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AIM: To describe perceived needs of support among patients close to discharge from the hospital and at the end of primary curative radiotherapy for breast, colorectal or prostate cancer.

BACKGROUND: Few studies have specifically explored patients' early support needs when ending primary curative treatment.

DESIGN: Qualitative interview study design.

METHODS: A purposive sample of 27 participants with breast, colorectal or prostate cancer aged 33-88 years. The interviews were analysed by qualitative content analysis. Reporting followed the COREQ guidelines.

RESULTS: Personal support to reach a sense of control and Social support for personal growth were two main themes, highlighting that people required adapted support from health care since needs of support could change over time. This support from health care was also relying on that trust-based relationships were developed. Through mutuality with others and engagement in meaningful activities people became enabled and felt further supported. Personal support from health care seems specifically important for the patients' feelings of control and could be a facilitator for patients to identify further support for personal growth in how to manage, on the one hand, illness and insecurity, and on the other, their well-being and everyday life with cancer.

CONCLUSION: To empower patients who are ending primary treatment and being close to discharge from hospital, healthcare professionals should recognise patients' shifting needs and adapt the support. Adapted support is significant for patients' sense of safety. Biomedical information is not sufficient to fully support patients.

RELEVANCE TO CLINICAL PRACTICE: Offering easy access to supportive care when primary treatment is finished could diminish people's stress, insecurity and avoidable use of healthcare services. Even after discharge, nurses preferably should adapt and offer support tailored to patients' needs. Such support may improve patients' sense of control and safety, trust in health care, feelings of community and encourage personal growth.

Purpose: This 2-year follow-up study explores aspects of body image after mastectomy due to breast cancer.

Materials and Methods: This population-based study included 76 women living in northern Sweden who, during November 2006 to October 2007, underwent mastectomy due to breast cancer. The women completed a questionnaire entitled “Life After Mastectomy (LAM)” 10 months after the mastectomy and again 2 years later. We used SPSS version 18.0 for data processing and analysis.

Results:The findings indicate that few significant changes in body image had taken place during the 2-year interval between the first and second completion of the questionnaire. An exception was a significant decrease in feelings of sexual attractiveness and comfort during sexual intimacy. At follow-up, 21% of the women had undergone breast reconstruction (BR). They were significantly younger than the women who had not had BR (53 v. 63 years). Besides being younger, no other significant differences could be found between those women who had undergone BR and those who had not. The fact that the decrease in sexual attractiveness and feelings of comfort during sexual intimacy also applied to the subgroup of women who had had BR may therefore be surprising. A better understanding of issues related to breast cancer treatment and sexual function is vital.

Conclusion: It is important for health care professionals to be aware of problems related to sexual intimacy and to be prepared not just to provide information about these, but also to reflect on expectations v. reality together with the women.

Breast cancer is the most common type of cancer among women. In Sweden, about 40% of women diagnosed with breast cancer undergo a mastectomy; breast reconstruction (BR) may be an option for these women. However, the experience of undergoing reconstructive surgery appears to be only very scarcely researched, despite its importance in clinical nursing.

Aim: The purpose of this study was to explore women's experiences of undergoing breast reconstructive surgery after mastectomy due to breast cancer.

Methods: Six women participated in narrative interviews about their experiences of reconstructive surgery, and the interview data were analysed using thematic narrative analysis.

Results: All six women were unprepared for the strenuous experience of undergoing a BR. They described the process as difficult and painful, entailing several operations and an unexpectedly long recovery period. They were also unprepared for how arduous it would be, both physically and emotionally. However, getting a BR had been important to all the women. The BR process was captured in four themes: (1) uninformed care; (2) arduous experiences; (3) body alterations; and (4) moving on.

Conclusions: Obtaining adequate information and being involved in the decision-making process along the pathway of a BR could help the women to prepare physically and emotionally for the strenuous experiences related to reconstructive surgery.

Background: Because of early detection and advanced treatment options, more women with breast cancer survive after mastectomy and thus have to face the choice of living with or without a reconstructed breast for many years to come. O

bjective: This article investigates these women’s narratives about the impact of mastectomy on their lives, as well as their reflections on breast reconstruction.

Methods: Fifteen women were strategically chosen from a previous population-based study on mastectomy. They were contacted for further exploration in thematic narrative-inspired interviews 4.5 years after mastectomy.

Results: Three types of storylines were identified. In the first storyline, the mastectomy was described as ‘‘no big deal’’; losing a breast did not disturb the women’s view of themselves as women, and breast reconstruction was not even worth consideration. In the second storyline, the women described the mastectomy as shattering their identity. Losing a breast implied losing oneself as a sexual being, a woman, and a person. The third storyline fell in between the other two; the sense of femininity was wounded, but not to the extent that they felt lost as women.

Conclusion: Our findings suggest that the experience of mastectomy due to breast cancer is very much individual and contextual. Losing a breast may be of minor or major importance.

Implications for Practice: Healthcare practitioners should be attentive to how the women themselves experience the personal meaning of losing a breast and guard against vague preconceptions based on the breast-sexuality-femininity discourse and its connection to what the patient needs.

