Quality of life of women after mastectomy

Introduction

In Poland, breast cancer is the leading cause of cancer among women and has been characterized by a constantly increasing incidence over the last 50 years. Breast cancer is the second cause of cancer deaths in women after lung cancer [1]. According to the National Cancer Registry (KRN), in 2021, 21,079 new cases of breast cancer in women and 6,406 deaths due to this cancer were recorded in Poland. Risk factors for breast cancer include: age, BRCA1 and BRCA2 gene mutations, family history of breast cancer, early menarche, late menopause, use of hormone replacement therapy or oral contraceptives, overweight, obesity, benign breast hyperplastic diseases and exposure to ionizing radiation. Breast cancer in its early stages is usually asymptomatic and in most cases is diagnosed accidentally as a palpable thickening (hard lump) in the breast. Symptoms that may indicate the presence of breast cancer include: a change in the size and shape of the nipple, skin or nipple retraction, skin changes or discharge from the nipple, redness, thickening or ulceration of the nipple skin, itching or burning of the nipple and enlargement of the lymph nodes [1]. Due to such a diagnosis of the disease, many women are deprived of one or sometimes even both breasts. Breast amputation is a procedure that changes the image of women, which is why it brings with it many changes in life and unpleasant experiences. Women have to adapt to new circumstances. Breasts are a symbol of every woman, so when they are gone, their sense of self-confidence and attractiveness decreases significantly. Patients after mastectomy are exposed to physical pain associated with the symptoms after the procedure, as well as mental pain, they often become depressed and prefer to be alone [2]. The procedure itself causes fear, anxiety about what will happen. The next stages of recovery are also not pleasant, rehabilitation, following basic medical recommendations require a lot of physical strength and perseverance [3].

The quality of life of every person concerns all areas of human existence. In patients after mastectomy, the quality of life often decreases. Therefore, it is important that all actions are aimed not only at treatment, but also at improving this quality [4].

The aim of the conducted research was to assess the quality of life of women after mastectomy.

Material and methods

The research group consisted of 200 women diagnosed with breast cancer and then undergoing mastectomy or breast-conserving surgery. The study used two survey questionnaires: an author’s questionnaire and a standardized WHOQoL-BREF Quality of Life Assessment Questionnaire. The research began in December 2023 and was completed in November 2024. The survey questionnaires were distributed in paper form among women after mastectomy who were residents of the Łódź province. The questionnaires were also made available to members of the Amazons Club. Before the study, the respondents were informed about the purpose of the study and gave their informed consent to participate in it. The study was conducted in accordance with the principles of the Declaration of Helsinki.

The author’s questionnaire contained 22 questions, which were intended to enable the creation of a characterization of the study group.

The WHOQoL-BREF questionnaire contains 26 questions regarding the assessment of quality of life and can be used in studies in relation to healthy and sick people. In the first two questions of the questionnaire, the subject assesses his/her general quality of life and satisfaction with his/her own health. The next questions refer to four domains of quality of life: domain 1 - somatic dimension, domain 2 - psychological dimension, domain 3 - social dimension, domain 4 - environmental dimension. The overall assessment of quality of life is the result of the average obtained from the individual domains [5].

The collected responses from the survey questionnaires were entered into a Microsoft Excel spreadsheet, which enabled the creation of a database. After collecting the necessary data from the respondents, a statistical analysis of selected relationships was performed. The analysis was conducted using the Pearson chi-square test for independent samples. A 5% risk of inference error was assumed for all relationships. A significance level of p<0.05 was assumed during the analysis.

Results

The characteristics of the study group are presented in graphic form in Table 1.

In the group of respondents, as many as 64% (N=128) of the surveyed women experienced a total mastectomy, 10% of respondents (N=20) experienced a radical mastectomy, while breast-conserving surgery was performed in 26% of women (N=52).

When asked about the time that has passed since the surgical intervention in the breast area, 33% of women (N=66) answered that it was 1-4 years ago, and 18% of respondents underwent this procedure between 5-8 years ago (N=36). Women who underwent this procedure more than 8 years ago constituted 13% of the surveyed group (N=26). The smallest percentage were women who had a mastectomy performed less than a year ago - 10% (N=20).

In the surveyed group of women, only 26% (N=52) were able to have the neoplastic lesion removed through breast-conserving surgery.

