1. Introduction
Breast cancer is the most frequent malignant neoplasm in women. In 2020, there were 2.3 million women diagnosed with breast cancer and 685,000 deaths globally. As of the end of 2020, there were 7.8 million women alive who were diagnosed with breast cancer in the past 5 years, making it the world’s most prevalent cancer. There are more lost disability-adjusted life years (DALYs) by women to breast cancer globally than any other type of cancer [
1]. In the U.S., in 2021, an estimated 281,550 new cases of invasive breast cancer are expected to be diagnosed in women in the U.S., along with 49,290 new cases of non-invasive (in situ) breast cancer.
About 43,600 women in the U.S. are expected to die in 2021 from breast cancer. Death rates have been steady in women under 50 since 2007, but have continued to drop in women over 50. The overall death rate from breast cancer decreased by 1% per year from 2013 to 2018. These decreases are thought to be the result of treatment advances and earlier detection through screening [
2].
Recently Miller et al. analyzed population-based cancer incidence and mortality for AYAs in the U.S. by age group (ages 15–19, 20–29, and 30–39 years), sex, and race/ethnicity. In 2020, it was estimated approximately 89,500 new cancer cases and 9270 cancer deaths in AYAs [
3].
In Spain it represents 36% of tumors in women with almost 33,000 new cases per year. It is the leading cause of death from cancer in Spanish women, although, since the 1980s, there has been a downward trend in mortality. This is due to the combined effect of screening programs, improved treatments, and multimodal therapy [
4].
Despite the significant advances in tumor biology in recent years, surgery remains an essential part of the primary treatment of breast cancer, although this has also evolved over the years. Nowadays, it is possible to diagnose the tumor in its early stages, which allows conservative surgery to be performed, thus minimizing the esthetic impact, as long as the oncologic conditions allow it. However, conservative techniques are not always possible, so mastectomy remains a frequent procedure, and approximately 20–30% of women with breast cancer undergo it [
5].
On the other hand, recent discoveries in the genetic basis of breast cancer have led to increased interest in risk-reducing mastectomy as a method of breast cancer prevention [
6,
7].
Over the years, surgical strategies have changed. Although the primary objective of treatment continues to be disease control, improved cosmetic results have become more critical to reduce patients’ physical and psychological trauma. Thus, according to the Halsted technique, mastectomy was replaced by modified radical mastectomy; the objective has been to produce the aggression as atraumatic as possible. To this end, skin-sparing mastectomy, where most of the skin envelope is preserved, and skin- and nipple-sparing mastectomy, where, in addition, the nipple-areola complex can be preserved, have emerged allowing better esthetic results after post-mastectomy reconstruction [
8].
In addition, the increased survival of breast cancer patients has led to greater attention to their quality of life. It is why breast reconstruction is now a necessary part of the overall treatment. It has been shown not to influence patient survival [
9] and helps restore body image and relieve the stress associated with mastectomy [
10].
Post-mastectomy reconstruction can be performed immediately or deferred. There are various procedures for performing it (tissue expansion-prosthesis; autologous tissue), the choice of which will depend on the patient’s characteristics, thus allowing the most personalized treatment possible to be obtained [
11].
Nevertheless, choosing the type of breast reconstruction is a difficult decision and optimizing the results of breast cancer surgery remains a challenge. Approximately 40% of women who undergo surgery reported dissatisfaction with their surgery’s decision and esthetic results [
12,
13]. Some authors such as Shechter et al. reported that patients in the breast reconstruction group had higher scores for esthetic outcome and a higher degree of patient satisfaction from the surgical outcome compared to the patients in the breast conservating treatment-alone group [
14].
Lei et al. in a multi-center study identified factors of higher patient satisfaction, such as NAC preservation and absence of radiotherapy, in order to help breast surgeons make better decisions about individualized reconstruction plan [
15].
Schmidt et al. reported that patients who found their breast to be highly important were more likely to decide for a reconstruction. For these authors patients reporting a high significance of their breast showed the greatest decrease in satisfaction with their breast after reconstruction [
16].
Therefore, the objective of this surgery, beyond the final esthetic result, must consider how it will affect the patient’s quality of life and satisfaction. Thus, these variables have become a fundamental part of evaluating the success of breast surgery [
17].
