There is no evidence that women who seek breast reconstruction are, as a group, psychologically vulnerable.247
No randomised trials of the impact of breast reconstruction on patient wellbeing have been located. However, it appears that reconstruction may help women worry less about their health, as the surgery helps repair the constant reminder of the life threatening nature of the disease.248 Psychological health may be improved in the short term and body image may be improved at three and twelve months.249
Women who have breast reconstruction are almost always happy with their decision. They report a number of benefits, including: a feeling of being whole again, better psychological and social adjustment to their cancer and mastectomy, more positive body image, better sexual adjustment, less depression and feeling more comfortable without a prosthesis.237
4 . 6 E X T E R N A L B R E A S T P RO S T H E S E S
Specialists performing mastectomy should ensure that the woman is aware of services available which can organise the fitting of a temporary or permanent prosthesis (while some patients are suitable for immediate reconstruction, others who have delayed reconstruction will need to use an external prosthesis in the interim). Follow-up should include assessment of post-mastectomy wound oedema, neuralgia, and radiation skin change or swelling that may impair the
correct fitting and use of an external prosthesis. Clinicians should also be aware of the consequences of a poor fitting, such as postural pain.
There is little literature concerning consumer access to and satisfaction with the current range of external breast prostheses.250
4 . 7 C O M P L I C AT I O N S O F S U R G E RY
Breast surgery requiring general anaesthesia has a low risk of complications. The main risks are:
• post-operative wound infection • haematoma
• deep venous thrombosis
Women who have other unrelated diseases may have increased risk associated with anaesthesia. In appropriate cases, this increased risk should be discussed prior to surgery.
Following mastectomy and axillary dissection, a woman may experience: • seroma of the axilla (following axillary dissection) or skin flap • pain in the upper medial aspect of the arm and chest wall
• impact of loss of the breast on body image, appearance and self-esteem; • lymphoedema of the arm (following axillary dissection)—which can occur
at any stage, even years after treatment
• chest wall discomfort—which should settle within six months
Following breast conservation and subsequent breast irradiation, a woman may experience:
• seroma of the axilla (following axillary dissection) • breast oedema
• breast pain and/or chest wall pain—which may last from three months to up to several years in some cases
• lymphoedema of the arm (following axillary dissection and/or
irradiation)—which can occur at any stage, even years after treatment Following breast reconstruction, a woman may experience:
• partial necrosis (death of tissue) of a soft tissue reconstruction • infection and delayed healing
• infection and rejection of a prosthesis (in prosthetic breast reconstruction) • a second primary tumour in retained breast tissue
• weakness of the abdominal wall (where tissue is in the rectus flap method of reconstruction)
Women should be clearly informed of these potential side effects when treatment options are being discussed, so they may make an informed decision.
After either total mastectomy with axillary dissection or breast conservation with axillary dissection, limitation of shoulder movement (particularly abduction and elevation) may occur, usually during the first few weeks. Appropriate exercises with or without physiotherapy will usually restore full function. Frozen shoulder is a rare complication of these operations. Arm exercises to restore function should be commenced on the first post-operative day.
When axillary dissection has been performed, it is usual to have some sensory loss in the chest wall below or posterior to the axilla and in some cases on the medial and posterior aspect of the upper arm. Preservation at the intercosto- brachial nerve reduces the extent of sensory loss.
As a generalisation, radical surgery combined with radical radiotherapy to the axilla results in a significantly increased risk of late complications such as lymphoedema. The risk of morbidity from combined treatment is relatively constant, while the benefits (a reduction in the risk of death and/or a
locoregional recurrence) increase the higher the risk of recurrence or death. The matter becomes one of individual choice as it is obvious that not all women will see these costs and benefits in the same light.
The predisposing factors to the development of lymphoedema remain poorly understood. Analysis of research about the prevalence of lymphoedema is
complicated by the lack of comparability between studies and by methodological problems in individual studies (see section 4.4).216
Evidence supporting many forms of proposed treatments for lymphoedema, such as compression techniques, physical therapy, and surgical techniques, is less than optimal.216,251Higher quality research is needed to examine the most efficacious treatments for this condition. (See NHMRC National Breast Cancer Centre
Lymphoedema: prevalence, risk factors and management: a review of research,
1997.)
Patients with lymphoedema are at high risk of psychological distress.252-254 A special garment designed to compress the limb, and regular massage to the arm may be recommended to reduce the swelling of lymphoedema; there is some evidence of the effectiveness of these techniques (Level III).216The management of lymphoedema requires the input of both medical practitioners and
Key point
Women who have lymphoedema, or who have had both surgery and radiotherapy to the axilla resulting in a high risk of developing lymphoedema, need to look after their arm as the risk of infection is high. Women should be advised that the risk of problems associated with lymphoedema may be decreased by adhering to the following:
• if the arm on the same side as the surgery is cut or infected, or becomes hot, red, or swollen, immediate medical advice should be sought, the area cleaned and oral antibiotics commenced at the earliest sign of infection • if possible, avoid in the affected arm: having blood taken,
blood pressure checked, a drip inserted and an injection or vaccination
• avoid cuts, burns and insect bites • avoid washing the dishes without gloves • avoid letting the arm become sunburnt
• avoid gardening without gloves and long sleeves • avoid carrying anything heavy with the affected arm • wear loose clothing and loose jewellery
• use skin cream to keep the skin of the arm moist • keep cool during hot weather
• eat a healthy diet to maintain body weight within reasonable limits
• undertake regular gentle exercise
Any intervention in the affected arm should be very carefully considered.
Studies of the psychosocial impact of lymphoedema have found that
lymphoedema is associated with a diminished quality of life and that women with lymphoedema may experience not just functional impairment but also
psychological morbidity.252,253,255A recent review of the literature also reports that studies have shown that women who develop lymphoedema exhibit higher levels of psychological, social, sexual and functional morbidity than women with breast cancer who do not develop this complication.256The review concludes that it is important that information about the condition and its consequences is given to women early in the treatment cycle.256