**3. Results**

The sociodemographic, clinical, and psychological characteristics of women who received BCT or MTC and the women who had a benign breast problem are summarized in Table 1.


Note: 1 more than one treatment possible; 2 higher scores on body image indicate higher quality of life Abbreviations: BBP: Benign Breast Problems; BCT: Breast-Conserving Therapy; MTC = mastectomy

Table 1. Patient characteristics

The sociodemographic, clinical, and psychological characteristics of women who received BCT or MTC and the women who had a benign breast problem are summarized in Table 1.

(n = 381)

123 (32.1%) 171 (44.6%) 72 (18.8%)

Age at diagnosis, yrs 52.9 ± 10.4 58.4 ± 8.5 58.5 ± 9.7 .91

No partner 50 (13.1%) 14 (13.2%) 21 (18.6%) .29

No children 57 (14.9% 14 (13.2%) 14 (12.4%) .77


Chemotherapy - 20 (18.9%) 41 (36.3%) .01

Hormone therapy - 32 (30.2%) 52 (46.0%) .02

Radiotherapy - 96 (90.6%) 20 (17.7%) <.0001

16.0 ± 3.3 31.1 ± 6.9 40.1 ± 5.8 36.7 ± 5.4 43.7 ± 4.2 45.4 ± 4.9

Note: 1 more than one treatment possible; 2 higher scores on body image indicate higher quality of life Abbreviations: BBP: Benign Breast Problems; BCT: Breast-Conserving Therapy; MTC = mastectomy

BCT (n = 106)

38 (35.8%) 46 (43.4%) 19 (17.9%)

8 (7.5%) 60 (56.6%) 33 (31.1%) 5 (4.7%)

16.6 ± 2.8 30.7 ± 7.5 40.6 ± 5.7 36.2 ± 6.6 43.7 ± 4.2 45.9 ± 5.6 MTC (n = 113)

43 (38.1%) 47 (41.6%) 17 (15.0%)

17 (15.5%) 32 (28.3%) 34 (30.1%) 30 (26.5%)

16.5 ± 3.1 29.4 ± 7.1 41.9 ± 5.4 35.0 ± 4.9 43.3 ± 4.2 45.9 ± 5.2 .81 .23 .09 .20 .44 .96

p-value

.84

<.0001

**3. Results** 

*Demographics* 

Educational level

0-9 years 10-14 years > 14 years

*Clinical values* 

Disease stage Stage 0 Stage I Stage IIa Stage IIb

*Adjuvant therapy¹* 

*Psychological* 

Body image WHOQOL2 [range: 4-20]

Openess to experience [range: 12-60]

Neuroticism [range: 12-60] Extraversion [range: 12-60]

Agreeableness [range: 12-60] Conscientiousness [range: 12-60]

Table 1. Patient characteristics

BBP

Patients who underwent MTC were more often treated with chemotherapy and hormone therapy, compared to patients who received BCT (p *<*.05). As expected, based on standard treatment, women with BCT were more often treated with radiotherapy (p<.0001) and differed regarding disease stage (p<.0001). No other differences between the surgical groups were found with regard to other sociodemographic, clinical, and psychological variables. Figure 2 shows the change in scores on WHOQOL-facet Body Image. Body Image changed significantly over time [F(4,239) = 3.0; p =.020], after correcting for potential confounders. Furthermore, an interaction effect was found for time by surgical treatment, indicating that the pattern of change over time in Body Image is different for women with MTC, women with BCT, and women with BBP [F(8,480) = 2.8; p =.004]. From Time-1 to Time-2, women with MTC reported a significant deterioration in their Body Image (p=.035), while women

with BCT and BBP were stable. Although their Body Image improved in time, they had significantly lower scores at Time-5 when compared to Time-1 (p = .004). Radiotherapy and disease stage did not interact with Body Image (p >.05). Overall, women with BBP and women with BCT and MTC did not score differently on Body Image, except at Time-2 (p<.036).

