Sm. Sci. Med. Vol. 26, No. 6. pp. 583-585, 1988 Printed in Great Britain

0277-9536188 53.00+0.00 Perpamon Press plc

OFFERING PATIENTS A CHOICE OF SURGERY FOR EARLY BREAST CANCER: A REDUCTION

IN ANXIETY AND DEPRESSION IN PATIENTS AND THEIR HUSBANDS*

JENNY MORRIS’ and G. T. ROYLE* ‘Department of Psychology, The University, Southampton SO9 5NH and 2Honorary Consultant Surgeon, University Department of Surgery, Royal South Hants Hospital, Graham Road, Southampton SO9 4PE,

England

Abstract-Thirty patients with early breast cancer have been studied prospectively to assess whether being offered a choice of surgery (simple mastectomy or wide excision plus radiotherapy) influences levels of anxiety and depression pre- and post-operatively. A significantly higher percentage of the patients not offered a choice of surgery experienced clinical levels of anxiety and depression pre-operatively and up to 2 months post-operatively compared with patients offered a choice; the results were also similar for the husbands of these patients. At 6 months, differences between the 2 groups were not statistically significant, although the trend remained the same with more patients nor offered a choice of treatment showing high levels of anxiety and depression. Patients offered a choice of surgery had similar pre-operative levels of anxiety and depression to patients with benign breast disease and patients undergoing surgery for non-cancerous conditions. This study indicates that with proper counselling patients and husbands suffer less stress if they are allowed to take an active part in the treatment of their cancer.

INTRODUCTION

One in 12 women in the United Kingdom develop breast cancer. Until recently, mastectomy was the usual form of surgical management. A study published in 1985 has shown that 5 year survival and disease-free interval are similar following simple mastectomy, and wide excision plus radiotherapy for early breast cancer [l].

There is, therefore, a choice of surgery available to many patients with early breast cancer. Such results may lead to one of two approaches in the manage- ment of early breast cancer: surgeons can continue to make decisions on behalf of their patients, or patients can become more involved in the decisions made about treatment.

It has recently been suggested that in general, doctors underestimate the amount of information patients want, and that there are strong arguments in favour of women’s involvement in treatment decisions [2]. However, some surgeons might feel that offering patients a choice of surgery reflects indecisiveness, and that this might have deleterious effects on patients’ well-being. There are, however, little published data which indicate psychological outcome following choice of treatment.

The purpose of this study, therefore, was to prospectively record psychological parameters in patients and their husbands in order to ascertain the effect that offering patients a choice of surgery has on pre- and post-operative adjustment.

*A companion paper “Choice of surgery for early breast cancer: pre- and post-operative levels of clinical anxiety and depression in patients and their husbands” was published in Br. J. Surg. 74, 1017-1019, 1987.

METHOD

Thirty consecutive patients with early breast cancer (stage I or II) referred to the Royal South Hants breast clinic between October 1985 and April 1986 participated in the study. There were 2 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 2 groups arose because patients with centrally located tumours were not offered a choice of surgery. At the time of this study, it was the policy to perform mastectomy for centrally positioned tumours.

Twenty patients were given a choice of operation, 7 choosing mastectomy and 13 choosing wide ex- cision plus radiotherapy. Patients who chose mastec- tomy 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 to undergo a “less drastic procedure”. The 10 patients not given a choice due to the central position of the tumour underwent mastec- tomy; all patients had an axillary clearance. External beam radiotherapy for all the wide excision patients and 3 of the mastectomy patients was commenced approx. 4 weeks post-operatively and given on 5 days a week for 5 weeks. Two groups of patients acted as controls: one group (n = 31) with benign breast’ disease who did not undergo surgery, and a second group (n = 20) of general surgical patients who had surgery for non-cancerous conditions such as varicose veins and gallstones.

Patients were told the diagnosis in outpatients by 1 of 3 consultants and, where relevant, the treatment options were outlined. A pre-operative diagnosis of breast cancer was made in all patients and was based upon results from 3 tests: cytology, mammography

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584 JENNY MORRIS and G. T. ROYLE

Table I. Median age and sample size of each group

Interview number

GtWttD Age I 2 3 4

Choice of surgery: Patients 49.5 20 19 17 17 Husbands 49.0 II II - 9

No choice of surgery: Patients 44.5 IO 8 8 8 Husbands 51.0 5 6 - 5

Benign breast disease 44.0 31 - - 22

General surgical 39.5 20 - - 17

and clinical examination [3]. All patients were seen pre-operatively by a breast specialist nurse for further advice. Both groups were counselled by the breast specialist nurse who took care to ensure that those patients not offered a choice of surgery were aware that this was due to the position of the tumour. Patients were admitted to hospital either 1 or 2 weeks after diagnosis which allowed them time to consider the options and have further consultations if neces- sary. The final decision was taken on the day before surgery.

All patients attending the breast clinic saw the interviewer (JM) on their first visit. Where a diagnosis of cancer was made, patients were asked if they would be willing to be interviewed upon admission to hospital; at this stage, no patient refused. Patients, and husbands if present, were then seen on the ward on the day prior to surgery, and the nature of the project was explained. Thirty-one patients, aged under 70 years with no previous history of psychiatric illness, were approached and all but 1 agreed to participate; 25 were married, 4 were widowed and one was single.

Details of the median age and sample size of each group are shown in Table 1.

