Risk-reducing mastectomy with immediate reconstruction: an exploratory study of psychosocial and sexual well-being using the BREAST-QTMABSTRACT
Introduction: Risk-reducing mastectomy significantly decreases the incidence of breast cancer in women with a genetic predisposition. However, its effects on psychosocial and sexual well-being remain insufficiently explored, particularly among women without a previous diagnosis of breast cancer.
Objective: To evaluate the psychosocial and sexual well-being of women undergoing risk-reducing mastectomy with immediate breast reconstruction.
Methods: This observational, cross-sectional study involved the retrospective collection of clinical data and was conducted at a specialized center. Women aged >18 years, with no history of breast cancer, who underwent bilateral risk-reducing mastectomy with immediate implant-based reconstruction between 2018 and 2023 were included. Psychosocial and sexual well-being domains were assessed using the BREAST-Q™, with standardized scores ranging from 0 to 100. Descriptive analyses, Spearman’s correlation, and nonparametric tests were performed, adopting a significance level of P < 0.05.
Results: Twenty-eight patients were included. The mean age was 41.8 ± 9.6 years at the time of surgery and 45.5 ± 9.4 years at the time of assessment. Mean scores were 68.5 ± 20.4 for psychosocial well-being and 55.4 ± 17.8 for sexual well-being. A strong correlation was observed between the two domains (ρ = 0.81; p < 0.001). Early postoperative complications and the need for reoperations were associated with lower scores in both domains. Higher educational attainment was associated with better sexual well-being scores. No significant associations were found for the remaining variables.
Conclusion: Risk-reducing mastectomy with immediate reconstruction is associated with variable psychosocial and sexual outcomes, primarily influenced by postoperative complications and reoperations. These findings highlight the importance of incorporating quality-of-life assessment into the counseling and follow-up of these patients.
Keywords:
Breast Implants; Hereditary Breast and Ovarian Cancer Syndrome; Patient-Reported Outcome Measures; Prophylactic Mastectomy; Quality of Life; Sexuality
RESUMO
Introdução: A mastectomia redutora de risco reduz significativamente a incidência de câncer de mama em mulheres com predisposição genética. Entretanto, seus impactos sobre o bem-estar psicossocial e sexual ainda são pouco explorados, especialmente em pacientes sem diagnóstico prévio da doença.
Objetivo: Avaliar o bem-estar psicossocial e sexual de mulheres submetidas à mastectomia redutora de risco com reconstrução imediata.
Métodos: Estudo observacional, transversal, com coleta retrospectiva de dados clínicos, realizado em centro especializado. Foram incluídas mulheres >18 anos, sem histórico de câncer de mama, submetidas à mastectomia bilateral redutora de risco com reconstrução imediata com implantes, entre 2018 e 2023. Os domínios de bem-estar psicossocial e sexual foram avaliados por meio do BREAST-Q™, com escores padronizados de 0 a 100. Foram realizadas análises descritivas, correlação de Spearman e testes não paramétricos, adotando-se P < 0,05.
Resultados: Foram incluídas 28 pacientes, com média de idade de 41,8 + 9,6 anos na cirurgia e 45,5 + 9,4 anos na avaliação. Os escores médios foram de 68,5 + 20,4 para bem-estar psicossocial e 55,4 + 17,8 para bem-estar sexual. Observou-se forte correlação entre os domínios (ρ = 0,81; p < 0,001). Complicações pós-operatórias precoces e necessidade de reoperações associaram-se a piores escores em ambos os domínios. Maior escolaridade associou-se a melhores escores de bem-estar sexual. As demais variáveis não apresentaram associação significativa.
Conclusão: A mastectomia redutora de risco com reconstrução imediata está associada a desfechos psicossociais e sexuais variáveis, influenciados principalmente por complicações pós-operatórias e reoperações. Esses achados reforçam a importância de incorporar a avaliação de qualidade de vida no aconselhamento e no seguimento dessas pacientes.
Palavras-chave:
Breast Implants; Patient Reported Outcome Measures; Prophylactic Mastectomy; Quality of Life; Sexuality; Síndrome Hereditária de Câncer de Mama e Ovário
INTRODUCTION
Breast cancer is the most common malignancy worldwide, excluding non-melanoma skin cancer, with an estimated 2.3 million new cases diagnosed in 20221. In Brazil, approximately 78,000 new cases are expected annually during the 2026-2028 triennium, corresponding to an estimated incidence of 42 cases per 100,000 women2. Hereditary breast cancer is primarily associated with germline pathogenic variants in hereditary cancer predisposition genes. These variants can be classified according to the lifetime probability that a carrier will develop the disease, referred to as penetrance3. Accurate characterization of these genetic profiles is essential for guiding individualized surveillance, prevention, and treatment strategies.
