. 1, Percentages of patients and husbands concerned about disease recurrence “Most/All of the Time” (‘P < 0.05; +*P < 0.01).

Choice of surgery for early breast cancer 1259

q Choice

n NO choira

Fig. 2. Percentages of patients and husbands who

2 months 10 months pact - op*rot ivaly

Patientr

groups neither wanted to avoid their family and friends, nor felt avoided by family and friends.

Marital relationships. The majority of patients and husbands did not experience changes in the quality of their sexual relationships, although more patients and husbands not offered a choice of surgery reported a loss of interest in sex as measured by one of the questions from the Rotterdam Symptom Checklist (see Fig. 3). In other aspects of the marital re- lationship, the vast majority of patients in both groups (as well as the husbands) reported feeling ‘as close’ or ‘closer’ to their partner as they had felt previously.

Work, future and coping. Pre-operatively, more of the patients not offered a choice of surgery felt that their work had been impaired as a consequence of the cancer diagnosis (If = 5.76, d.f. = 1, P c 0.01). Simi- larly, at 10 months post-operatively more of the patients offered a choice of surgery were able to undertake the work to the same degree as they could prior to diagnosis (H = 4.76, d.f. = I, P < 0.05). The

100 -

90 -

0 No choice 60 -

70 -

60 -

% 60 -

40 -

I-l l-l

trend in results was similar for the husband groups, although differences were not significant.

Furthermore, more choice patients than no choice patients felt positive about the future and, as can be seen, there was a decrease over time in the percentage of no choice patients who felt positive about the future (Fig. 4). Differences between the patient groups were only significant at the 10 month inter- view (H =4.32, d.f. = 1, P < O.OS), although the trend was consistent throughout the post-operative period. Similarly, a greater number of choice than no choice husbands felt positive about the future. Differences between the husband groups were significant pre-operatively (H = 5.79, d.f. = 1, P < 0.01).

Additional results indicated that the patients not offered a choice of surgery felt more negative about the future 2 months (H = 4.38, d.f. = 1, P c 0.05) and 10 months post-operatively (H = 4.17, d.f. = 1, P < 0.05). Overall, the husbands did not report feel- ing negative about the future.

poSt -0perativrly pott operatively

Potirntr Hurbandr

Fig. 3. Percentages of patients and husbands who reported a loss of interest in sex “Somewhat/Very Much”.

1260 JENNY MORRIS and ROGER INGHAM

Fig. 4.

60 -

% 60 -

40 -

Percentages of

q Choice

patients

Pmonths 10 months post operatively

prc-op

Patients Husbands

and husbands who felt positive about the future “Most/Ail (P < 0.05).

100

90 F 60 -

% 50-

40 -

30-

2months lomonths post operatively

With regard to perceived levels of coping, there was an increase over time in the percentage of patients in both groups who felt they were coping ‘well’ or ‘very well’ with the cancer experience. Differences between the patient groups were significant pre-operatively (H = 6.42, d.f. = 1, P < O.Ol), and 2 months post- operatively (H =4.38, d.f. = 1, P <0.05), with a greater number of choice patients reporting that they were coping ‘well’ or ‘very well’ with the cancer experience than no choice patients (see Fig. 5).

Pre-operatively, more husbands of the choice pa- tients reported that they were coping ‘well’ or ‘very well’ than the husbands of the no choice patients (H = 5.79, d.f. = 1, P < 0.01) (see Fig. 5).

Furthermore, the results indicated an increase in the percentage of patients in both groups who felt they were coping ‘the same’ or ‘better’ than others would in a similar situation.

pm-op Pmonc

of the Time”

Questionnaire data Results from the Hospital Anxiety and Depression

Scale have been reported elsewhere [5,6]. Self-Esteem Scale. There were no significant

differences between groups. Rotterdam Symptom Checklist. Data were analysed

using the Mann-Whitney test. Results from three subscales are presented: physical complaints, psycho- logical complaints, and severe toxicity.

With regard to the physical complaints subscale, the only significant difference between groups was ob- tained pre-operatively with more physical complaints reported by the husbands of the patients not offered a choice of surgery (U = 15.5, P < 0.05) (see Table 2).

Pre-operatively, more psychological complaints were reported by the patients not offered a choice of surgery (U = 49, P < 0.05), and their husbands (U = 14.5, P < O.Ol), than the patients and husbands

pre-0p 2months lOmonths po*t- operatively

Husbands

post-operatives

Patients

Fig. 5. Percentages of patients and husbands who felt they were coping “Well/Very Well” with the cancer experience (*P < 0.05; **p < 0.01).