Fig. 2. Mean scores on Body Image and Appearance (WHOQOL-100) across time for women who undergonebreast-conserving therapy (BCT) and mastectomy (MTC) and women with a benign diagnosis

Changes in Body Image in Women with Early Stage Breast Cancer 35

Timepoint Factor β-value R2 Adjusted R2 p-value Time-2\* Age .31 .34 .32 <.0001 BCT/MTC -.21 .005 Neuroticism -.31 <.0001 Agreeableness .20 .011 Time-3\* Age .35 .27 .26 <.0001

Disease stage -.25 .001

Neuroticism -.29 <.0001

Time-4 Age .18 .29 .26 .024 Educational level .08 .328 Chemotherapy -.28 .001 Neuroticism -.23 .006 Agreeableness .24 .003 Time-5 Age .22 .30 .28 .006 Chemotherapy -.16 .038 Neuroticism -.30 <.0001 Agreeableness .26 .001 Note: \*chemotherapy was not entered at Time-2 and Time-3 as a factor, since women with breast cancer

Table 2. Final results of hierarchical multiple regression analysis with body image (WHOQOL-100) as the dependent variable, for one (Time-2), three (Time-3), six (Time-4),

Body image is an important aspect of QOL in women with breast cancer. For years, it was hypothesized that MTC contributed to some extent to the development of psychological problems of women with breast cancer. It was intuitively thought that BCT would remove some of the stress because of its less mutilating effect compared to MTC.(Meyer and Aspegren, 1989) Until now, body image was mostly studied in cross-sectional designs. Therefore, this prospective study examined the impact of surgical treatment, personality, and sociodemographic factors on body image during a follow-up period of one year after primary surgical treatment. In addition, this study examined if scores on body image were lower in women who received MTC compared to women who underwent BCT or women with benign breast problems. In general, a temporary decrease was found in body image scores due to treatment. Although we found that scores of women with MTC were lower

had not yet received chemotherapy

**4. Discussion** 

and 12 months after surgery (Time-5)

Figure 3 shows the change in scores on EORTC QLQ BR-23 subscale Body Image. In the adjusted analysis, Body Image improved significantly over time when correcting for potential confounders [F(3,93) = 2.8; p =.043]. Scores on Time-4 (85.2 ± 20.3), and Time-5 (86.4 ± 18.4) were statistically higher compared with the scores on Time-2 (79.7 ± 23.1; ps<.05). On average, women with BCT and MTC scored differently on Body Image, i.e. women with BCT scored significantly higher on Body Image [F(1,95) = 7.4; p =.008]. However, no interaction effect was found, indicating that the pattern of change over time in Body Image was not significantly different for both groups (p =.348). Radiotherapy and disease stage did not interact with Body Image (p >.05).

Fig. 3. Mean scores on Body Image (EORTC QLQ-BR23) across time for women who undergone breastconserving therapy (BCT) and mastectomy (MTC)

Table 2 shows those factors associated with Body Image (WHOQOL-100) scores across time. Being older, receiving chemotherapy, high scores on neuroticism, and low scores on agreeableness were significantly associated with lower Body Image scores at all time points. The regression models at different time points explained 26% to 32% of the variance. Table 3 shows those factors associated with Body Image (EORTC QLQ BR23) scores across time. High scores on neuroticism were significantly associated with lower Body Image scores at all time points. The regression models at different time points explained 16% to 30% of the variance. Chemotherapy, radiotherapy, and hormone therapy were not entered in the regression analysis at Time-2 and Time-3, since women not received this treatment yet.


Note: \*chemotherapy was not entered at Time-2 and Time-3 as a factor, since women with breast cancer had not yet received chemotherapy

Table 2. Final results of hierarchical multiple regression analysis with body image (WHOQOL-100) as the dependent variable, for one (Time-2), three (Time-3), six (Time-4), and 12 months after surgery (Time-5)

#### **4. Discussion**

34 Topics in Cancer Survivorship

Figure 3 shows the change in scores on EORTC QLQ BR-23 subscale Body Image. In the adjusted analysis, Body Image improved significantly over time when correcting for potential confounders [F(3,93) = 2.8; p =.043]. Scores on Time-4 (85.2 ± 20.3), and Time-5 (86.4 ± 18.4) were statistically higher compared with the scores on Time-2 (79.7 ± 23.1; ps<.05). On average, women with BCT and MTC scored differently on Body Image, i.e. women with BCT scored significantly higher on Body Image [F(1,95) = 7.4; p =.008]. However, no interaction effect was found, indicating that the pattern of change over time in Body Image was not significantly different for both groups (p =.348). Radiotherapy and