Levels of anxiety and depression were assessed using the Hospital Anxiety and Depression Scale [4], self esteem using the Rosenberg (1965) scale [5], and a general assessment of symptoms using the Rotterdam Symptom Checklist [6]. In addition to completing the above, patients were interviewed using a semi-structured interview schedule to assess the effect breast cancer has on social and work activities, and marital relationships. However, in this preliminary report, only the data obtained from the Hospital Anxiety and Depression Scale for the first 4 interviews are presented. All patients were inter- viewed on the day prior to surgery and thereafter at 2-3 monthly intervals for a total of IO-12 months (I pre-operative and 5 post-operative interviews). Husbands completed the questionnaires and the interview schedule on the day prior to surgery, 2, 6 and 10-12 months post-operatively (1 pre-operative and 3 post-operative assessments). Patients in the control groups completed the questionnaires only; the benign disease group at 1 week, 6 months and 10 months post-diagnosis; and the general surgical group on the day prior to surgery, 6 months and IO months post-operatively. It is hoped that further results will be published as they become available.

RESULTS

Figure 1 illustrates the percentage of patients and husbands with clinical levels of anxiety pre- and

70

60

%

50

40

30

20

10

0

Patient choice

Husband fchoice)

q Patient no choice

tzl Husband Ino choice)

1 2 3 4

Interview number

Fig. 1. Cases of clinical anxiety.

post-operatively, and Fig. 2 illustrates the percentage of patients and husbands with clinical levels of de- pression pre- and post-operatively. Clinical levels reflect scores of 11 plus (maximum of 21) on each of the anxiety and depression subscales [4]. The data were analysed using a unified analysis of variance for ranks test [7].

Interview I: pre-operative assessment

Significantly more patients not offered a choice of surgery were clinically anxious (H = 5.437, df= I, P ~0.01) and depressed (H =4.143. cif= I, P < 0.05) compared with the patients offered a choice.

Similarly, more husbands of the oatients not offered a choice were clinically anxious‘ (H = 5.255,

70 -

60 -

50 -

40 -

%

30 -

20 -

10 -

Patient choice

Husband (choice)

Patient no choace

Husband Ino choice)

Interview number

Fig. 2. Cases of clinical depression.

Offering patients a choice of surgery for early breast cancer 585

df = 1, P < 0.05) and depressed (H = 4.714, df = 1, P < 0.05) compared with the husbands of the patients offered a choice of surgery.

There was no significant difference in levels of anxiety and depression between those patients who chose mastectomy and those who chose wide excision plus radiotherapy. Furthermore, the patients offered a choice of surgery had similar levels of anxiety and depression to the patients in the 2 control groups.

Interview 2: 2-3 months post-operatively

Significantly more patients not offered a choice of surgery were clinically anxious (H = 7.719; df = 1. P < 0.01) and depressed (H = 4.940, df = 1, P < 0.05) compared with the patients offered a choice.

Differences between the husband groups were statistically insignificant.

The trend was similar for the third and fourth interviews, although the differences were not significant.

DISCUSSION

There was a marked difference in psychological adjustment between the 2 groups of breast cancer patients: those patients offered a choice of surgery and their husbands suffered less anxiety and depres- sion than those not offered a choice. The suggestion of others [8] that patients not given a choice were less anxious pre-operatively than those given a choice was not observed. There are 4 possible explanations for the results.

1. The results may be attributable to the effects of mastectomy. However, this may be discounted because there were no differences in anxiety and depression between those who chose mastectomy, and those who chose wide excision plus radiotherapy.

2. The results may be due to the factor which distinguished the 2 groups clinically: the position of the tumour. However, there is no evidence to suggest that this would affect levels of anxiety and depression.

3. The patients in the no choice group may have believed their disease to be more serious. However, both groups of patients were counselled by a breast specialist nurse who explained the rationale behind the decision for surgery for those patients not offered a choice. We believe, therefore, that this explanation is probably not the reason for the differences between the groups with regard to levels of anxiety and depression.

4. Offering a choice of operation may reduce distress. This is the most likely explanation as levels of anxiety and depression in the choice group are lower than those commonly reported in the literature [9]. Furthermore, levels of anxiety and depression are lower in those patients who chose mastectomy, com- pared with those mastectomy patients not given a choice of surgery.

In conclusion, we would like to suggest that

offering a choice of surgery does not appear to be doing any harm to patients, and may in fact be reducing the levels of anxiety and depression com- monly observed in breast cancer patients. Further- more, the levels of anxiety and depression in breast cancer patients were mirrored by those in their husbands and were similarly reduced.

However, offering patients a choice of surgery is not a simple matter. In our opinion, a choice should only be offered after counselling in conjunction with written information. Accordingly. we have produced an information leaflet outlining the 2 types of surgical procedure which reinforces what patients have been told in the outpatient clinic and which can be read at home. Although the choice is generally in favour of wide excision plus radiotherapy, there may well be a minority of patients who will choose mastectomy. For those mastectomy patients who have not been offered a choice of surgery, it might aid post- operative adjustment if breast reconstruction is dis- cussed at an early stage.

Finally, we hope that the results of our study might allay the fears of some doctors that breast cancer patients may be distressed by taking an active part in choosing their treatment. Our study supports the view that some patients are likely to benefit from having some control over the treatment of their cancer.

Acknowledgements-Jenny Morris was funded by the Wes- sex Cancer Trust. We thank the doctors, nurses and patients of the Royal South Hants hospital for their help in this study.

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REFERENCES

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