Psychological and Psychosocial Aspects of Medical Tattoos in Women with Breast Cancer.

A review of the literature reveals a high incidence of body-image distress among breast cancer survivors who have undergone surgery, which is a natural response to the significant changes in their appearance. Reconstructive surgery, utilizing implants or flaps, may be employed to restore breast size and shape. Medical tattooing can recreate the nipple-areola complex and decorative appliques can conceal scars and skin color variations. Both reconstructive surgery and medical tattoos are associated with patient-reported satisfaction, yet further research is necessary to understand their combined impact on body-image distress. To investigate this, a survey was distributed among national breast cancer support groups and advocacy organizations, yielding 207 responses from individuals meeting the study's criteria. The participants were categorized into two groups: those who received post-surgical medical tattoos (n = 61) and those who did not (n = 146). The study also examined how participants evaluated the cosmetic and decision satisfaction of patients who made various surgical and cosmetic intervention choices. This was accomplished by having participants rate images of patients who had received three types of intervention: mastectomy and reconstruction only, mastectomy and medical tattooing only, and mastectomy, reconstruction, and medical tattooing. Using linear regression and multilevel modeling that controlled for demographic and clinical factors associated with body-image distress, the findings demonstrated that participants with medical tattoos reported significantly lower levels of body-image distress, depressive symptoms, and perceived stress compared to those without medical tattoos. Furthermore, participants rated images of patients who underwent both reconstruction and medical tattooing post-mastectomy as having significantly higher cosmetic and decision satisfaction ratings than images of patients who received reconstruction or medical tattooing alone. This research expands on our understanding of body-image distress in survivors as a multidimensional construct and may serve to indicate potential means for intervention. Enhancing our understanding of how breast cancer treatment and surgery affects survivors' body-image distress may aid healthcare professionals in offering additional psychoeducation and recommendations. Furthermore, presenting information about medical tattooing as a complementary cosmetic option early in the treatment process allows patients the opportunity to consider it within the context of their overall treatment plan. Table. Linear regression results using BIBCQ as the outcome variable and medical tattoo group as the predictor variable with covariates included. Note. PHQ9 = Patient Health Questionnaire-9. PSS = Perceived Stress Scale. Citation Format: Miranda Proctor, Jeffrey Cassisi. BODY-IMAGE DISTRESS IN BREAST CANCER SURVIVORS AND THEIR EVALUATION OF MEDICAL TATTOOING FOLLOWING SURGERY [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-28-02.

Does adjuvant therapy reduce postmetastatic survival?

A review of the literature revealed a high incidence of body-image distress among breast cancer survivors who had surgery. This cross-sectional study examined the relationship between medical tattooing as a complementary cosmetic intervention and body-image distress and mental health outcomes among breast cancer survivors following surgery. We examined 330 post-surgical breast cancer survivors collected through a nationwide online survey in the U.S., pursuing two main objectives. First, we investigated body-image distress, depression and anxiety symptoms, and perceived stress in survivors who underwent breast cancer surgery, comparing those with medical tattooing (n = 89) and those without (n = 226). Second, we assessed the influence of the participant's surgery type on body-image distress, depression and anxiety symptoms, and perceived stress. Additionally, we evaluated whether individual factors, such as appearance investment, satisfaction with decision, and cosmetic expectation discrepancy, predicted the participant's body-image distress. Findings suggest that participants with medical tattoos reported significantly lower body-image distress, depression and anxiety symptoms, and perceived stress compared to those without medical tattoos. The participant's surgery type did not significantly predict body-image distress, depression or anxiety symptoms, or perceived stress. However, participants who reported greater appearance investment endorsed higher body-image distress. Participants who reported higher satisfaction with their treatment decisions and lower cosmetic expectation discrepancy endorsed lower body-image distress. Medical tattooing may be a valuable tool in improving body-image distress and mental health for those who wish to pursue it, but more research is needed. Empirical studies supporting the mental health benefits of medical tattooing among survivors are crucial to standardize insurance coverage and promote its inclusion as a complementary intervention across insurance providers nationwide. This complementary intervention should be considered using a patient-centered approach that aligns with the patient's values and preferences.