Fig. 3. Mean scores on Body Image (EORTC QLQ-BR23) across time for women who

Table 2 shows those factors associated with Body Image (WHOQOL-100) scores across time. Being older, receiving chemotherapy, high scores on neuroticism, and low scores on agreeableness were significantly associated with lower Body Image scores at all time points. The regression models at different time points explained 26% to 32% of the variance. Table 3 shows those factors associated with Body Image (EORTC QLQ BR23) scores across time. High scores on neuroticism were significantly associated with lower Body Image scores at all time points. The regression models at different time points explained 16% to 30% of the variance. Chemotherapy, radiotherapy, and hormone therapy were not entered in the regression analysis at Time-2 and Time-3, since women not received this treatment yet.

undergone breastconserving therapy (BCT) and mastectomy (MTC)

disease stage did not interact with Body Image (p >.05).

Body image is an important aspect of QOL in women with breast cancer. For years, it was hypothesized that MTC contributed to some extent to the development of psychological problems of women with breast cancer. It was intuitively thought that BCT would remove some of the stress because of its less mutilating effect compared to MTC.(Meyer and Aspegren, 1989) Until now, body image was mostly studied in cross-sectional designs. Therefore, this prospective study examined the impact of surgical treatment, personality, and sociodemographic factors on body image during a follow-up period of one year after primary surgical treatment. In addition, this study examined if scores on body image were lower in women who received MTC compared to women who underwent BCT or women with benign breast problems. In general, a temporary decrease was found in body image scores due to treatment. Although we found that scores of women with MTC were lower

Changes in Body Image in Women with Early Stage Breast Cancer 37

added questions to general questionnaires to measure body image.(Engel et al., 2004, Hartl et al., 2003, Janni et al., 2001, King et al., 2000) In this study, a generic QOL instrument (WHOQOL-100) and a disease-specific health status instrument (EORTC QLQ BR-23) were used. The results based on both instruments indicated that body image scores changed significantly over time, irrespective of diagnosis/treatment. However, this effect was partly explained by the differences in scores between the baseline measure and the first follow-up measure (WHOQOL-100), when body image scores dropped considerably in the MTC group. Body image scores measured with the EORTC-QLQ BR23 also improved significantly; but, this measure could not register the drop in body image scores between Time-1 and Time-2, since it can only be assessed in a cancer population. In our study, the baseline assessment was before diagnosis. (Engel et al., 2004) Our findings are in line with other studies. For instance, Ganz et al. (Ganz et al., 1992) reported an improvement in body image one year after surgery in both surgical groups, just as Bloom et al. (Bloom et al., 2004) did between baseline (soon after diagnosis) and five year follow-up. In our study, body image scores completely returned to baseline values, except for the body image scores of women with MTC. It is possible that a study in which a longer follow-up is taken, body

Older women were more satisfied with their bodies, which is in line with the majority of other studies in this field. (Al-Ghazal *et al.*, 1999, Fehlauer *et al.*, 2005, Janz *et al.*, 2005, Kenny *et al.*, 2000, King *et al.*, 2000) However, it should be noted that the results on the direction of the relationship between age and body image in the literature is inconsistent. That is, several studies did not find differences in body image scores between age groups(Engel *et al.*, 2004, Schou *et al.*, 2005) or found that body image issues may be particularly salient for younger women(Avis *et al.*, 2005). Since older women are often excluded from clinical studies, future

Adjuvant therapies, like radiotherapy and hormone therapy were not strongly related to body image. Chemotherapy predicted scores on body image at all time points included. From the few studies that are available on this topic, women who received chemotherapy reported lower scores on body image (Janz *et al.*, 2005, Schover *et al.*, 1995), probably due to

