Research Article: Determinants of satisfaction with cosmetic outcome in breast cancer survivors: A cross-sectional study

Date Published: February 21, 2018

Publisher: Public Library of Science

Author(s): Peh Joo Ho, Mikael Hartman, Danny A. Young-Afat, Sofie A. M. Gernaat, Soo Chin Lee, Helena M. Verkooijen, Sabine Rohrmann.


Little research has been done into cosmetic outcomes in non-Western breast cancer populations. We aimed to study the prevalence and determinants of dissatisfaction with cosmetic outcome after breast cancer surgery of Asian breast cancer survivors, and its association with patient-reported anxiety, depression, and quality of life. In a hospital-based cross-sectional study, 384 breast cancer survivors of at least 12 months after diagnosis completed questionnaires on satisfaction with cosmetic appearance, quality of life (EORTC-QLQ-C30) and anxiety and depression (HADS). Cumulative logit models were used to examine the adjusted association between dissatisfaction with cosmetic appearance and demographic and clinical characteristics. Kruskal-Wallis test was used to test for associations between dissatisfaction with cosmetic appearance and patient-reported outcomes. Overall, 20% of women reported to be (very) dissatisfied with cosmetic appearance. Survivors of Chinese ethnicity were more likely dissatisfied with cosmetic appearance compared to Malay survivors (22% and 14% respectively, adjusted OR = 2.4, 95%CI: 1.4–3.9). Women with DCIS (adjusted OR = 2.2, 95%CI: 1.3–3.7) or advanced stage disease (adjusted OR = 2.2, 95%CI: 1.2–3.9) had a higher risk of being dissatisfied with their cosmetic appearance. Women treated with mastectomy were at a higher risk of dissatisfaction with cosmetic appearance (adjusted OR = 1.7, 95%CI: 1.1–2.5). Dissatisfaction with cosmetic appearance was associated with increased depression scores. In this South-East Asian population, one in five breast cancer patients were (very) dissatisfied with the cosmetic outcome of treatment. Chinese women, women with larger tumors and women treated with mastectomy were most likely to report dissatisfaction with cosmetic appearance.

Partial Text

Breast cancer accounts for 18% of all cancers diagnosed in the Asia-Pacific region, where 42% of breast cancers are diagnosed in women under the age of 50 years [1]. Due to increasing incidence, and improving survival, the number of women living with consequenses of breast cancer and its treatment is increasing.

This cross-sectional study was conducted at the National University Hospital (NUH), Singapore, between April 2014 and April 2015 and received institutional ethical approval. Female breast cancer survivors, who were at least one year post diagnosis and visiting outpatient clinics for routine follow-up, were eligible for inclusion in the current study. Participants were selected from the daily patient list of the Breast Care Centre, the Breast Imaging Centre, and the Oncology Centre. Breast cancer survivors who were unable to communicate in English or Mandarin or who had psychological disorders other than anxiety and depression recorded in their medical records were excluded.

A total of 384 breast cancer survivors were included of which 292 (76%) were Chinese, 71 (19%) were Malay, and 21 (5%) were Indian. Chinese participants had the oldest median age at diagnosis (52 years), followed by Malays (49 years), and Indians (46 years) (Table 1). The median time since diagnosis was 5 years for Chinese survivors and 4 years for Malay and Indian survivors. Tumor stage at diagnosis varied by ethnicity, with 90%, 80%, and 67% of Chinese, Malay, and Indian survivors, respectively, diagnosed with early stage breast cancer (in situ, stage I or II). Otherwise survivors of different ethnicities were similar in terms of tumor characteristics and treatments (Table 1).

In this South-East Asian population of breast cancer patients, one in five patients was (very) dissatisfied with cosmetic outcome after breast cancer treatment. Breast cancer survivors of Malay ethnicity were most likely to be satisfied, and Chinese survivors were the least satisfied. Accounting for ethnicity differences, being diagnosed with in situ or stage III/IV tumors, and having had mastectomy were independent risk factors of being dissatisfied with cosmetic appearance. Dissatisfaction with cosmetic appearance was associated with higher levels of depression.

Twenty percent of breast cancer survivors in Singapore report dissatisfaction with cosmetic appearance following breast cancer surgery, and dissatisfaction with cosmetic outcome is most common among Chinese women. Being diagnosed with in situ or stage III/IV breast cancer and having had mastectomy as compared with breast conserving surgery, were independent determinants of dissatisfaction with cosmetic appearance. Prospective studies are needed to assess if interventions aimed at improving information of patients and expectation management, such as shared decision making and joining support groups, may improve satisfaction with appearance and reduce depression.




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