Psychological outcomes of nipple sparing mastectomy

Women diagnosed with breast cancer often experience significant psychological distress from the time of diagnosis, as well as during and after their surgery. Decisional conflict, post-decision regret and body image disturbances have been shown to contribute to a woman's psychological distress and satisfaction with the outcome of her breast surgery. Nipple sparing mastectomy with immediate breast reconstruction (NSM+IBR) is a relatively new yet oncologically safe surgical technique that may help to minimise psychological distress from decisional conflict, regret and body image disturbances as it is a single-step procedure and preserves a woman's skin and areola complex. The current thesis is presented in three parts. First a literature review of research investigating the effects of surgery for breast cancer on a woman's body image and the relationship of body image with distress, decisional conflict and regret is presented. The second section of the thesis comprises two chapters corresponding to empirical work investigating: Study 1. Body image disturbance and psychological distress in women who have undergone NSM+IBR, inclusing investigation of the mediating effect of self-compassion, and the moderating effect of appearance investment on this body image-distress relationship via self-compassion. Study 2. Decisional conflict and post-decision regret in NSM+IBR, as well as factors that are associated with increased levels of decisional conflict and regret, such as satisfaction with reconstructed breasts, physical and sexual well-being after breast surgery, partner reactions to the woman's reconstructed breasts and the importance a woman places on her partner's reaction. Methods: Women diagnosed with breast cancer (N=80) who had previously undergone NSM+IBR completed online questionnaires including the Body Image Scale (Hopwood et al., 2001), Depression, Anxiety and Stress Scales (Lovibond & Lovibond, 1992), Impact of Event Scale (Horowitz et al., 1979), Self-Compassion Scale (Short Form; Raes et al., 2011), Appearance Schemas Inventory (Revised; Cash et al., 2004), Decisional Conflict Scale (O’Connor, 1995), Decision Regret Scale (Brehaut, 2003), BREAST-Q (Pusic et al., 2009) and a measure of perceived partner reactions and the importance placed on this reaction (scale designed specifically for the current study). Results:Study 1: Mean scores on general and cancer-specific psychological distress were within normal ranges and body image disturbance was moderately low. Body image was positively correlated with depression, stress, impact of event scale scores and appearance investment, and negatively correlated with self-compassion. Bootstrap moderated mediation analyses indicated a significant indirect (mediating) effect of self-compassion (depression, anxiety, stress) but only for women with high levels of appearance investment. Study 2: Mean scores on decisional conflict and regret indicated that the majority of the current sample experienced low levels of decisional conflict and regret, although 15% indicated high levels of conflict, and 20% reported moderate to strong regret. Simple linear regression analyses indicated that the extent to which a woman cared about her partner’s reaction to her reconstructed breasts uniquely contributed to decisional conflict, while a woman’s satisfaction with her reconstructed breasts uniquely contributed to decision regret. No other factors were associated with conflict or regret. Conclusions: Findings suggest that NSM+IBR may minimise the adverse psychological impacts of mastectomy, with the majority of the current sample experiencing low levels of psychological distress, body image disturbance, decisional conflict and decision regret. However, NSM+IBR is not an available option for all women undergoing mastectomy. As such, identifying women high in appearance investment and low in self-compassion may be of particular clinical relevance for identifying women who are at greater risk for poorer psychological adjustment post-surgery. Additionally, recognition of factors that contribute to decisional conflict and regret, such as the importance placed by a woman on her partner’s reaction to her reconstructed breasts, and her satisfaction with her reconstructed breasts, respectively, may assist with interventions aimed at reducing decisional conflict and regret. The research documented in the current thesis may, therefore, be of particular relevance for clinicians engaged in supportive psychological interventions dedicated to women who have undergone breast surgery by: i) providing additional support to women identified as at risk for greater distress; ii) assisting clinicians in modifying existing breast surgery body image interventions for the most favourable outcome (e.g., by including psycho-education and practice on increasing self-compassion and lowering appearance investment); iii) routinely involving partners in the decision-making process to help reduce decisional conflict and post-decision regret; and iv) working with women on their expectations of the outcome of surgery.