The largest number of respondents, 75% (N=150), were afraid of limited physical fitness and further health problems after breast removal/conserving surgery. Additionally, every fifth woman questioned, 20% (N=40), was afraid of lack of acceptance from her loved ones.

After a mastectomy, rehabilitation plays a huge role in returning to physical fitness. As the analysis of the study shows, the vast majority of women 93% (N=186) underwent appropriate rehabilitation after such a procedure. Additionally, a significant majority of 74% (N=148) of these women declared that it brought satisfactory results. However, it is sad that 7% (N=14) of the respondents did not undergo any post-operative rehabilitation.

Satisfactory results of the study concern performing lymphatic massage, which plays an important role in the post-amputation period. In the study group of women, as many as 89% (N=178) declare that they know the technique and are able to perform it independently.

In difficult moments of their illness, slightly more than half of the 54% (N=108) of respondents sought help from a psychologist. It is also encouraging that almost all women 91% (N=182) who had a hard time could count on the support of their family and loved ones.

The greatest difficulties that women from the study group had to face included cleaning and dressing 78% (N=156), as well as washing and lifting, even not very heavy objects 69% (N=138).

The statistical analysis of the conducted study showed that the surgical procedure in the breast area was a difficult experience for the respondents and returning to performing daily activities before the procedure took more than 4 weeks 68% (N=136), every fourth woman (N=50) achieved the pre-procedure fitness after 3-4 weeks. A quick recovery period after the breast procedure lasting between 1-2 weeks was declared by only 4% (N=8) of the interviewed women. Unfortunately, for 3% (N=6) of respondents, such a return has not yet occurred.

Women are the group of society that attaches great importance to their appearance. This is also confirmed by the results of the study, where 75% (N=150) of respondents declared that they often paid attention to their appearance before surgery. Only 7% (N=14) claim that they do it sometimes or very rarely. A very similar percentage of women 73% (N=146) also attach great importance to their appearance after surgery. Only 2% (N=4) of respondents claim that after surgery they do not pay attention to their appearance at all.

More than half of the 64% (N=128) of the surveyed respondents assess their physical fitness after the procedure as worse compared to the time before the surgical intervention in the breast area, and 23% of women (N=46) describe it even as much worse.

The statistical analysis of the obtained results presents an optimistic picture in the subject of the sexual life of women after mastectomy. 65% (N=130) of the interviewed women claim that their sexual life has not changed after the procedure. However, 16% (N=32) of the respondents try to avoid sexual contact.

Analysing the respondents’ answers from the WHOQOL-BREF questionnaire, we can observe the quality of life in various areas, such as: social relations, physical, psychological or environmental.

In the physical area, the respondents most frequently declared that physical pain prevented them from performing everyday activities to a large extent - 35% (N=70) and to a very large extent - 38% (N=76).

The results obtained in the psychological field showed that more than half of the surveyed women – 55% (N=110) are moderately happy with their lives, only 28% of the surveyed (N=56) are very happy with their lives, and only one in twenty women after mastectomy are very happy. More than half of the respondents – 57% (N=114) – can accept their appearance after the surgical procedure in the area of the breasts to a moderate degree, while only 7% (N=14) of the surveyed women are able to accept it fully.

In the social field, statistical analysis showed that the majority of surveyed women are satisfied with their personal relationships with people 64% (N=128), and 7% (N=14) even declare very high satisfaction (N=7). Only 6% (N=12) of women are dissatisfied with their interpersonal relationships.

In the environmental field, the surveyed women showed that they feel quite safe in their everyday lives 43% (N=86) and averagely safe 40% (N=80). Only one in twenty surveyed women (N=10) has enough money to meet their own needs, while the majority of respondents 68% (N=136) have moderate funds for their needs.

Statistical analysis of the conducted study showed a significant relationship between the marital status of the respondents and their quality of life. The quality of life of married women is the best compared to other marital statuses.

The study also showed a statistically significant relationship between the type of surgical procedure performed on the breast and the quality of life of women. The analysis shows that 82.8% of women assess their quality of life as average (neither good nor bad) and these are those who had simple amputation. Detailed data are provided in Table 2.

The statistical analysis was also performed on the relationship between having support from family and the quality of life of women after mastectomy. During the assessment, attention was paid to whether women could count on support from their loved ones or not, and how they assessed their quality of life (Table 3).