Clinical management varies according to the level of risk conferred by the identified pathogenic variant. For carriers of high-penetrance variants, early surveillance is recommended, typically beginning between 25 and 35 years of age, with annual breast magnetic resonance imaging combined with mammography4. Bilateral risk-reducing mastectomy may also be considered, particularly for women with BRCA1/BRCA2 pathogenic variants, as well as risk-reducing salpingo-oophorectomy at the appropriate age. For moderate-penetrance variants, breast cancer screening generally begins at 40 years of age with annual mammography, with breast magnetic resonance imaging considered according to individual family history and overall risk. In contrast, management of low-penetrance variants is individualized based on polygenic risk scores, family history, and other cumulative risk factors5,6.
Previous evidence indicates that women from diverse ethnic and cultural backgrounds may experience impaired sexual function following mastectomy, with consequences that extend beyond the physical and oncologic domains to substantially affect psychosocial and sexual well-being7. In a systematic review published in 2021, Faria et al. evaluated the impact of mastectomy on body image and sexuality among women treated for breast cancer. An association between breast surgery and sexual dysfunction was reported in 56% of the included studies8. In a study of Brazilian women who underwent mastectomy, the most frequently reported difficulties involved body exposure, sexual expression, and feelings of helplessness regarding their altered body image9. These findings are consistent with an anthropological analysis conducted in a cohort from the Midwest region of Brazil, which identified “beauty, body image, and intelligence” as among the primary concerns related to self-image among middle-class Brazilian women during the study period10.
Nipple-sparing mastectomy, frequently combined with immediate implant-based breast reconstruction, has become established as a safe and effective approach for risk-reducing surgery, providing favorable aesthetic outcomes while preserving body integrity11. Despite its effectiveness in reducing breast cancer risk, the decision to undergo surgery requires a patient-centered, shared decision-making process that carefully considers its substantial physical, aesthetic, and psychosocial implications. Beyond its oncologic benefits, this intervention affects key dimensions of women’s quality of life, including body image, sexuality, and emotional well-being, all of which remain insufficiently investigated in the scientific literature.
Several validated instruments are currently available to assess expectations and satisfaction among women undergoing breast surgery12. Among these, the BREAST-Q™13 is regarded as the gold standard for measuring patient-reported outcomes in breast surgery. The BREAST-Q™ was developed to provide a standardized assessment of quality of life and patient satisfaction following breast surgery, encompassing physical, psychosocial, sexual, and aesthetic outcome domains.
The literature remains limited regarding women without a previous diagnosis of breast cancer who are nevertheless at high risk of developing the disease and undergo risk-reducing mastectomy with immediate breast reconstruction. Therefore, the present study aimed to evaluate the impact of this surgical procedure on body image and sexuality by analyzing postoperative psychosocial and sexual well-being scores measured using the BREAST-Q™.
METHODOLOGY
Study design and population
The study protocol was approved by the Research Ethics Committee of Universidade Federal do Paraná (UFPR; approval no. 5,932,977; CAAE 64795022.2.0000.0102), and the study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. This was an observational, cross-sectional study involving the retrospective collection of clinical data. Given this study design, the findings allow associations among the investigated variables to be identified but do not permit causal relationships to be established.
Patients were identified through a review of surgical procedures performed at the Center for Breast Diseases in Curitiba, Brazil, between January 2018 and May 2023. Women who underwent bilateral risk-reducing mastectomy without a previous diagnosis of breast cancer were eligible for inclusion. Data were collected between June and October 2024. During this period, eligible patients were approached at outpatient follow-up visits and invited to participate in the study. After providing written informed consent, the participants completed the psychosocial and sexual well-being domains of the BREAST-Q™ in a private setting. Electronic medical records were retrospectively reviewed in October 2024 to obtain clinical and surgical data.
Inclusion and exclusion criteria
Women aged ≥ 18 years without a personal history of breast cancer who underwent bilateral risk-reducing mastectomy with immediate implant-based reconstruction because of a high risk of breast cancer, as determined by genetic testing and/or validated risk-prediction models, were included.
Patients diagnosed with breast cancer at the time of surgery, those who underwent autologous reconstruction, and those with incomplete questionnaire data were excluded.
Sample selection
A total of 45 patients were initially identified. After the exclusion of 15 patients with a previous diagnosis of breast cancer and two patients with carcinoma in situ identified on histopathologic examination, the final sample comprised 28 patients, all of whom were included in the analysis, as shown in Figure 1. The sample size was therefore determined by convenience based on the number of eligible patients with available data during the study period. Accordingly, the findings should be interpreted in light of the available sample size and the potentially limited statistical power to detect associations or differences of smaller magnitude.