Increasing the incidence of breast cancer worldwide is an alarming factor for the medical community and also an additional reason for accountability. Oncological treatment, followed by subsequent reconstructive stages, are traumatic events that without a doubt exert their adverse effects on the quality of life of these patients. The reconstruction of the nipple-areola complex represents the final element in the treatment of patients who have suffered from cancer breast and must follow basic principles such as: reproducibility, efficacy, short duration of treatment and low rate of complications. The present material presents the various surgical techniques dedicated to the reconstruction of the nipple-areola complex, presenting their advantages and disadvantages based on a 5-year study. The use of single-stage techniques associated with medical tattooing were the main factor in increasing the satisfaction of the patients included in the research.

Studies indicate that physical appearance changes affect a significant proportion of breast cancer survivors, often leading to post-surgical distress. Both reconstructive surgery and medical tattoos are associated with patient-reported satisfaction, yet further research is necessary to understand their combined impact on aesthetic outcomes from the patient perspective. This study examined how breast cancer survivors evaluated the cosmetic and decision satisfaction of other patients who made various cosmetic intervention choices post-mastectomy. Breast cancer survivor support networks (n = 180) across 20 states agreed to share information about the online survey to their members. Participants (n = 251) rated the cosmetic outcome and decision satisfaction of images depicting other patients who had received mastectomy with three types of intervention: reconstruction alone, medical tattooing alone (flat closure), and reconstruction and medical tattooing combined. A factorial MANOVA produced significant within-subjects effects indicating participants consistently rated images of patients with a combination of reconstruction and medical tattooing highest in cosmetic quality, lowest in scar visibility, and highest in treatment decision satisfaction. The findings suggest that medical tattooing serves as a valuable complementary cosmetic intervention, with many survivors expressing interest and recognizing potential benefits once informed about the option. However, the study's limitations, such as the need for a more diverse range of patient images for evaluation, should be acknowledged. Future research should address these gaps by incorporating photographs of patients across varying demographics, including age, body weight, disease severity, and surgical procedures, to minimize bias. Despite these limitations, this study highlights the significant role that medical tattooing can play in enhancing aesthetic outcomes after surgery, particularly from a patient-centered perspective. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://link.springer.com/journal/00266 .

Adjuvant bisphosphonates in patients with breast cancer: does the potency matter?

Sir, Nipple-areola complex reconstruction, which is the final step in breast reconstruction surgery, is extremely important for good aesthetic outcomes and improved patient satisfaction.1 Among the many procedures reported,2 nipple-areola complex reconstruction using a local flap or nipple graft in combination with medical tattooing is widely used today. However, only a few studies have reported its procedural details and modifications.3 Here, the authors report our 4 innovative modifications of medical tattooing that enhance cosmetic outcomes of nipple-areola complex reconstruction. This study was approved by the Ethics Committee of Tokyo Women’s Medical University. Subjects were 56 breasts of 56 patients who underwent nipple-areola complex reconstruction using medical tattooing at the Department of Plastic and Reconstructive Surgery, Tokyo Women’s Medical University between April 2014 and October 2016. Our modified medical tattooing technique was performed using a Permark UltraEnhancer (PMT Corp., Minn.), a #18 needle (PMT Corp.) and several pigments (PMT Corp.). All medical tattoos were performed by a plastic and reconstructive surgeon. The time required for the procedure was about 30 minutes. The first of the 4 modifications was blurring the margin of the areola to create a natural appearance by depositing pigments in irregular alignment for a gradation effect. A needle angled perpendicular to the skin was used to ensure the finest micropigmentation, together with a scratch micropigmentation method. The degrees of gradation created were adjusted for individual patients (Fig. 1A). The second modification was creating the illusion of the uneven surface (bumps) of the areola due to the Montgomery glands. A polka dot pattern was created using either a darker or a lighter shade of pigment based on close examination of the contralateral healthy areola, to maintain similar appearances in individual cases (Fig. 1B). The third modification was adjustment of the areola position so that the breasts looked as symmetric and natural as possible. The conventional method that determines the areola position in relation to the apex of the reconstructed breast or the nipple would have emphasized asymmetry when breast reconstruction did not provide good symmetry. Instead of opting for conventional approaches such as determining the areola position in relation to the apex of the ipsilateral breast or the reconstructed nipple, the provisional position of the areola was marked for evaluation by using that of healthy side, and the final position, agreed with by the patient, was determined after fine adjustment in this study (Fig. 1C). The fourth modification was creating the illusion of the height of the transplanted or reconstructed nipple, by adding a shadow effect such as a trick art; the top and root of the nipple was covered by a lighter shade and a darker shade of pigment, respectively (Fig. 1D). The appropriate combinations of each of these 4 modifications was determined individually for each patient, resulting in successful nipple-areola complex reconstruction without complications (eg, cutaneous ulceration) in all patients (Fig. 2). Patient satisfaction, which was not examined in this study, needs to be studied in the future. Also, the optimal timing of tattooing, long-term follow-up results, pigment preparation methods, and the necessary number of tattooing sessions need to be elucidated in future studies.Fig. 1.: Our 4 modifications of medical tattooing procedures in nipple-areola complex reconstruction. A, Blurring the areola margin. B, Creating the illusion of the Montgomery glands (areolar bumps). C, Adjusting the areola position to achieve symmetry. D, Creating the illusion of the height of the nipple by using shading.Fig. 2.: Clinical photographs of the nipple-areola complexes reconstructed using the modified medical tattooing techniques.

