Comparison of Psychological Influence on Breast Cancer Patients Between Breast-conserving Surgery and Modified Radical Mastectomy

With a rising diagnostic rate of breast cancer in early stage, and a progress of comprehensive treatment modality, breast conserving surgery (BCS) is considered to be an appropriate treatment for patients with stage I or II disease (Borgen et al., 1995). BCS is reported to alleviate the suffering of patients by reducing the extent of surgical resection and not impairing treatment efficacy, thus fulfills cosmetic requirements and could improve quality of life. Although BCS can ensure the postoperative body appearance, patients are still concerned about the survival time. It is reported that the survival rate of BCS is similar to that of traditional radical mastectomy in patients with early stage breast cancer (Fung et al.,1997). At present, there is a general consensus on BCS for treating Chinese patients with early stage breast cancer (Liu et al., 2003). However, no comparative study is conducted to investigate the influence of surgical procedures on the psychological state of breast cancer in Chinese patients. Here, we reported a comparison between BCS and modified radical mastectomy (MRM) in Jiangsu Cancer Hospital & Research Institute. The general information of this hospital has been introduced elsewhere (Jiang et al., 2010; Yan et al., 2010; Gao et al., 2011; Huang et al., 2011).


Introduction
With a rising diagnostic rate of breast cancer in early stage, and a progress of comprehensive treatment modality, breast conserving surgery (BCS) is considered to be an appropriate treatment for patients with stage I or II disease (Borgen et al., 1995). BCS is reported to alleviate the suffering of patients by reducing the extent of surgical resection and not impairing treatment efficacy, thus fulfills cosmetic requirements and could improve quality of life. Although BCS can ensure the postoperative body appearance, patients are still concerned about the survival time. It is reported that the survival rate of BCS is similar to that of traditional radical mastectomy in patients with early stage breast cancer (Fung et al.,1997). At present, there is a general consensus on BCS for treating Chinese patients with early stage breast cancer (Liu et al., 2003).
However, no comparative study is conducted to investigate the influence of surgical procedures on the psychological state of breast cancer in Chinese patients. Here, we reported a comparison between BCS and modified radical mastectomy (MRM) in Jiangsu Cancer Hospital & Research Institute. The general information of this hospital has been introduced elsewhere Yan et al., 2010;Gao et al., 2011;Huang et al., 2011). After consent was obtained, participants were required to complete the questionnaires on site guided by a standard guidance phrases. For patients with low education level, the questionnaire was explained by investigators in a neutral, unbiased manner, and reported by the patient. Qualified questionnaire was retrieved on site. Patients were required to complete a questionnaire at admission, discharged from hospital, and 6 months after surgery, and the questionnaires after surgery were retrieved at outpatient department or by mail. The questionnaires used are as follows: (1): self-reporting inventory (SCL-90) at admission; (2) self-rating depression scale (SDS) when discharged from hospital; (3): SCL-90 and SDS at 6 months after surgery.

Data collection and statistical analysis
Qualified questionnaires were retrieved and collected. Result of each questionnaire item was transformed into numeric and input to computer by two investigators independently. Student test was applied and p value less than 0.05 indicated statistically significant. All analyses were conducted by software SPSS 18.0 and all p values were two-side.

Results
From September 2007 to September 2009, 70 patients with MRM and 50 patients with BCS were recruited.

SCL-90 scores
The scores of SCL-90 in the BCS and MRM groups were showed in Table 1. Compared with the national standard, patients in both groups suffered from somewhat psychological problems. For example, the scores of somatization, anxiety, hostility and horror were higher than the national standard; but there was no statistical difference between BCS and MRM. Six months after surgery, patients in the MRM suffered from interpersonal sensitivity, depression, anxiety, phobic anxiety and other psychological problems; patients in the BCS groups suffered from anxiety, hostility and phobic anxiety. The scores of international sensitivity, anxiety and phobic anxiety and total score of patients with MRM were significantly higher than those of patients received BCS.

SDS scores
The SDS scores of patients were present in Table 2. When discharged from hospital, the SDS score in the BCS group was significantly higher than that in MRM; however, the SDS score of patients with BCS was statistically lower than that of patients with MRM 6 months after surgery. In the MRM group, the SDS score increased at 6 months after surgery compared with the score discharged from hospital, but the SDS score decreased in the BCS group. The SDS scores of two groups were significantly higher than the national standard (Zhang et al.,1998).

Discussion
According to the national survey, breast cancer patients are complicated with certain extent of psychological problems, such as somatization, anxiety, phobic anxiety, depression, etc. Grade of many items in the SCL-90 scale and the general performance of SDS scale suggest that psychological status of patients with breast cancer was significantly different compared with general population. Age, economy, treatment and other factors could impose impact on the psychological state of breast cancer patients. However, several critical factors affecting psychological state could be different during diagnosis, treatment and rehabilitation, especially surgery.
Breast-conserving surgery (BCS) is a landmark for treating patients with early stage breast cancer. Currently, the percentage of BCS is about 50% in the United States and west Europe, 75% in Singapore and 40% in Japan. However, rate of BCS is still lower in China and is only available in several cancer center hospitals. Patients after BCS often experienced more psychological pressure, concerned about the recurrence, metastasis, and sideeffects of chemotherapy or radiotherapy, etc. This could be explained by the consideration of patients that radical mastectomy is the only effective treatment and usually they have little knowledge regarding the indications and long-term efficacy of BCS.
Our results suggested that psychological features of patients after BCS or MRM varied afterwards. At 6 months after surgery, normal life of patients in the MRM group was impaired due to the resection of breast. Stevens and colleagues reported that the psychological alterations were resulted from the weakened female sexy and impaired sexual life, actually 80% patients have completely no sexual life (Stevens et al.,1984). Other factors affecting psychological state are depression, lack of sports, eg. swimming, etc (Rowland et al.,2000). However, at this time, patients with BCS have already experienced chemotherapy or radiotherapy and the psychological pressure was reduced by the tolerable side-effects, no recurrence or metastasis and comparatively satisfactory body appearance. Therefore, scores of interpersonal sensitivity, anxiety and horror and the SDS scores in the MRM group were significantly higher than those in the BCS group. This is inconsistent with previous report (Yang etal., 2005). Thus, in the treatment of breast cancer, it is important to communicate with patients and explain to them that BCS is also a radical surgery, and has similar long-term survival rate for early stage breast cancer comparing with MRM.
In conclusion, this study revealed that the short-term psychological state of patients received BCS is worse than MRM but superior to MRM at 6 months postoperatively. BCS imposed less influence on long term psychological state of breast cancer patients compared with MRM. Healthcare workers should consider active and effective psychological interventions according to psychological features of patients, and it is also necessary to teach patients to understand cancer, change their wrong minds and preconceptions.