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Original Investigation
September 16, 2020

Association of Breast Cancer Surgery With Quality of Life and Psychosocial Well-being in Young Breast Cancer Survivors

Author Affiliations
  • 1Dana-Farber Cancer Institute, Boston, Massachusetts
  • 2Brigham and Women’s Hospital, Boston, Massachusetts
  • 3Mayo Clinic, Rochester, Minnesota
  • 4Stanford University, Stanford, California
  • 5Beth Israel Deaconess, Boston, Massachusetts
  • 6Massachusetts General Hospital, Boston, Massachusetts
  • 7University of Colorado Cancer Center, Denver
JAMA Surg. Published online September 16, 2020. doi:10.1001/jamasurg.2020.3325
Key Points

Question  Among young women with breast cancer, are there differences in quality of life and psychosocial health by primary surgery type in the years after surgery?

Findings  In this prospective cohort study, among women diagnosed as having breast cancer at 40 years or younger, outcomes improved over time; however, differences by surgery persisted. Women who had bilateral mastectomy experienced more sexual and body image issues, particularly among those who did not have reconstruction.

Meaning  Understanding differences in quality of life and psychosocial health by surgery type may be useful to young women making preference-sensitive surgical decisions.


Importance  Young women with breast cancer are increasingly choosing bilateral mastectomy (BM), yet little is known about short-term and long-term physical and psychosocial well-being following surgery in this population.

Objective  To evaluate the differential associations of surgery with quality of life (QOL) and psychosocial outcomes from 1 to 5 years following diagnosis.

Design, Setting, and Participants  Cohort study

Setting  Multicenter, including academic and community hospitals in North America

Participants  Women age ≤40 when diagnosed with Stage 0-3 with unilateral breast cancer between 2006 and 2016 who had surgery and completed QOL and psychosocial assessments.

Exposures (for observational studies)  Primary breast surgery including breast-conserving surgery (BCS), unilateral mastectomy (UM), and BM.

Main Outcomes and Measures  Physical functioning, body image, sexual health, anxiety and depressive symptoms were assessed in follow-up.

Results  Of 826 women, mean age at diagnosis was 36.1 years; most women were White non-Hispanic (86.7%). Regarding surgery, 45% had BM, 31% BCS, and 24% UM. Of women who had BM/UM, 84% had reconstruction. While physical functioning, sexuality, and body image improved over time, sexuality and body image were consistently worse (higher adjusted mean scores) among women who had BM vs BCS (body image: year 1, 1.32 vs 0.64; P < .001; year 5, 1.19 vs 0.48; P < .001; sexuality: year 1, 1.66 vs 1.20, P < .001; year 5, 1.43 vs 0.96; P < .001) or UM (body image: year 1, 1.32 vs 1.15; P = .06; year 5, 1.19 vs 0.96; P = .02; sexuality: year 1, 1.66 vs 1.41; P = .02; year 5, 1.43 vs 1.09; P = .002). Anxiety improved across groups, but adjusted mean scores remained higher among women who had BM vs BCS/UM at 1 year (BM, 7.75 vs BCS, 6.94; P = .005; BM, 7.75 vs UM, 6.58; P = .005), 2 years (BM, 7.47 vs BCS, 6.18; P < .001; BM, 7.47 vs UM, 6.07; P < .001) and 5 years (BM, 6.67 vs BCS, 5.91; P = .05; BM, 6.67 vs UM, 5.79; P = .05). There were minimal between-group differences in depression levels in follow-up.

Conclusions and Relevance  While QOL improves over time, young breast cancer survivors who undergo more extensive surgery have worse body image, sexual health, and anxiety compared with women undergoing less extensive surgery. Ensuring young women are aware of the short-term and long-term effects of surgery and receive support when making surgical decisions is warranted.

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