The impact of age on patient-reported outcomes after oncoplastic versus conventional breast cancer surgery

Over the last decades, significant improvements have been made in the treatment of breast cancer (BC), resulting in improved survival rates, especially in early-stage disease [1]. As a result of improved survival outcomes, breast cancer is increasingly perceived as a chronic disease, and thus survivors’ health-related quality of life (QoL) has become a major focus of overall treatment. Since BC can affect different age groups, it seems important to examine age-related differences in terms of QoL. This might contribute to personalized decision making, taking into account this important variable when counseling our patients.

While a vast body of literature examining age-specific differences in QoL related to systemic treatments and survivorship exists [2‐4], only few studies have investigated age-related differences in postoperative QoL, comparing different breast surgery procedures [5, 6]. In particular, there is a lack of data on QoL in older patients after BC surgery. This is relevant as a high proportion of newly diagnosed BC affects older women, and evidence is needed to provide proper counseling to this patient population in clinical practice. Previous studies have shown that younger patients have worse QoL outcomes in the social domain, being more concerned with their physical appearance and femininity. Older patients, in contrast, often see their breast appearance as a less important aspect of their QoL, but they tend to score lower in the physical well-being domains [5]. As such, it is important to further investigate possible age-related differences in patient-reported outcomes. Additionally, in the era of personalized BC therapy, age-related differences and requirements should be considered when planning the patient’s treatment [7, 8]. The aim of this study was to compare QoL in two distinct age groups after conventional and oncoplastic breast surgery using the Breast-Q as validated, patient-reported outcome assessment tool [9‐11].

133 patients operated by breast surgeons with or without plastic surgeons were included in the study. The group of older patients consisted of 73 patients: 15 (20.5%) of them underwent RB/OBCS, 10 (13.7%) NSM with DIEP reconstruction, 23 (31.5%) CBCS, and 25 (34.2%) TM. The younger patient group consisted of 60 women: 15 (25%) underwent RB/OBCS, 22 (36.7%) NSM with DIEP, 17 (28.3%) CBCS, and 6 (10%) TM. In the older patient group the mean age was 71.63 (SD 8.39) years and in the younger patient group 49.72 (SD 7.29) years. The mean time from surgery to follow-up Breast-Q was 37.27 (SD 22.25) months in the older group and 35.34 (SD 25.24) months in the younger group. The groups differed significantly in terms of comorbidities (p < 0.001) and type of surgery (p = 0.001): older patients had significantly more comorbidities (65.8% vs. 25.0%) and underwent TM more often (34.2% vs. 10.0%); younger patients underwent NSM with DIEP more often (36.7% vs. 13.7%). Additionally, younger patients were significantly more often treated with neoadjuvant chemotherapy (13.3% vs. 2.7%; p = 0.042). Other characteristics, such as T-stage, recurrence or surgical complications did not differ significantly (Table 1).

This study analyzed patient-reported outcomes in 133 stage I-III BC patients who underwent NSM with DIEP, OBCS, CBCS or TM, comparing older patients, over 60 years of age, with younger patients under the age of 60 years. We have found that older patients achieved significantly higher scores in the psychosocial well-being and physical well-being chest domains compared to younger patients. These findings confirm our hypothesis that there are relevant age-specific differences to be taken into account when informing patients on their surgical options.

The main limitation of this study is the relatively small sample size. This is due to the fact that we included consecutive patients undergoing a specific set of procedures performed by three senior surgeons during a limited study period since introduction of OPS at the study site. This, in turn, increased comparability of outcomes due to similarities in technical performance of the procedures. Additionally, to make the groups as homogeneous as possible we only included specific types of operations. However, further studies with larger sample sizes are necessary to validate these data.

Another limitation is the considerable variation in the timing of Breast-Q assessment due to the cross-sectional nature of the survey. As mentioned above, previous studies have shown varying results concerning changes of Breast-Q scores over time, suggesting that questionnaires should be collected at comparable postoperative intervals [6, 19, 25‐28]. However, the mean time from surgery to follow-up Breast-Q was found to be comparable in both groups.

As this study is a cross-sectional study, there is also no preoperative survey available for comparison, which can also represent a limitation to interpretation of our data.

Finally, this is an observational study, and selection criteria for type of surgery may have an impact on QoL. One strength of our study is that all surgeons in our unit are specialized in oncoplastic surgery, and therefore all surgical procedures are highly standardized. Furthermore, to prevent bias, we specifically looked at the cases of three experienced breast surgeons. Our study provides new insights in a field, where there is still paucity of evidence and our results confirm the relevance of age-specific differences in surgical-related QoL outcomes.

The current study indicates that age does have an impact on postoperative QoL. Patient counseling should include age-related considerations although age itself should, in our opinion, not be regarded as a contraindication for oncoplastic and reconstructive surgery. It is important not to withhold any surgical techniques from patients based solely on age, since, despite preconceptions, they can have a good or even better postoperative quality of life than younger patients. Our findings support personalized counseling for all women undergoing BC surgery and tailored care to address and anticipate the specific age-related physical and psychosocial needs of these patients. Attention to life-stage issues and concerns can help to improve postoperative QoL and patient satisfaction, as such improving overall patient care. Further studies with larger patient cohorts are necessary to corroborate our findings.