The occurrence of the relationship between the type of procedure that the respondents had undergone and their sexual life after the procedure was analyzed successively. The statistical analysis took into account the types of procedures and the answers given to the question whether the sexual life of the surveyed women had changed. The answers given were: yes for the better, it has not changed, yes for the worse and I try to avoid sexual contacts. The analysis of the studies shows that in 84.6% of women after breast-conserving surgery and in 65.6% of respondents after simple mastectomy, the sexual life did not change. The level of significance was calculated, the exact value of which was p<0.001 and the chi-square value of 46.05. The theoretical chi-square value was 12.59 with the calculated number of degrees of freedom equal to 6 for the analyzed variables and with the significance level of p<0.05. Based on the above data, it can be concluded that there is a relationship between the type of procedure performed and the sexual life of the surveyed women after the procedure, as the theoretical chi-square value is lower than the value calculated at the assumed significance level of p<0.05 and also at the exact probability level of p<0.001, in which the chi-square value was 22.46.

An analysis of the relationship between the age of the surveyed women and their quality of life was also performed. It was noted that all the surveyed women of younger age assessed their quality of life as good (40%) or very good (60%), while those aged 51 and over largely chose the answer neither good nor bad (60.7%). With the calculated probability level p=0.001, the theoretical chi-square value was 32.91 and is slightly higher than the calculated value, which indicates no relationship between the studied variables (Table 4).

The relationship between having children and the quality of life of the surveyed women was also analyzed. The statistical analysis took into account whether the respondents had children or not, and what answers they gave to the question about the quality of their life. The existence of a relationship between having children and quality of life was based on calculations of the probability level and the value of the chi-square test, and it was shown that the quality of life was better in women who were mothers.

Another assessment of the relationship was made between performing/not performing mastectomy and the mental state of women. The study shows that 52.7% of women after mastectomy assess their mental health as „bearable”. None of the surveyed women after mastectomy marked the answer „excellent”. For the statistical analysis, it was taken into account whether amputation was performed and how women assess their mental health after mastectomy by marking answers such as: excellent, very good, good, bearable, bad. After conducting the statistical analysis, it can be stated that there is a significant relationship between the variables studied because at the calculated probability level of p<0.001 and with the adopted p<0.05, the theoretical value of the chi-square test is lower than the calculated value.

Discussion

As the studies show, the quality of life of women after mastectomy changes. The analysis of our own studies showed a relationship between marital status and the quality of life of women after mastectomy. More than half of married women assessed their quality of life as neither good nor bad, and only one in twenty as very good. Single women more often chose the answers bad and very bad. Divorced women in 85.7% chose the answer neither good nor bad, while the rest of them (14.3%) assessed their quality of life as very bad. Those women who were in partnerships and married women did not choose such answers. However, the studies conducted by Cipora et al. [6] show that the marital status of the surveyed women did not differentiate the quality of life of women after mastectomy. In the case of the studies by Musiał et al. [4] it was similar, as no statistical relationship was found between the variables studied, i.e. between marital status and the level of quality of life.

The analysis of the relationship between the type of procedure performed and the quality of life of the respondents shows that the quality of life of women after radical mastectomy is assessed most often as very poor and poor. As can be seen, women after radical mastectomy do not assess their quality of life well. The research also shows that none of the women after radical mastectomy assess their quality of life as good or very good. The quality of life is assessed as good in 57.7% of women who underwent breast-conserving surgery, while women after total amputation in 82.8% chose the answer neither good nor bad.

Based on the conducted research, it can be stated that there is a relationship between the type of procedure and the quality of life of the surveyed women. Similar results from the conducted research were obtained by Szutowicz-Wydra et al. [7]. They show that women after breast-conserving surgery also assess their quality of life highly. The fact that women after breast-conserving procedures assess the quality of their own life better may result from the fact that using this type of procedure involves less interference in changing the appearance of women. The research conducted by Rybka and Ziółkowska [8] also shows that there is a relationship between the type of procedure performed and the assessment of the quality of life of the surveyed women. Women after breast-conserving surgery demonstrated the highest level of their quality of life, while the lowest assessment was recorded among women who underwent bilateral mastectomy.