Medical tattoos are used for camouflage of a wide range of disfiguring skin pathologies and conditions. Recently, tattooing of the nipple and areola of the breast has been introduced as a corrective treatment of sequelae from breast cancer surgery and radiotherapy. The psychologic impact of a disfigured nipple and areola can invalidate self-esteem of the sufferer lifelong with major consequences for social life. Medical tattooing can often restore the visual appearance of the nipple-areolar complex back to normality and even improve the 3D impression of the entire breast. High skills of the operator are needed. The article reviews the theoretical background, patient selection and information, technical performance, and aftercare. Close cooperation between surgeon, dermatologist, and medical tattooist is essential. Medical centers treating breast cancer should routinely have access to corrective medical tattooing.

News from the 2007 San Antonio Breast Cancer Symposium

Elucidating the Role of Chest Wall Irradiation in ‘Intermediate-risk’ Breast Cancer: the MRC/EORTC SUPREMO Trial

PURPOSECOVID-19 caused a disruption in cancer management around the world, resulting in an estimated excess burden secondary to screening disruption and excess lag time for treatment initiation.METHODSWe gathered information from primary reimbursement data sets of the public health system of São Paulo, Brazil, from April 2020 to November 2021, and compared these data with those of the pre–COVID-19 period. We used an interrupted time series model to estimate the effect of the COVID-19 pandemic on the rate of key procedures of breast and cervical cancer health care chain.RESULTSWe estimated that 1,149,727, 2,693, and 713,616 pap smears, conizations, and mammograms, respectively, were missed or delayed during the COVID-19 pandemic, compared with those in the years immediately before the COVID-19 stay-at-home restrictions. Specifically, we observed an acute decrease of procedures after the COVID-19 stay-at-home restrictions, with a trend to recovery in the long term. Regarding the systemic treatment analysis, we observed a 25% reduction in the rate of initiation of adjuvant systemic treatment for early breast cancer (stage I/II). However, we did not find a clear effect on the other settings of systemic treatment for breast cancer. We estimated an excess of 156 patients starting palliative care for cervical cancer after the COVID-19 stay-at-home restrictions.CONCLUSIONThe COVID-19 pandemic significantly reduced the performance rate of pap smears, conizations, and mammograms. The initiation of adjuvant treatment for early-stage breast cancer was most susceptible to COVID-19's health system disruption. Furthermore, the downward trend of treatment of advanced cervical cancer was interrupted. Therefore, public health policies are urgently needed to decrease the incidence of advanced cervical and breast cancers caused by delayed diagnosis and treatment initiation.The COVID-19 control policies resulted in reduction of cancer patients' delivery of care. This study evaluated the pandemic's influence in key procedures of breast and cervical cancer chain of care in São Paulo, Brazil. We observed a substantial reduction in the number of mammograms, pap smears, and conizations performed since the onset of the COVID-19 pandemic. In addition, stage I and II breast cancer adjuvant treatment presented a reduced realization rate, whereas palliative treatment delivered for advanced cervical cancer increased. Our results support the need for public health policies focused on mitigating the long-term effects of COVID-19 in cancer-related mortality.