Variables assessed
Clinical and sociodemographic data were obtained through a review of electronic medical records and integrated with the BREAST-Q™ results. The variables assessed included sociodemographic characteristics (age, educational attainment, menopausal status, and smoking status), clinical characteristics (genetic mutation, family history, comorbidities, and hormone therapy use), surgical characteristics (reconstructive technique and implant characteristics), and outcomes related to complications and reoperations.
Postoperative complications were classified as early, when occurring within 90 days after surgery, or late, when occurring more than 90 days after surgery. These complications included seroma, hematoma, infection, necrosis, capsular contracture, implant extrusion, and wound dehiscence.
Assessment of outcomes
Psychosocial and sexual well-being were assessed using the BREAST-Q™, Mastectomy Module, version 2.0, Brazilian Portuguese version8, a validated instrument for evaluating quality of life among patients undergoing breast surgery. Scores were converted to a scale ranging from 0 to 100 according to the Rasch transformation method, with higher scores indicating better perceived well-being.
Statistical analysis
Statistical analyses were performed using Microsoft Excel® and IBM SPSS Statistics for Windows, version 29.0.2 (IBM Corp., Armonk, N.Y., USA). Quantitative variables were summarized as means, standard deviations, medians, and ranges. Categorical variables were presented as absolute and relative frequencies. The correlation between psychosocial and sexual well-being scores was assessed using Spearman’s correlation coefficient. Between-group comparisons were performed using the nonparametric Mann-Whitney U test or Kruskal-Wallis test, as appropriate.
To complement the interpretation of p-values, effect estimates were calculated for between-group comparisons and expressed as Hodges-Lehmann differences with their respective 95%CIs. The Hodges-Lehmann difference represents the median of all possible pairwise differences between the groups being compared. The normality of quantitative variables was assessed using the Shapiro-Wilk test. 95%CIs were estimated using bootstrap resampling. Statistical significance was set at 5% (p < 0.05).
RESULTS
Sample characteristics
The study sample comprised 28 women who underwent bilateral risk-reducing mastectomy with immediate implant-based reconstruction. The mean age at surgery was 41.8 ± 9.6 years, whereas the mean age at the time of assessment was 45.5 ± 9.4 years. The mean interval between surgery and BREAST-Q™ administration was 3.7 ± 1.6 years.
Most participants had completed higher education (82.1%) and were non-smokers (85.7%). Regarding menopausal status, 42.9% were postmenopausal, with menopause resulting from risk-reducing oophorectomy in a subset of these patients. High-penetrance pathogenic variants were identified in 64.3% of the participants. The remaining clinical characteristics are presented in Table 1.
Well-being scores
The mean BREAST-Q™ scores were 55.4 ± 17.8 for the Sexual Well-Being domain and 68.5 ± 20.4 for the Psychosocial Well-Being domain. The corresponding median scores were 60.5 and 70.0, respectively (Table 2).
A strong positive correlation was observed between Sexual Well-Being and Psychosocial Well-Being scores (Spearman’s correlation coefficient = 0.81; p < 0.001), as shown in Graph 1. This finding indicates that higher scores in one domain were associated with higher scores in the other, suggesting a close relationship between psychological and sexual aspects of quality-of-life perception.
Associations with clinical variables
Exploratory analyses revealed that several clinical variables were significantly associated with Sexual Well-Being and Psychosocial Well-Being scores. Patients who experienced early postoperative complications (within 90 days after surgery) had significantly lower Sexual Well-Being scores (39.3 ± 14.6 vs. 59.8 ± 16.1; p = 0.007) and Psychosocial Well-Being scores (50.3 ± 22.1 vs. 73.4 ± 17.3; p = 0.020).
Similarly, patients who did not require reoperation had higher scores in both domains than those who underwent additional surgical procedures. These differences were statistically significant for both Sexual Well-Being (p = 0.014) and Psychosocial Well-Being (p = 0.016).
Educational attainment was associated with Sexual Well-Being, with patients who had completed higher education reporting higher scores than those without a university degree (58.3 ± 17.5 vs. 41.8 ± 12.9; p = 0.027). No significant association was observed between educational attainment and Psychosocial Well-Being.
None of the remaining variables evaluated showed statistically significant associations with well-being scores. These included age, body mass index, menopausal status, hormone therapy use, smoking status, family history of cancer, genetic profile, previous breast surgery, breast reconstruction characteristics (implant type and volume), and late postoperative complications (Table 3; Table 4).