Bakgrund: I Sverige är bröstcancer den vanligaste formen av kvinnlig cancer och utgör nära en tredjedel av kvinnlig cancer. I behandlingen av bröstcancer har kirurgi en betydande roll. Nära hälften av kvinnorna genomgår mastektomi, men det finns en stor variation inom landet. Att förlora ett bröst efter mastektomi har såväl en kroppslig som psykologisk innebörd. Avhandlingen omfattar fyra delstudier som beskriver detta på olika sätt.

Syfte: Det övergripande syftet med avhandlingen är att studera betydelsen av att förlora ett bröst på grund av cancersjukdom samt motiv och beslutsprocess i ställningstagande till att leva med eller utan ett rekonstruerat bröst.

Metod: Avhandlingen baseras på två populationer av kvinnor boende i norra Sverige som genomgått mastektomi på grund av bröstcancer: de kvinnor som genomgått mastektomi under 2003 (delstudie I–III) samt de kvinnor som genomgått mastektomi mellan oktober 2006 och september 2007 (delstudie IV). Dessa kvinnor identifierades via det regionala cancerregistret, onkologiskt centrum, Norrlands universitetssjukhus. Statistiska analyser genomfördes i delstudie I och IV och tematisk narrativ analys har tillämpats i delstudie II och III.

Resultat: Delstudie I: År 2007 skickades ett nykonstruerat självskattningsformulär ”Life After Mastectomy” (LAM) ut till 149 kvinnor varav 85% (n=126) besvarades. Av dessa kvinnor hade 25% genomgått bröstrekonstruktion. Resultaten av en multipel regressionsanalys visade att bröstrekonstruktion var signifikant relaterat till lägre ålder, känsla av att vara attraktiv och sexuellt intresse. För att få en djupare och mer nyanserad förståelse kring innebörder av att förlora ett bröst efter mastektomi och motiv till att avstå från eller genomgå bröstrekonstruktion gjordes ett strategiskt urval av 15 kvinnor från delstudie I som deltog i en forskningsintervju(delstudie II). I den tematiska narrativa analysen identifierades tre typberättelser. I den första typberättelsen beskrevs mastektomin som ”no big deal” och att genomgå en bröstrekonstruktion var inte ens värt att överväga. I den andra typberättelsen beskrevs mastektomin som ”att förlora sig själv” och en bröstrekonstruktion beskrevs som ett sätt att återställa sig som person, kvinna och sexuell varelse. Den tredje typberättelsen intog en position mellan ”no big deal” och ”att förlora sig själv” och en bröstrekonstruktion beskrevs som ett välkommet erbjudande vilket gjorde det enklare att se och känna sig som kvinna. I delstudie III undersöktes sex kvinnors erfarenheter av att genomgå bröstrekonstruktion. Samtliga kvinnor var oförberedda på den krävande procedur som de genomgick. De beskrev processen som svår och smärtsam med upprepade operationer och en oväntat lång konvalescenstid. Även om kvinnorna var oförberedda på hur tufft det skulle komma att bli både fysiskt och emotionellt beskrevs bröstrekonstruktionen  som betydelsefull för dem. Delstudie IV: I denna uppföljningsstudie inkluderades kvinnorna 10 månader efter mastektomin då självskattningsformuläret LAM skickades ut. Datainsamlingen med samma formulär upprepades två år senare (tre år efter mastektomin). Kvinnornas (n=76) känsla av attraktivitet och kvinnlighet hade inte förändrats mellan de två mättillfällena, med undantag för vissa aspekter av sexualitet som hade försämrats. Vid uppföljningen hade 21% av kvinnorna genomgått bröstrekonstruktion och dessa kvinnor var yngre. I övrigt kundeinga signifikanta skillnader ses mellan de kvinnor som genomgått respektiveej genomgått bröstrekonstruktion.

Slutsats: Denna avhandling ger en inblick i betydelsen av att förlora ett bröst efter mastektomi. Att förlora ett bröst efter mastektomi kan vara av mindre eller större betydelse. För de kvinnor som upplevde bröstförlusten som en förlust av sig själva, kom en bröstrekonstruktion att betraktas som en livsnödvändighet (delstudie II). De flesta av kvinnorna 75% i delstudie I och 79% i delstudie IV genomgick inte någon bröstrekonstruktion. De kvinnor som genomgick rekonstruktiv kirurgi beskrev proceduren som svår fysiskt och emotionellt, men trots detta sågs den som viktig för dem (delstudie III). Vid uppföljningen i delstudie IV, var kvinnornas upplevelse av attraktivitet och kvinnlighet oförändrade, men upplevelsen av att känna sig bekväm vid sexuell intimitet utvecklades negativt. Detta var oberoende av om kvinnan genomgått bröstrekonstruktion eller inte, vilket kan ses som överraskande. Det är viktigt att som sjukvårdpersonal uppmärksamma hur den enskilda kvinnan själv upplever betydelsen av att ha förlorat ett bröst för att inte låta sig styras av vaga schabloner kring relationen bröst–sexualitet–kvinnlighet.