Choice of surgery for early breast cancer 1261

Table 2. Median scores from the physical complaints, psychological

complaints and severe toxicity subscales

Patients Husbands

No No

Choice choice Choice choice

Physical complainrs

he-operation

2 months post-op

IO months post-op

Psychological complainu

Pre-operation

2 months post-op

IO months post-op

Severe roxiciry

Pre-operation

2 months post-op

10 months post-op

6.5 10.5 5.5 11.0 6.0 10.5 3.0 3.5

5.5 7.5 2.5 2.0

8.0 15.0 8.0 14.5

5.0 5.5 1.0 7.0

3.5 2.0 0.0 8.0

6.0 8.0 5.5 8.0

5.0 8.0 2.0 2.5

4.0 5.0 1.0 2.0

offered a choice. At 10 months post-operatively, more psychological complaints were reported by the hus- bands of the patients not offered a choice of surgery (U = 7.5, P < 0.05) (see Table 2).

The only significant difference between groups on the measure of severe toxicity was obtained pre- operatively with more symptoms being reported by the patients not offered a choice of surgery (CJ = 69, P < 0.05) (see Table 2).

DISCUSSION

The results from this study suggest that patients offered a choice of surgery, and their husbands, adjust more readily to the cancer experience in terms of psychosocial functioning than do patients, and husbands, not offered a choice of surgery. Improved reported adjustment was found with respect to the ability to undertake work, attitudes towards the future, beliefs about coping, and in physical and psychological functioning. There were minimal differences with regard to changes in social activities. Although the study involved relatively small numbers in each group, the consistency of the direction of differences in the various measures permits a level of confidence in the overall trends obtained.

It has been argued that offering patients a choice of surgery reduces distress [5,6]. This report provides further support to this argument. However, it is conceivable that there may be problems associated with offering patients a choice of surgery which did not emerge during this study because of the relatively short follow-up period. The results should, therefore, be treated with some caution. For example, some patients who choose their treatment may feel they have only themselves to blame if they subsequently regret the decision, or if the treatment should turn out to be unsuccessful. Specifically, some patients who choose mastectomy may later wish they had elected to preserve their breast; or some patients who choose wide excision plus radiotherapy and subsequently develop disease recurrence may believe wide excision to be less effective than mastectomy in preventing recurrence.

These areas emphasise the need for counselling, pre- and post-operatively, if patients are to be offered a choice of surgery [5,6].

The patients who participated in this study re-

ceived the optimum level of care as they were initially seen in a breast clinic, and were also counselled by a specialist nurse. A larger scale study needs to be undertaken in other regions in order to widen the base of the findings, and also to determine the extent to which variations in clinic and ward procedures may be relevant.

A larger scale study would also be able to incorpo- rate additional measures, such as perceived health locus of control, as well as aspects of knowledge and beliefs about breast cancer and its treatment, in order to look more closely at the link between active participation in treatment decisions and psychosocial outcomes and adjustment. Such a study could also incorporate a more direct assessment of the ways in which choice is offered to patients, and the possible effects of different forms of presentation on the patients’ perceived involvement in the subsequent decision.

Finally, it must be recognised that studies of this kind which rely primarily on quantitative data, present only a limited picture of the processes in- volved in coming to terms with this serious disease. Only a certain amount can be inferred from statistical analyses, and researchers and practitioners should not lose sight of the experiential aspects. In this context, it is of interest to consider the comments of a 34 yr old patient admitted into a London teaching hospital for the removal of a lump in the breast which subsequently proved to be malignant:

“A mastectomy could, if I agreed, be performed immedi- ately if the lump proved to be malignant. I refused to accept this. horrified at the thought of playing Russian roulette with my own body. When the lump did turn out to be malignant the surgeon came and held my hand and told me that he thought I should have a mastectomy. He could do it for me the next day. I was stunned. I knew nothing about cancer or its treatment” [12. p. 9201.

This patient was fortunate enough to have medical colleagues, and also to be in a position to obtain further information about the treatment options. She sought a second opinion and finally underwent wide excision followed by radiotherapy. This was willingly performed by the surgeon who had initially recom- mended mastectomy. This woman concludes her ac- count as follows:

“I am pleased that I was able to cope and that I did get a choice. but I should not have had to fight for this. I should have had the options explained to me by some form of counsellor. Approaches to breast cancer should not vary so much from one hospital to another, nor should treatment be dependent on the opinion of one surgeon. It should not be, as one doctor put it, ‘a kind of lucky dip’.

I hope that in future all women will be given the opportunity to choose the most appropriate form of treat- ment on the basis of clearly presented information. Until there is a clear consensus that one form of treatment is better than all others in terms of survival, the patient must be able to participate in any decision about what is to be done with her body. Every effort should be made to help her to do this” (12. p. 9201.

Acknowledgements-Jenny Morris was funded by the Wes- sex Cancer Trust whilst this study was conducted. We thank the Trustees for their support, as well as the patients at the Royal South Hants hospital, and their husbands, who participated in the study.

1262 JENNY MORRIS and ROGER INGHAM

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