DISCUSSION
The present study addresses an important gap in the literature by evaluating psychosocial and sexual well-being among Brazilian women who underwent risk-reducing mastectomy with immediate breast reconstruction, a population that remains underrepresented in previous research. Although the BREAST-Q™ has been widely used across different clinical settings, most studies have focused on women with a diagnosis of breast cancer or on reconstructive procedures performed for therapeutic purposes, with limited evidence available for women without prior breast cancer undergoing prophylactic surgery. Our findings demonstrate that women undergoing risk-reducing mastectomy with immediate reconstruction reported moderate levels of psychosocial and sexual well-being, with considerable interindividual variability. A strong correlation was observed between these domains, indicating that higher psychosocial well-being was associated with better perceived sexual well-being. This relationship between psychosocial and sexual outcomes has previously been described in the literature, although predominantly through qualitative investigations14. Previous studies have shown that changes in body image following mastectomy may negatively affect sexual functioning and overall patient satisfaction, reinforcing the close interrelationship between these dimensions. For example, Gahm et al. reported that, despite low levels of decision regret, a substantial proportion of women undergoing risk-reducing mastectomy perceived a reduction in the sexual importance of their breasts (69%) and in sexual pleasure (75%), highlighting the impact of surgery on both physical and emotional well-being15. Similarly, Metcalfe et al. observed that body image changes following risk-reducing mastectomy were associated with alterations in sexual well-being and overall life satisfaction16.
In the present study, early postoperative complications and the need for reoperation were associated with poorer outcomes in both well-being domains. These findings suggest that the postoperative course plays a central role in patients’ perceptions of quality-of-life following surgery. Similar results have been reported in recent studies, in which surgical complications were associated with worse patient-reported outcomes, including physical and sexual domains17. A study published in 2022 involving 63 women who underwent mastectomy demonstrated that postoperative complications were associated with greater decision regret, as measured using the Decision Regret Scale, although they did not negatively affect breast satisfaction as measured by the BREAST-Q™18. Comparable findings were reported in the multicenter Pre-BRA study conducted by Harvey et al., which evaluated patient-reported outcomes following prepectoral breast reconstruction. In that study, surgical complications, particularly implant loss, were associated with substantial reductions in BREAST-Q™ scores, with the greatest impairment observed in the physical and sexual domains. The authors also found that women undergoing therapeutic mastectomy consistently reported worse outcomes than those undergoing prophylactic surgery, suggesting that the negative impact on well-being may be amplified by the oncologic context and the physical and emotional burden of cancer treatment19.
Higher educational attainment was also associated with better sexual well-being scores. This finding may reflect greater access to health information, higher health literacy, and increased engagement in decision-making and postoperative adaptation, although this association should be interpreted with caution. In a study conducted by Raman et al., women with higher educational attainment were significantly more likely to independently research breast reconstruction before their surgical consultation (p = 0.0206) and to identify the internet as their primary source of information (p = 0.0267)20.
The remaining variables evaluated, including age, body mass index, menopausal status, smoking status, and reconstruction characteristics, were not significantly associated with well-being scores. These findings suggest that isolated clinical characteristics may exert less influence on patients’ subjective perceptions than postoperative events and individual psychosocial factors.
The findings of the present study underscore the importance of considering not only the oncologic benefits of risk-reducing mastectomy but also its psychosocial and sexual consequences. Incorporating these dimensions into clinical care is essential to delivering person-centered care that aligns with the principles of more humanized, inclusive, and equitable health care. In this context, the use of patient-reported outcome measures such as the BREAST-Q™ enables a more comprehensive assessment of these outcomes and may contribute to improving both preoperative counseling and postoperative follow-up.
The main limitations of this study include its relatively small sample size, cross-sectional design, and the retrospective collection of part of clinical data. Consequently, the findings should be interpreted as associations between the variables evaluated rather than evidence of causal relationships between risk-reducing mastectomy and the observed psychosocial and sexual outcomes. Furthermore, the absence of preoperative assessments precludes determining whether the levels of well-being identified resulted from surgery or reflected pre-existing characteristics of the participants. Prospective longitudinal studies incorporating both preoperative and postoperative assessments are needed to better establish the causal effects of surgery on these outcomes. Nevertheless, the present findings provide clinically relevant insights into patient-reported outcomes following this type of intervention.
Another potential limitation is the heterogeneity in follow-up duration, as the interval between surgery and BREAST-Q™ administration ranged from 1 to 6 years. Patients assessed at different postoperative time points may exhibit different levels of physical, emotional, and psychosocial adaptation and may also be subject to varying life-stage influences and recall bias, a phenomenon previously described in studies evaluating long-term outcomes after risk-reducing mastectomy15,16. However, exploratory analyses performed in the present study found no significant association between follow-up duration and either Sexual Well-Being or Psychosocial Well-Being scores, suggesting that this variable did not exert a measurable influence on the outcomes in this sample. Nevertheless, this temporal heterogeneity should be considered when interpreting the findings.
CONCLUSION
Risk-reducing mastectomy with immediate breast reconstruction is associated with variable psychosocial and sexual outcomes, which appear to be strongly influenced by postoperative complications and the need for reoperation. These findings highlight the importance of integrating quality-of-life assessment into both the decision-making process and the postoperative management of women undergoing this procedure.
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