Most Women Satisfied With ‘Going Flat’ After Mastectomy

Women who did not have reconstructive surgery after mastectomy were generally satisfied with the decision, a survey of 931 patients suggested.

The survey results yielded an average satisfaction level of 3.72 on a 5-point scale. The strongest predictor of low satisfaction was perceived lack of support from a surgeon for the decision to “go flat.”

“At least 20% of patients felt that their surgeon did not support their decision to forgo reconstruction, and a high level of flat denial was strongly related to dissatisfaction with the outcome,” Deanna J. Attai, MD, of the University of California Los Angeles, and co-authors concluded in their study online in Annals of Surgical Oncology. “Our findings show a need for additional study and validated tools to use for optimal counsel and support of women not interested in breast-mound reconstruction.”

“Some patients were told that excess skin was intentionally left — despite a preoperative agreement to perform a flat chest wall closure — for use in future reconstruction, in case the patient changed her mind,” Attai said in a separate statement. “We were surprised that some women had to struggle to receive the procedure that they desired.”

The results contrast with previous studies showing that women who opted not to have breast reconstruction had poorer quality of life as compared with women who had reconstruction, including implants, she added.

Despite similar outcomes with breast-conserving surgery (BCS) and mastectomy, rates of the latter have increased in recent years in the United States, even among women who are candidates for BCS. As more women have opted for mastectomy, the question of immediate breast reconstruction (IBR) has arisen more often.

Previous studies yielded conflicting findings regarding the association between IBR and improved quality of life as compared with mastectomy alone, the researchers said. Concern about disproportionate use of reconstruction for vulnerable and underserved populations led to increased efforts, including federal legislation, to ensure that patients are informed about and have access to IBR.

‘Going Flat’ Movement

Even with adequate information and access to IBR, women may choose to have mastectomy alone, giving rise to advocacy groups and online communities to increase awareness and acceptance of mastectomy alone, the authors continued. Within that context, the concept of “flat denial” has emerged: Surgeons who advise against mastectomy alone, do not offer the option, or leave excess tissue after mastectomy, against a patient’s wishes, for future reconsideration of reconstruction.

Attai and colleagues sought to determine whether the experiences of the “Going Flat” communities reflect the information and positions in the medical literature. The team developed an online survey in an effort to identify predictors of satisfaction (or lack thereof) with surgical outcomes among women who are active in the communities. The aim was also to learn more about factors that motivate women to choose mastectomy alone and evaluate the impact of flat denial.

The survey was posted on Facebook and Twitter and via personal blog during a 7-day period in 2019. Several leaders of online breast cancer support groups and Going Flat communities were encouraged to participate and make their community members aware of the survey.

Investigators used a five-point Likert scale to assess survey participants’ agreement or lack of agreement with statements about satisfaction with surgical outcome, appearance, body image, and experiences with flat denial. The survey also elicited information about patients’ reasons to forgo IBR.

Of the almost 1,100 responses, 931 completed surveys met criteria for inclusion in data analysis. All of the respondents were women, who had a mean age of 49. Almost 95% of survey participants were white, 78% were married or in a stable relationship, 71% had private insurance, and 79% lived in the United States. A total of 80.3% of the respondents had bilateral mastectomy procedures, the researchers reported.

Overall, 73.7% of the respondents said mastectomy alone was their first choice for postmastectomy care. The most common reasons for choosing mastectomy alone were a desire for faster recovery and avoiding placement or implantation of a foreign device.

The data showed that 139 (14.9%) of respondents underwent breast mound reconstruction that was subsequently removed, most often (69% of cases) because of problems with an implant. The remaining participants preferred BCS or mastectomy with some form of reconstruction, but the participants were either not candidates for BCS or IBR or the procedures were unsuccessful.

Predictors of Satisfaction

The 3.72 mean satisfaction score showed that most patients were satisfied with the surgical outcomes; dissatisfaction was defined as a score less than 3. In a multivariable analysis, perceived low surgeon support for the decision to go flat was the strongest predictor of dissatisfaction (odds ratio [OR] 3.85, 95% CI 2.59-5.72, P<0.001).

Overall, 20.7% of patients felt their surgeons did not support or respect the decision to go flat. Other predictors of a score less than 3 were body mass index (BMI) ≥30 (OR 2.74, 95% CI 1.76-4.27, P<0.001) and unilateral mastectomy (OR 1.99, 95% CI 1.29-3.09, P=0.002).

Greater satisfaction was associated with receiving adequate information about surgical options (OR 0.48, 95% CI 0.32-0.69, P<0.0001) and having a breast surgery specialist (OR 0.56, 95% CI 0.38-0.83, P=0.002).

The study highlights the fact that patients have three options after mastectomy — going flat, autologous reconstruction, or implant-based procedures, said Sarah Cate, MD, of the Icahn School of Medicine at Mount Sinai in New York City, who was not involved in the research.

“Patients are encouraged to choose whichever meets their goals, which are complex, and often difficult to distill initially,” Cate told MedPage Today via email. “Surgeon support is, of course, an important part of this process, as patients form a very close attachment to their surgical oncologist, and will need that support to pursue going flat.”

“We know that obesity or an elevated BMI may make the chest wall more difficult to contour completely flat, and this may explain why these patients were less satisfied overall with being flat,” she explained. “Of note, the survey was not a validated survey, so more research would need to be done on this with a validated survey, but the study included a large number of patients, and I think highlights that patients need to be supported no matter what they choose.”