In order to measure these variables of effect, we have questionnaires based on the results reported by the patients themselves (“Patient-reported outcomes-PROs”). These instruments quantify aspects related to health-related quality of life (HRQOL), such as, for example, satisfaction; obtaining the information directly from the patient themself without any interpretation by third parties; and, in addition, they include broader concepts such as satisfaction with the care received [
18].
Multiple instruments have been used to measure PROs in breast surgery patients. However, until just over a decade ago, few of these questionnaires had sufficient evidence to be used specifically in these patients, as they had limitations in certain areas, such as those related to esthetics and body perception [
19].
In 2009, the BREAST-Q questionnaire was developed to meet this need, a validated PRO instrument specific to breast surgery. Since its release, it has substantially improved our ability to study the results of this procedure from the patient’s point of view and patient satisfaction [
20].
Drs. Pusic, Klassen, and Cano developed the BREAST-Q© questionnaire, owned by Memorial Sloan-Kettering Center and Columbia University (U.S.). It has been available for use in Spain since 2016 after linguistic validation, and in 2017 they launched version 2.0, which was tested on a much larger group of patients. It consists of six modules; two modules related to esthetic purposes (breast augmentation and reduction) and the breast cancer module, which encompasses the mastectomy, breast reconstruction, reconstruction expectations, and breast-conserving surgery modules. All modules are based on a conceptual structure with six domains that are grouped into two: the first domain related to the quality of life that included: physical well-being, psychological well-being, and sexual well-being. Moreover, the second domain is related to patient satisfaction (the breasts, the results, and the medical care received). Each module contains preoperative and postoperative scales, which can be used independently or together to measure changes [
21].
Since the appearance of the BREAST-Q© questionnaire, many studies have used it to evaluate breast surgery patients. However, these studies have identified limitations, such as short follow-up periods or small sample sizes [
13,
22]. In contrast, other studies, although extensive, are only limited to therapeutic reconstruction techniques, excluding other techniques from the study [
14,
23,
24]; or they are limited to patients who underwent breast cancer surgery, excluding risk reduction surgeries [
25].
The objective has been to evaluate the satisfaction and quality of life in women who have undergone mastectomy with breast reconstruction, compare the esthetic results, and identify risk factors that may influence these results.
2. Materials and Methods
2.1. Study Design
This study is a descriptive cross-sectional study of women who underwent mastectomy surgery with reconstruction and were submitted to a questionnaire of satisfaction and quality of life specific to breast reconstructive surgery (BREAST-Q Version 2.0—Reconstruction module, validated in Spanish).
2.2. Study Population
Patients undergoing mastectomy with breast reconstruction from 2010 onwards, at the Hospital Universitario Torrecárdenas and in private clinics in Almería, operated on by the same surgical team, met the following selection criteria:
Women with breast cancer with an indication for a mastectomy followed by reconstruction.
Women with breast cancer who refuse conservative treatment.
Women undergoing uni- or bilateral risk reduction surgery followed by reconstruction.
Who has undergone surgery at least 12 months before the time of inclusion in the study.
Who sign informed consent for inclusion in the study.
Exclusion criteria were:
2.3. Sample Size
Patients who had undergone mastectomy with breast reconstruction since 2010 operated on at the Hospital Universitario Torrecárdenas and in private clinics in the province of Almería by the same surgical team and met the criteria for inclusion in the study were selected. The type of sampling was by convenience through access to the patients’ medical records.
The sample size was calculated based on a series of estimates considering the latest data recorded on the number of patients diagnosed with breast cancer and undergoing mastectomy in the province of Almeria during the year 2020, whose figure was 111 patients.
For a finite population, the Ene 3.0 statistical program (UAB, Barcelona, Spain) was used to obtain the sample size, assuming an alpha error of 0.05, an expected proportion of 50%, and a precision of 5%, obtaining an estimated sample of 70 patients.
2.4. Data Collection and Sources of Information
After signing the corresponding informed consent, the patients selected during the period included in the study were invited to participate in the study by filling in the questionnaires referred to above, with at least one year having elapsed since the surgical intervention. A series of pre-and post-surgical variables of a demographic nature and relating to the characteristics of the tumor, surgical intervention, complications and adjuvant treatments, obtained from the patient’s clinical history, were also collected.