Personality characteristics (neuroticism and agreeableness) played an important role in predicting outcome in this study. Neuroticism contributed in a negative way to scores on body image at all follow-up measures, after controlling for all other variables. This result is consistent with other research on personality in breast cancer, in which patients, who experienced high levels of chronic stress one year after treatment for breast cancer, were characterized by higher levels of neuroticism. (Millar *et al.*, 2005) In other studies, this trait also in part explained the variance in depressive symptoms after breast cancer surgery (Den Oudsten *et al.*, 2009a, Golden-Kreutz and Andersen, 2004), as well as of poor adjustment to

After discussing the results of the study, certain limitations and strengths should be acknowledged. Strength of the underlying study is the baseline measurement, before the diagnosis is known. At the same time, this is also a weakness, because women are probably scared and nervous because an abnormality has been seen on the mammography (i.e., only applies for those women who had a screening mammography) or that a lump (whether it is benign or malign) is in the breast. However, in this study the BBP group showed stable scores regarding body image. The optimal moment for the baseline measurement would be

studies should examine the psychosocial concerns in this age group.

the loss of hair that is accompanied by this type of treatment.

image will further improve.

mastectomy. (Morris *et al.*, 1977)

compared with women with benign breast problems and women with BCT, the results were only significant at one month after surgery. Type of surgical treatment predicted body image at one month (WHOQOL-100; EORTC QLQ-BR23), three months (EORTC QLQ-BR23), and six months after surgical treatment (EORTC QLQ-BR23). Most studies found BCT to be superior with regard to scores on body image, which is in line with our study. (Avis *et al.*, 2004, Ganz *et al.*, 2002, Hartl *et al.*, 2003, King *et al.*, 2000, Schou *et al.*, 2005, Yeo *et al.*, 2004) BCT patients were more satisfied with their appearance than patients who received MTC. (Engel *et al.*, 2004, Janni *et al.*, 2001)


Note: \*chemotherapy was not entered at Time-2 and Time-3 as a factor, since women with breast cancer had not yet received chemotherapy

Table 3. Final results of hierarchical multiple regression analysis with body image (EORTC-QLQ BR23) as the dependent variable, for one (Time-2), three (Time-3), six (Time-4), and 12 months after surgery (Time-5)

Studies in this field show a wide variation with regard to the methodological aspects. First, different instruments were used to assess body image. There is a wide variation in body image scales, and they are composed of different items. For example, some instruments contain items assessing satisfaction with body image, as the breast specific module from the European Organization for Research and Treatment of Cancer (EORTC QLQ-BR23)(Fehlauer et al., 2005, Janz et al., 2005), or with the Cancer Rehabilitation Evaluation System (CARES). (Avis et al., 2004, Ganz et al., 1992) Others constructed their own scale or

compared with women with benign breast problems and women with BCT, the results were only significant at one month after surgery. Type of surgical treatment predicted body image at one month (WHOQOL-100; EORTC QLQ-BR23), three months (EORTC QLQ-BR23), and six months after surgical treatment (EORTC QLQ-BR23). Most studies found BCT to be superior with regard to scores on body image, which is in line with our study. (Avis *et al.*, 2004, Ganz *et al.*, 2002, Hartl *et al.*, 2003, King *et al.*, 2000, Schou *et al.*, 2005, Yeo *et al.*, 2004) BCT patients were more satisfied with their appearance than patients who received

Timepoint Factor β-value R2 Adjusted R2 p-value Time-2\* BCT/MTC -.29 .18 .16 .001 Neuroticism -.24 .008 Agreeableness .16 .079 Time-3\* Age .26 .33 .31 <.0001 BCT/MTC -.30 <.0001 Neuroticism -.43 <.0001 Conscientiousness -.29 <.0001 Time-4 Age .28 .34 .30 .001 Educational level .07 .400 BCT/MTC -.21 .007 Chemotherapy -.16 .044 Neuroticism -.32 <.0001 Agreeableness .19 .024 Conscientiousness -.22 .007 Time-5 Age .22 .23 .20 .006 Neuroticism -.25 .004 Agreeableness .27 .002 Conscientiousness -.29 .001 Note: \*chemotherapy was not entered at Time-2 and Time-3 as a factor, since women with breast cancer