Scarring in the skin after trauma, surgery, burn or sports injury is a major medical problem, often resulting in adverse aesthetics, loss of function, restriction of tissue movement and/or growth and adverse psychological effects. Current treatments are empirical and unpredictable, and there are no prescription drugs for the prevention or treatment of dermal scarring. We have investigated the cellular and molecular differences between scar-free healing in embryonic wounds and scar-forming healing in adult wounds. We have identified Transforming Growth Factor beta 3 (TGFβ3) as a key regulator of the scar-free phenotype in embryonic healing. Exogenous addition of TGFβ3 to cutaneous wounds in pre-clinical (adult) in vivo models reduces early extracellular matrix deposition and these molecules are deposited with a markedly improved architecture in the neodermis, resembling that of normal skin. This improvement of structural organisation in the healing wound is self-propagating and leads to a reduction of subsequent scarring. TGFβ3 has completed safety studies and entered human clinical trials. Data from these studies have demonstrated that TGFβ3 (Juvista™) in humans is safe and well tolerated. Acute, local administration of TGFβ3 (Juvista™) significantly reduces dermal scarring in a dose responsive manner resulting in the regeneration of a skin structure that is permanently improved.

Breast cancer is the most common malignancy in women, with increasing incidence in Europe and North America. The frequency of involvement of the eye and visual pathways is reported to be as high as 30% in patients with known metastatic disease. In some cases, ophthalmic involvement can be the first sign of metastatic spread. Metastasis occurs via the haematogenous route and predominantly involves the choroid. Metastases to other ocular structures, the orbit and the visual pathways have also been described. Paraneoplastic effects are rare but significant. Different modalities are employed in the treatment of breast cancer and its metastases. These include chemotherapy and radiotherapy. The ocular adverse effects of these have been well described, but recently developed new treatment modalities, such as monoclonal antibodies, may have different side-effects. With the increasing incidence of breast cancer and the advent of new treatment strategies, the complications of the disease and the sequelae of therapy are highly relevant to both oncologists and ophthalmologists.

Chemotherapy

Anastrozole (Arimidex) is an aromatase inhibitor approved in the EU, the US and in other countries worldwide for use as an adjuvant treatment in postmenopausal women with early-stage, hormone receptor-positive breast cancer. It is also approved in the EU and other countries worldwide for continuing adjuvant treatment in women who have already had 2-3 years of adjuvant tamoxifen treatment for breast cancer. Anastrozole is an effective primary adjuvant treatment for postmenopausal women with early-stage breast cancer. In patients with hormone receptor-positive tumours, 5 years of anastrozole treatment was more efficacious in reducing breast cancer recurrence than 5 years of tamoxifen, both in a head-to-head comparison and in switching trials when given after 2-3 years of tamoxifen treatment. The treatment benefits have now been shown to extend to 100 months following breast surgery. To date, overall survival was better in anastrozole than tamoxifen recipients in one switching trial and in a meta-analysis of three switching trials. There was no increased benefit in health-related quality of life with anastrozole over tamoxifen. In women who had received 5 years of tamoxifen treatment, continuation of treatment with anastrozole further reduced the risk of breast cancer recurrence. Ongoing head-to-head trials against other third-generation aromatase inhibitors will provide data as to its relative efficacy against these agents. Anastrozole is a generally well tolerated treatment for early-stage breast cancer. Like other aromatase inhibitors, its most important adverse effect was an increased risk of bone fractures, which for anastrozole was restricted to the treatment period. It is still unclear whether primary adjuvant treatment extended beyond 5 years is of benefit and whether primary adjuvant treatment with anastrozole for 5 years is preferable to switching to anastrozole after 2-3 years of tamoxifen treatment. However, the evidence to date establishes anastrozole as a valuable adjuvant and extended adjuvant treatment for postmenopausal women with hormone receptor-positive, early-stage breast cancer.