Our own research also showed a relationship between the support from family received by women after the procedure and their quality of life. More than half of the surveyed women who had support from their family assessed their quality of life as neither good nor bad, the rest marked the answers good or even very good. None of the respondents who had the support of their loved ones after the procedure stated that their quality of life was bad or very bad. In the case of women who could not count on support from their loved ones, only 22.2% of them chose the answer neither good nor bad, while the rest assessed the quality of life bad or even very bad. It can therefore be seen that women whose families supported them after the procedure have a higher quality of life than women who did not experience such support. Rybka and Ziółkowska [8] state that there is a relationship between support provided by their closest relatives and the quality of life of the surveyed women. Similarly, Połocka-Molińska et al. [9] in their research draw attention to the quality of life of women depending on the support they receive from their loved ones after the procedure. According to them, women who receive such support and are more professionally active rate their quality of life higher.

A significant correlation was also demonstrated when analyzing the type of procedure and the sexual life of women after the surgery. The analysis of our own research shows that the sexual life of most women, as many as 84.6%, did not change after the breast-sparing procedure, and for 15.4% it changed for the better. However, in the case of women who underwent radical mastectomy, the sexual life of 70% of them unfortunately changed for the worse, and the remaining 30% try to avoid sexual contacts. Zdończyk [10] in his work examined the sexual health of women suffering from breast cancer after surgical treatment. His research shows that after the disease, satisfaction with women’s sexual life decreases by 20% compared to before the disease. The quality of life after mastectomy was also assessed by Cipora et al. [6], who in their study showed that the sexual life of almost half of the women included in the study changed. Similar studies were also conducted by Musiał et al. [4], who examined the quality of life of respondents belonging to the Amazonka club and who had undergone mastectomy and obtained the following results. Slightly more than half of the women were neither satisfied nor dissatisfied with their sexual life. Based on the above information, it can be concluded that the quality of sexual life changes in women after mastectomy. The research conducted by Szutowicz-Wydra et al. [7] shows that among women after breast-conserving surgery, their functioning in the sexual sphere is lower than in women who had both mastectomy and reconstruction.

Based on the analysis of our own research, no statistically significant relationship was found between the age of the respondents and their quality of life. It was found that as many as 60% of respondents aged 20-30 assessed their quality of life as very good, while 40% assessed it as good. Women aged 31-40, 41-50 and 51 and above assessed their quality of life to a large extent as neither good nor bad. In the research by Cipora et al. [7], women aged 41-50 assessed their quality of life as bad and satisfactory. The best, i.e. very good quality of life was declared by women aged 51-60, while good quality of life was declared by women aged 61-70 and older. Their research on these variables also did not show any significant relationship. Rocławska [11] did not show any relationship between age and quality of life in her research. In the study conducted by Pacian et al. [12], women who were over 50 years old indicated a worse level of quality of life than respondents who were under 50. On the other hand, the study by Musiał et al. [4] proved a statistically significant relationship between age and quality of life of women after mastectomy. According to them, women who are older show a lower quality of life.

A statistically significant relationship results from the study of variables such as: having children and the quality of life of the respondents. None of the women who have children assessed their quality of life as very bad or bad. More than half, i.e. as many as 65.1%, claim that their quality of life is neither good nor bad, 26.5% that it is good, and 8.4% that it is very good. However, women who do not have children assessed their quality of life as bad in 29.4%, and very bad in 11.8%. On the other hand, Musiał et al. [4] did not find any relationship between them when examining the same variables. In her study, Szpurtacz [13] took into account, among others, the number of children women had and areas such as: social, environmental, psychological and physical. In the presented areas, no relationship was found between the number of children women had and the assessment of the quality of life in the women studied.

Another statistically significant relationship is the relationship between mastectomy and the mental health of the respondents. Women after mastectomy assessed their mental health as bearable in 52.7% of cases. Unfortunately, slightly over 40% of respondents assessed it as bad. Women who did not have mastectomy assessed their mental health much better. As many as 53.8% assessed it as very good. The results of Rocławska’s research [11] are similar, as they show that mental functioning after mastectomy is assessed worse by women.

Conclusions

1. Marital status has an impact on the quality of life of women after mastectomy. 2. Having support from loved ones has a statistically significant impact on the increase in the quality of life of women after mastectomy. 3. The type of procedure performed has an impact on the sexual life of women after the removal of the mammary gland and is significantly higher in women who underwent breast conserving surgery. 4. The age of women who underwent mastectomy does not affect the quality of life they experience. 5. Having children by women after mastectomy has a significant impact on improving the quality of their life. 6. Removal of the mammary gland significantly affects the deterioration of mental functioning in women.