Table 3. Final results of hierarchical multiple regression analysis with body image (EORTC-QLQ BR23) as the dependent variable, for one (Time-2), three (Time-3), six (Time-4), and 12

Studies in this field show a wide variation with regard to the methodological aspects. First, different instruments were used to assess body image. There is a wide variation in body image scales, and they are composed of different items. For example, some instruments contain items assessing satisfaction with body image, as the breast specific module from the European Organization for Research and Treatment of Cancer (EORTC QLQ-BR23)(Fehlauer et al., 2005, Janz et al., 2005), or with the Cancer Rehabilitation Evaluation System (CARES). (Avis et al., 2004, Ganz et al., 1992) Others constructed their own scale or

MTC. (Engel *et al.*, 2004, Janni *et al.*, 2001)

had not yet received chemotherapy

months after surgery (Time-5)

added questions to general questionnaires to measure body image.(Engel et al., 2004, Hartl et al., 2003, Janni et al., 2001, King et al., 2000) In this study, a generic QOL instrument (WHOQOL-100) and a disease-specific health status instrument (EORTC QLQ BR-23) were used. The results based on both instruments indicated that body image scores changed significantly over time, irrespective of diagnosis/treatment. However, this effect was partly explained by the differences in scores between the baseline measure and the first follow-up measure (WHOQOL-100), when body image scores dropped considerably in the MTC group. Body image scores measured with the EORTC-QLQ BR23 also improved significantly; but, this measure could not register the drop in body image scores between Time-1 and Time-2, since it can only be assessed in a cancer population. In our study, the baseline assessment was before diagnosis. (Engel et al., 2004) Our findings are in line with other studies. For instance, Ganz et al. (Ganz et al., 1992) reported an improvement in body image one year after surgery in both surgical groups, just as Bloom et al. (Bloom et al., 2004) did between baseline (soon after diagnosis) and five year follow-up. In our study, body image scores completely returned to baseline values, except for the body image scores of women with MTC. It is possible that a study in which a longer follow-up is taken, body image will further improve.

Older women were more satisfied with their bodies, which is in line with the majority of other studies in this field. (Al-Ghazal *et al.*, 1999, Fehlauer *et al.*, 2005, Janz *et al.*, 2005, Kenny *et al.*, 2000, King *et al.*, 2000) However, it should be noted that the results on the direction of the relationship between age and body image in the literature is inconsistent. That is, several studies did not find differences in body image scores between age groups(Engel *et al.*, 2004, Schou *et al.*, 2005) or found that body image issues may be particularly salient for younger women(Avis *et al.*, 2005). Since older women are often excluded from clinical studies, future studies should examine the psychosocial concerns in this age group.

Adjuvant therapies, like radiotherapy and hormone therapy were not strongly related to body image. Chemotherapy predicted scores on body image at all time points included. From the few studies that are available on this topic, women who received chemotherapy reported lower scores on body image (Janz *et al.*, 2005, Schover *et al.*, 1995), probably due to the loss of hair that is accompanied by this type of treatment.

Personality characteristics (neuroticism and agreeableness) played an important role in predicting outcome in this study. Neuroticism contributed in a negative way to scores on body image at all follow-up measures, after controlling for all other variables. This result is consistent with other research on personality in breast cancer, in which patients, who experienced high levels of chronic stress one year after treatment for breast cancer, were characterized by higher levels of neuroticism. (Millar *et al.*, 2005) In other studies, this trait also in part explained the variance in depressive symptoms after breast cancer surgery (Den Oudsten *et al.*, 2009a, Golden-Kreutz and Andersen, 2004), as well as of poor adjustment to mastectomy. (Morris *et al.*, 1977)

After discussing the results of the study, certain limitations and strengths should be acknowledged. Strength of the underlying study is the baseline measurement, before the diagnosis is known. At the same time, this is also a weakness, because women are probably scared and nervous because an abnormality has been seen on the mammography (i.e., only applies for those women who had a screening mammography) or that a lump (whether it is benign or malign) is in the breast. However, in this study the BBP group showed stable scores regarding body image. The optimal moment for the baseline measurement would be