Background: Breast cancer is the most common cancer in women, representing nearly one-third of all cancer cases among women in Sweden. The mainstay in breast cancer treatment is surgery and nearly half of the women undergo a mastectomy but there is considerable variation between different counties. Understanding the impact of losing a breast and what motivates women to decide for or against breast reconstructive surgery after mastectomy is necessary in caring for women affected by breast cancer. This PhD thesis comprises four studies that examine this topic in different ways.

Aim: The overall aim of the thesis is to explore meanings of losing a breast after mastectomy and what motivates women to opt for reconstruction or no reconstruction of the lost breast.

Methods: The thesis is based on two populations, all women who underwent mastectomy in 2003 (Studies I–III) and all women living in northern Sweden who underwent mastectomy during November 2006 to October 2007 (Study IV). The women were identified by the Oncological Centre, at Umeå University Hospital, Umeå, Sweden. In Studies I and IV statistical analyses were performed while in Studies II and III thematic narrative analyses were applied.

Results: Study I: in 2007 149 women received a newly developed selfreported questionnaire titled ‘Life After Mastectomy (LAM)’. In total 85% (n=126) of the women completed and returned the questionnaire, 25% of whom had undergone breast reconstruction. Multiple regression analysis showed that these women were younger and scored lower on feelings of attractiveness and higher on sexual activity compared with the women who had opted not to have breast reconstruction. In Study II, to gain a more nuanced understanding of the women’s lived experiences of losing a breast and what had motivated them to opt for or against breast reconstruction, a strategic sample of 15 women from Study I were selected to participate in a research interview. Using thematic narrative analysis of the interviews we identified three types of storylines. In the first storyline the mastectomy was described as ‘no big deal’ and breast reconstruction was not even worth considering. In the second storyline the mastectomy was described as a ‘loss of self’ and the breast reconstruction was perceived as a means to be restored as a person, a woman and a sexual being. The third storyline fell in between ‘no big deal’ and ‘loss of self’, with breast reconstruction described as a welcome offer that made it easier to look and feel like a woman. In Study III, a pilot study, we explored six women’s experiences of undergoing breast reconstructive surgery. All women had not been prepared for the strenuous experience: the process was described as difficult and painful, consisting of several operations and an unexpectedly long recovery period. Although the women were ill prepared for how arduous it would be, both physically and emotionally, having a breast reconstruction had been important to all of them. Study IV: in this follow-up study, women completed the self-reported LAM questionnaire 10 months after mastectomy and again 2 years later, i.e. about 3 years after mastectomy. It appeared that their feelings of attractiveness and femininity had not changed during the follow-up time, except for some aspects of sexuality which had been negatively affected. At follow-up, 21% of the women had undergone breast reconstruction. When comparing these women with those who had not undergone reconstructive surgery, we found no significant differences apart from their younger age.

Conclusion: This thesis provides insight into the meanings of losing a breast due to mastectomy. Loss of a breast can be of minor or major importance. For those women who experienced the loss of a breast as a loss of the self, breast reconstruction became a necessity for restoring personhood (Study II). However, most women studied, 75% in study I and 79% in study IV, chose not to undergo breast reconstruction. Those who did, described it as a very tough procedure, both physically and emotionally. Having a breast reconstruction had been important for them (Study III). After a 2-year follow-up of the women (Study IV), their feelings of attractiveness and femininity were unchanged, but not their experiences of sexual intimacy and comfort, which had decreased regardless of whether they had undergone breast reconstruction or not. This finding was unexpected. It is important for health care professionals to be attentive to how women themselves experience the personal meaning of losing a breast. Care professionals should guard against popular preconceptions of the female breast and how it is associated with sexuality and womanliness, and hence of the patient’s needs.

Aim: This study compares potential differences between women with breast cancer who after mastectomy had undergone breast reconstruction with those who had not. Material and methods: All women (N=149) in the northern medical region of Sweden who had undergone mastectomy in 2003 received a self-reported questionnaire entitled “Life After Mastectomy (LAM)” that included standardized measures of sociodemographic, decision-making process, breast reconstruction (BR) yes or no, sexuality, and body image. SPSS was used for data processing. Results: In total 85% of the women returned the questionnaire and of these 25% had undergone BR. In accordance with previous studies, we found that the mean age of the women in the BR group was significantly lower (52 vs. 64 years), they had a higher education, and a higher proportion were employed, influenced by the physician's opinion regarding BR, sexually active, and rated a negative impact concerning the factors attractiveness and body disclosure. A multiple regression analysis, however, showed that the choice to undergo breast reconstruction or not was only independently associated with age, feeling of attractiveness and sexual interest. Discussion: Age explained most differences found between the two groups. When researchers try to identify what differentiates the groups of women who undergo reconstruction between those who do not undergo reconstruction after mastectomy, it is thus necessary to take into consideration that the meanings of mastectomy, body image, attractiveness and similar variables may vary due to the phase of a woman's life. In conclusion, considering the impact of age is of paramount importance in future studies for our understanding of women's experiences.