Breast conservation versus mastectomy: Psychological considerations

Abstract

From the available evidence it is clear that mastectomy is associated with a substantial psychological and psychiatric morbidity. To date there is no convincing evidence that counseling can prevent this morbidity, but monitoring of women's psychological adjustment can lead to early detection and effective treatment of their problem. The use of immediate or delayed implantation or reconstruction appears to reduce the psychiatric morbidity in those women who are particularly concerned about their appearance at the time of surgery. Psychiatric morbidity is further increased when adjuvant chemotherapy is used and when treatment results in persistent arm pain and swelling. A shorter course of adjuvant chemotherapy and reduction of surgery within the axilla could reduce psychiatric morbidity. The role of radiotherapy is still unclear, but in some studies a link has been found between the amount of radiotherapy given, adverse effects, and psychiatric morbidity. In women undergoing breast conservation the reduction in body image problems is offset by greater anxiety about recurrence and depression caused by radiotherapy. Exploring and allowing choice when a patient has a strong preference for breast conservation or mastectomy appears to reduce morbidity. But attention still needs to be paid to the early recognition and treatment of psychological problems in patients with breast cancer, and guidelines are provided.