Changes in Body Image in Women with Early Stage Breast Cancer 39

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before visiting the doctor or taking a mammography, and then it is probably of better prospective value. The one-year follow-up period is another advantage of this study, because body image is a concept that probably changes over time when a woman is confronted with a threat to her body image. Moreover, this study included also a control group consisting of women with benign breast problems. Few studies have included a comparison group. (Andrykowski *et al.*, 1996) Finally, the data was collected in several hospitals in the Netherlands, which may facilitation generalization in women with breast cancer. Studies, like the current one, often show relatively high attrition(Arving *et al.*, 2008). Our study had 73.5% of the women with early stage BC in the study at one-year after surgical treatment. This may have influenced our results. However, women with breast cancer who dropped out of the study did not differ from women remaining in the study, except for age with women staying in the study being significantly younger. A limitation of this study is that a specific body image scale would have been appropriate, for instance Body Image Scale(Hopwood *et al.*, 2001). In addition to the EORTC QLQ BR23 items on body image, this scale includes also items on change in self-consciousness with appearance, less sexually attractive, less feminine, dissatisfaction with appearance when dressed, dissatisfaction with scars, body feeling less whole, and avoidance of people because of appearance. These topics were not assessed in our study. However, it should be noted that the women with BBP could not have been assessed on body image.

More longitudinal studies need to focus on body image, whether body image in the MTC group will eventually return to baseline values (i.e., before the breast cancer diagnosis), but also examine the associations with self-esteem, sexual functioning, and quality of life. In addition, studies should also include elderly women. Moreover, it is also reasonable to take women's partners into account, since patients and partners coping with cancer will exchange experiences and influencing each others acceptation process. (Manne and Badr, 2008, 2009) Recently, Zimmerman et al. (Zimmermann *et al.*, 2009) have shown that dyadic factors are important. They found that women's depressive symptoms, women's age and men's marital satisfaction predicted women's body image, explaining 24% of the variance. Given the importance of the marital relationship in adaptation, a greater understanding of this dyadic process may aid in the development of psychosocial interventions for couples adapting to breast cancer who may be at risk for distress.

### **5. Conclusion**

In conclusion, results from this study confirm previous findings that breast cancer temporarily affects satisfaction with body image in a negative way. Results are more obvious for women who underwent MTC, than for women who have had BCT. Older women seemed to have more problems with body image after surgery. Overall, it is important for women facing breast cancer to get assistance in adjusting to alterations in body image. (Kraus, 1999) Personality factors that influence these changes should be taken into account.

#### **6. References**

Al-Ghazal, S. K., Blamey, R. W., Stewart, J. & Morgan, A. A. (1999). The cosmetic outcome in early breast cancer treated with breast conservation. *Eur J Surg Oncol* 25, 566-70.

before visiting the doctor or taking a mammography, and then it is probably of better prospective value. The one-year follow-up period is another advantage of this study, because body image is a concept that probably changes over time when a woman is confronted with a threat to her body image. Moreover, this study included also a control group consisting of women with benign breast problems. Few studies have included a comparison group. (Andrykowski *et al.*, 1996) Finally, the data was collected in several hospitals in the Netherlands, which may facilitation generalization in women with breast cancer. Studies, like the current one, often show relatively high attrition(Arving *et al.*, 2008). Our study had 73.5% of the women with early stage BC in the study at one-year after surgical treatment. This may have influenced our results. However, women with breast cancer who dropped out of the study did not differ from women remaining in the study, except for age with women staying in the study being significantly younger. A limitation of this study is that a specific body image scale would have been appropriate, for instance Body Image Scale(Hopwood *et al.*, 2001). In addition to the EORTC QLQ BR23 items on body image, this scale includes also items on change in self-consciousness with appearance, less sexually attractive, less feminine, dissatisfaction with appearance when dressed, dissatisfaction with scars, body feeling less whole, and avoidance of people because of appearance. These topics were not assessed in our study. However, it should be noted that

