Before-and-after photographs are the stock in trade of house painters, auto repair shops, and, yes, plastic and reconstructive surgeons. But a new study may make the last group pause, since it hints that far more is at play in breast cancer patients’ definition of “successful’’ breast reconstruction surgery than how their breasts appear.
The study from Liverpool, England (J Plast Reconstr Aesthet Surg (2012): doi:10.1016/j.bjps.2012.03.005) sidestepped traditional measures used to evaluate outcomes of aesthetic breast surgery and instead asked open-ended questions of survivors who had undergone reconstruction 1-8 years previously.
What the researchers discovered, not surprisingly, is that reconstruction patients are quite unlike cosmetic surgery patients in fundamental and important ways.
Of particular interest in the initial study cohort of 95 patients were 38 whose subjective evaluations of their surgical results completely contradicted objective ratings of cosmesis, the final appearance of the reconstructed breast(s) by surgeons and surgical nurses.
Incredibly, the association between women’s assessments and objective cosmesis ratings failed even to reach statistical significance.
In a structured data analysis of themes that arose in open-ended interviews with 27 of the survivors, the strongest link to women’s satisfaction with the procedure was the surgeon-patient relationship.
Next came the significance of reconstruction in what patients saw as the “completion of the cancer journey,” the authors wrote. “Patients who focused on this were positive about reconstruction that practitioners had rated negatively.”
A previous study asked patients about scarring, finding a correlation between scarring and dissatisfaction with reconstruction. But scarring wasn’t even a blip on the radar when, quoting from the Liverpool study, “we allowed patients to tell us what mattered to them rather than imposing our preconceptions.”
“It seems that surgeons and patients normally ‘talk different languages’; one technical and the other drawing more from relationships and patients’ sense of how normal they feel and appear and from their sense that reconstruction completes their cancer journey,” the investigators concluded. “In preoperative consultations, surgeons concentrate almost exclusively on the technical and cosmetic aspects of reconstruction: what can be achieved and what complications can occur.”
Of course, women who struggled with complications tended to factor that in to their assessments of their results, even if their final cosmetic outcome was considered by surgeons to be excellent.
Others were disappointed despite what seemed to surgeons to be excellent cosmetic results because, as one said, “I was expecting to feel feminine again, but I don’t, I don’t at all.”
What is perhaps even more interesting is to eavesdrop on the comments of women whose surgeons judged their cosmetic result to be poor.
Said one, “I had a really good relationship with (the surgeon) and I just found it so reassuring to see her. That was part of the whole thing really. She was just so positive, and so, well, just understanding I think … I was really glad that I had chosen that form of reconstruction because I had this regular contact with her.”
Said another, who felt “normal” despite what her surgeon considered to be a poor result: “If I didn’t have it done, I wouldn’t have felt normal at all. It would always remind me of what had happened.”
A highly complex patient-surgeon dance occurs when breast surgery is performed for more than cosmetic reasons, the study found.
One woman, disappointed with the way her reconstructed breast fit in a bra, could not bring herself to voice her concern with the surgeon she credited with saving her life.
“It’s very difficult to come face to face with somebody who says, ‘You’ve had cancer but we can get rid of it,’ and does their best… without seeming ungrateful,” she said, tearfully.
The study concludes with a fascinating discussion about the potential clinical implications of the findings.
Considering the profound influence of the patient-surgeon relationship on these particular patients, the investigators offer a cautionary suggestion to avoid being overly effusive about the cosmetic result they may see. Patients, they explain, may not necessarily share their enthusiasm, if they continue to struggle with the sense that cancer has marred their bodies, their sense of self, or their security in relationships.
“Both patient and surgeon have invested physically and emotionally in the procedure and it is difficult for either to admit to the other that it was “not worth it,” they note.
Women, on the other hand, who appear to be disproportionately pleased with the result of surgery that objectively achieved a poor result may simply be expressing relief and gratitude. “Their apparent satisfaction,” they wrote, “should not excuse poor surgical practice.” Rather, routine assessments of reconstructive practice should be made by objective sources, not simply patient report.