2.5. BREAST-Q© Questionnaire
The questionnaire is a PRO tool designed to evaluate the results of women undergoing different types of breast surgery. Drs. Pusic, Klassen, and Cano developed it and it is owned by Memorial Sloan-Kettering Cancer Center and Columbia University (U.S.). Version 1.0 of the questionnaire was published in 2009 and has been available in Spain since 2016 after linguistic validation. In 2017, version 2.0 of the questionnaire was published, which is the one currently used.
The questionnaire contains six modules, of which the first two are related to cosmetic surgery and the rest to breast cancer surgery:
Breast augmentation;
Reduction/mastopexy;
Breast cancer;
Each module, in turn, is divided into multiple scales that can be used independently, allowing each researcher to generate a questionnaire tailored to his or her research. In addition, each module has preoperative and postoperative scales, which can be used individually or together, allowing changes over time to be assessed.
All modules are based on a conceptual structure comprising six domains, grouped into the two described below. In addition, due to the importance of body image for breast surgery patients, numerous questionnaire scales allow the measurement of this concept.
2.5.1. Health-Related Quality of Life
Psycho-social well-being: this scale contains items that inquire into the patient’s body image (e.g., body acceptance, feeling of being attractive) and her confidence in certain social situations;
Sexual well-being: Its items are intended to measure the patient’s sexual well-being through questions about sensations when she is dressed or naked, her sexual confidence concerning the appearance of her breasts and her sensations during sexual activity;
Physical well-being: This scale differs between the different modules. Depending on which one we are in, we will see questions relating to physical problems in the chest, back, abdomen or skin due to the adverse effects of radiotherapy.
2.5.2. Patient Satisfaction
Breast Satisfaction. This scale measures body image through patients’ satisfaction with their breasts, based on questions about the comfort of the operated or reconstructed breasts, both clothed and unclothed. It also evaluates symmetry, breast smoothness, and some items related to implants in the reconstruction module;
Satisfaction with the results. It includes items related to the patient’s satisfaction with the appearance after surgery of the nipple-areola complex, especially regarding the scars;
Satisfaction with the care received. It is a scale that only this questionnaire has and which makes it possible to evaluate the patients’ satisfaction with several points of their surgical process: the information received from their surgeon on the procedures and recovery times, satisfaction with the surgeon (professionalism, sensitivity, communication skills, accessibility), satisfaction with the care received by the rest of the medical team and satisfaction with other non-medical personnel involved in the process (for example, administrative personnel).
As mentioned above, it is not necessary to complete all the modules, but they are completed independently according to the purpose of each study. Brief instructions are given at the beginning of each scale to allow the patient to understand the items better. In addition, the questionnaire user’s guide expressly states that its use is permitted both in printed format and by creating its online version to facilitate its administration to the study subjects 88.
An overall score is not obtained for the questionnaire; each scale is scored independently. All scores fluctuate between 0 and 100, so that a higher score implies greater satisfaction or better quality of life.
Finally, since the questionnaire is the property of Memorial Sloan-Kettering Cancer Center and Columbia University, in order to use it for research purposes, a license for its use must be obtained, free of charge, through their official website (
http://qportfolio.org/breast-q/(Accessed on 4 January 2021)).
2.6. Study Variables
2.6.1. Independent Variables
Age (at the time of surgery): quantitative variable expressed in years;
Body mass index: quantitative;
Tobacco use YES/NO: dichotomous qualitative variable;
Educational level (Low/Medium/High): ordinal qualitative variable;
Previous surgery (No/Benign surgery/Conservative surgery for cancer + Radiotherapy/Augmentation surgery/Reduction-pexy): qualitative variable;
Reason for the intervention (Cancer/High risk/BRCA/BRCA + cancer);
Tumor location within the breast: qualitative variable;
Tumor size (mm): quantitative variable, expressed in millimetres;
Tumor extension (Single/Multifocal/Multicentric/Extensive): qualitative variable;
Molecular subtype (Luminal A/Luminal B/Triple positive/Her two neu overexpressed/Basal-like): qualitative variable;
Tumor pathologic TNM (Tis/T1/T2/T3): ordinal qualitative variable;
Nodal pathologic NCT (N0/N1/N2): ordinal qualitative variable;
Tumor stage (0/I/IIA-B/IIIA-B): ordinal qualitative variable;
Date of surgery;
Type of surgery: classic mastectomy/skin-sparing mastectomy type I-II/skin-sparing mastectomy type IV/skin- and nipple-sparing mastectomy/partial + dorsal mastectomy): qualitative variable;
Timing of breast reconstruction (Immediate/Different): dichotomous qualitative variable;
Type of reconstruction (Expansion-prosthesis/Becker-type expander/direct implant/dorsal-prosthesis/biological mesh): qualitative variable;
Treatment of the axilla (No/BSGC/axillary lymphadenectomy): qualitative variable.