More longitudinal studies need to focus on body image, whether body image in the MTC group will eventually return to baseline values (i.e., before the breast cancer diagnosis), but also examine the associations with self-esteem, sexual functioning, and quality of life. In addition, studies should also include elderly women. Moreover, it is also reasonable to take women's partners into account, since patients and partners coping with cancer will exchange experiences and influencing each others acceptation process. (Manne and Badr, 2008, 2009) Recently, Zimmerman et al. (Zimmermann *et al.*, 2009) have shown that dyadic factors are important. They found that women's depressive symptoms, women's age and men's marital satisfaction predicted women's body image, explaining 24% of the variance. Given the importance of the marital relationship in adaptation, a greater understanding of this dyadic process may aid in the development of psychosocial interventions for couples

In conclusion, results from this study confirm previous findings that breast cancer temporarily affects satisfaction with body image in a negative way. Results are more obvious for women who underwent MTC, than for women who have had BCT. Older women seemed to have more problems with body image after surgery. Overall, it is important for women facing breast cancer to get assistance in adjusting to alterations in body image. (Kraus, 1999) Personality factors that influence these changes should be taken

Al-Ghazal, S. K., Blamey, R. W., Stewart, J. & Morgan, A. A. (1999). The cosmetic outcome in early breast cancer treated with breast conservation. *Eur J Surg Oncol* 25, 566-70.

the women with BBP could not have been assessed on body image.

adapting to breast cancer who may be at risk for distress.

**5. Conclusion** 

into account.

**6. References** 


Changes in Body Image in Women with Early Stage Breast Cancer 41

Jolly, M., Pickard, A. S., Mikolaitis, R. A., Cornejo, J., Sequeira, W., Cash, T. F. & Block, J. A. Body Image in Patients with Systemic Lupus Erythematosus. *Int J Behav Med*. Joly, F., Espie, M., Marty, M., Heron, J. F. & Henry-Amar, M. (2000). Long-term quality of

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**4** 

*Italy* 

**Surgical Prevention of Arm** 

*Department of Surgery – Unit of Lymphatic Surgery,* 

*S. Martino Hospital, University of Genoa,* 

**Lymphedema in Breast Cancer Treatment** 

Corradino Campisi, Corrado C. Campisi and Francesco Boccardo

Disruption of the axillary nodes and closure of arm lymphatics can explain the significantly high risk of early and late lymphatic complications after axillary dissection, especially the most serious complication that is arm lymphedema which occurs in about 25% (ranging from 13 to 52%) of patients. Sentinel lymph node (SLN) biopsy has reduced the severity of swelling to nearly 6% (from 2 to 7%) and, in case of positive SLN, complete axillary dissection (AD) is still required. That is why ARM method was developed aiming at identifying and preserve lymphatics draining the arm. It consists in injecting intradermally and subcutaneously a small quantity (1-2 ml) of blue dye at the medial surface of the arm which helps in locating the draining arm lymphatic pathways. ARM technique allowed to find variable clinical anatomical conditions from what was already generally known, that is the most common location of arm lymphatics below and around the axillary vein. In about one-third of the cases, blue lymphatics can be found till 3-4 cm below the vein, site where SLN can easily be located, justifying the occurrence of lymphedema after only SLN biopsy. ARM procedure showed that blue nodes were almost always placed at the lateral part of the axilla, under the vein and above the second intercostals brachial nerve. Leaving in place lymph nodes related to arm lymphatic drainage would decrease the risk of arm lymphedema, but not retrieving all nodes, the main risk is to leave metastatic disease in the axilla. Conversely, arm lymphatic pathways when they enter the axilla, cannot be site of breast tumoral disease and their preservation would certainly bring about a significant

Another important aspect to point out is that, in the axilla, new lymphatic vessel formation (lymphangiogenesis) occurs in response to the ligation of lymphatic vessels involved in lymph node retrievement. Lymphangiogenesis and lymphatic hypertension were demonstrated experimentally in case of lymphatic drainage obstruction. And, in response to lymphatic hypertension, lympho-venous shunts open and provide alternative lymphatic pathways when the main ones are obstructed. These mechanisms represent an adaptive response to lymphatic hypertension but are not enough to restore normal flow parameters. Furthermore, chronic obstruction to lymph flow progressively leads to a reduced lymphatic

**1. Introduction** 

decrease of lymphedema occurrence rate (1-4).

**2. Lymphangiogenesis and other local changes** 