Implant size: quantitative variable expressed in grams;
Chemotherapy (No/Neoadjuvant/Adjuvant): qualitative variable;
Radiotherapy (No/Over expander/Over prosthesis/Over Becker/Over flap): qualitative variable;
Contralateral breast symmetrization (NO/Augmentation/Reduction/Pexia + Implant/Preventive mastectomy): qualitative variable.
2.6.2. Dependent Variables
Immediate complications (No/Seroma/Wound dehiscence/Skin or flap necrosis/CAP necrosis/Implant extrusion): qualitative variable;
General evolution after the first intervention (Favorable/Reoperation): qualitative dichotomous variable;
Late complications of breast reconstruction (Satisfactory/Discomfort/Asymmetry/Contracture III-IV/Discomfort + Asymmetry/Implant rupture/Delayed seroma/Others): qualitative variable;
Post-surgical complications of the symmetrized breast (NO/YES): dichotomous qualitative variable;
Number of reoperations: discrete quantitative variable;
Oncologic outcome (Disease-free/Systemic recurrence/Local recurrence/Exitus): qualitative variable;
Date of completion of the questionnaire;
Time elapsed between breast reconstruction and completion of the questionnaire in years: quantitative variable;
Time elapsed between breast reconstruction and completion of the grouped questionnaire (1–3 years/4–6 years/7–9 years/10 years): qualitative variable;
Results of the BREAST-Q questionnaire version 2.0 Post-surgical reconstruction module.
2.7. Ethical Implications
The project complies with the ethical principles of human research in the Declaration of Helsinki and the Biomedical Research Act. Likewise, it complies with the stipulations of the Organic Law 3/2018, of 5 December, on Personal Data Protection and guarantee of digital rights, guarding its strict confidentiality and its non-access to unauthorized third parties, as well as with the European Union Regulation 2016/679. Each patient who wished to participate was provided with a copy of the patient information sheet and informed consent. The Hospital Torrecárdenas Ethical Committee approved the study Code number: 47/2021.
2.8. Statistical Analysis
The study variables and questionnaire scores will be collected in a database and subsequently analyzed with IBM SPSS 26 (IBM Corp. Released 2019.Version 26.0. IBM Corp, Armonk, NY, USA).
A descriptive analysis of the main variables will be performed. For qualitative variables, their frequency distribution (number of cases and percentage) will be obtained. Quantitative variables will be expressed as a minimum, maximum, mean and standard deviation. Before performing the bivariate analysis, normality tests will be performed for quantitative variables using the Kolmogorov-Smirnov test. Parametric tests (Pearson’s correlation, t-Student, and ANOVA) will be used for those following a normal distribution and non-parametric tests (Spearman’s correlation, Mann Whitney U, and Kruskal-Wallis) for those not following a normal distribution.
5. Strengths and Weakness of the Study
The main limitation of the study is the reduced sample size of 70 patients, although the calculated sample size was met, as reflected in the methodology, for the population studied and other similar studies have even smaller sample sizes.
The type of sampling by which the study sample was chosen is a convenience sample, a non-probabilistic and non-random sample, as the patients were chosen because of the ease of access to their medical records, which means that it may not be a representative sample of the population. In addition, by selecting patients operated on by the same surgical team there may be a selection bias, although this is also a strength of the study, as having been operated by the same team the surgical techniques are more comparable, and so are the results.
Patients were followed up for up to 10 years, which is one of the strengths of the study. However, with such a long study period, it is possible that some patients may not be contacted, or that some may have died, so that data will be lost.
Finally, another potential limitation of our study is that we do not know the baseline status of the patients in terms of their well-being and satisfaction. Since the BREAST-Q© questionnaire also has preoperative scales, it would be interesting for future studies to analyze the state of the patients before surgery in order to better assess their changes.