The Psychology - Part III

Unless otherwise noted, information for this section was drawn from a literature review about the psychological history of conceptualization of breast reconstruction by Harcourt & Rumsey in 2001.

Demographic information obtained from various cancer related studies has indicated that typically younger married white women from higher socioeconomic backgrounds are more likely to decide upon reconstruction. Motivating factors have been identified that include attempts to "restore feelings of femininity and wholeness, avoid disfigurement and deformity, improve self-confidence and to avoid an external prosthesis." Women often choose reconstruction as a manner of coping or even processing their mastectomy and battle with their cancer diagnosis.

The original research of the intersection of breast reconstruction and psychology predominately focused on the affective response of women who had decided upon breast reconstruction.  

Dissertation work (Covich, 1999) and previous research (Harcourt & Rumsey, 2001) reported that there were not significant differences  for measures of depression, anxiety, or self-esteem between women who opted for immediate reconstruction, delayed reconstruction, or no post-mastectomy reconstruction. Additionally, although original research hypotheses predicted that body image satisfaction would be higher for both reconstructive groups than for the mastectomy-only group, women who had decided not to undergo reconstruction actually reported higher overall body satisfaction than their reconstruction peers. Covich (1999) proposed that women most likely opted for immediate reconstruction hoping to "put breast cancer behind them" and attempting to diffuse their anxieties around possible cancer recurrence. Despite the process though of reshaping their chest to somewhat of its previous form, they reported similar levels of anxiety to other survey participants, possibly because as one respondent stated "I can't believe that anyone who has had cancer does not worry."

Although research results varied to some extent, Harcourt & Rumsey (2001) concluded at the end of their extensive literature review that there was not necessarily a psychological benefit at a group level for women who had chosen reconstruction in comparison with those who remained mastectomy-only. In fact, additional research proposes that women contemplating reconstructive surgery may face greater psychological distress due to the decision making process, undergoing additional medical procedures, fears of complications, ongoing physical pain as a result of implants and/or further tissue removal, dissatisfaction with aesthetic, or logistical outcomes of the reconstructed breast (Harcourt & Rumsey, 2004). Although complications are more uncommon now than in the past few decades, Deborah Yardley, who had already undergone a double mastectomy and "two years later, desperate to reclaim her femininity... underwent reconstructive breast surgery", died on the operating table after receiving double the recommended dose of anesthetic.

After roughly two decades with limited discernible differences in affective states for women between various groups, more recent work has focused on motivating factors, the levels of satisfaction with their decision,  social support, influence of medical experts, and attempting to map and understand the decision making process. For example, the top three motivating factors identified on a survey for choosing reconstruction included not having to wear an external prosthesis, increasing feelings of femininity, and to feel sexually attractive and avoid changes to their sexual relations (Contant et al., 2000).  Regarding the topic of sexuality, dissertation work has indicated that a positive shift in sexual satisfaction is likely to occur after reconstructive surgery, in addition to reported improvement in quality of life (Lee, 2000). Intimacy concerns are generally prevalent amongst all patients and books such as Intimacy After Breast Cancer: Dealing With Your Body, Relationships, and Sex by Gina Maisano help women to begin understanding and navigating what can be a difficult road.

Given the discussion of the bulk of research covered above, Harcourt & Rumsey (2004) criticized much of the research for approaching these topics retrospectively. Instead, they attempted to understand the process leading up to the actual breast reconstruction decision. Their article, which has been cited at least nineteen times, aided the critical discourse in the field in trying to expand the methodological "net" wider to understand the process women engage in addition to the outcome. Ultimately, the research pair from the University of the West of England attempt to specify the psychological needs of women when entering into the decision making process and trying to identify avenues to successfully meet those needs within the healthcare field.

Evaluating women's decision making processes on variables including the time it takes to make a decision, the degree of information seeking the patient engages in, patient's mood and their overall confidence in their decision has allowed the authors to break down female patients into three main categories of information-seeking, instant/immediate, and indecisive decision makers. Furthermore, most women in the study who were instant/immediate decision makers (i.e. would decide in the first meeting regarding their cancer treatment whether or not to undergo reconstruction) did not choose to have reconstructive procedures. The authors attributed this trend to patients' attentions being focused on the immediate stressors of the diagnoses and unable to give psychological attention and energy to contemplating additional "extra" operations. Women in the study reported feeling rushed to make a decision or that they did not fully understand the options available to them when communicating with providers. Contingent upon the different approaches women may take, Harcourt & Rumsey suggested that the healthcare field should formulate materials to disseminate information in a way that is fitting of the patient's decision making style and provide better emotional support: "Future research needs to examine ways of facilitating decision-making including the use of decision-aids, amongst women who find the decision especially difficult" (Harcourt & Rumsey, 2004). It is through this route that the authors propose positive increases to patient satisfaction regardless of their choice.

[Although not directly related, to gain an understanding of Harcourt & Rumsey's theoretical approach to research and patient care, please consider watching their video for the Centre for Appearance Research that they are co-founders of in England.]  Try this link if embedded video link is broken. 

Centre for Appearance Research from Back To The Planet on Vimeo.







Contant C.M.E., Van Wersch A.M.E.A., Wiggers T., Wai R.T.J., Van Geel A.N. (2000). Motivations, satisfaction, and information of immediate breast reconstruction following mastectomy. Patient Education and Counseling, 40 (3), pp. 201-208.

 Covich, J. L. (1999). The relationship between breast reconstruction and psychological adjustment when a mastectomy is necessary. The University of Texas at Austin). ProQuest Dissertations and Theses, , 159-159 p. Retrieved from http://ezproxy.lib.utexas.edu/login?url=http://search.proquest.com/docview/304541984?accountid=7118

Harcourt, D. and Rumsey, N. (2001). Psychological aspects of breast reconstruction: a review of the literature. Journal of Advanced Nursing, 35: 477–487. doi: 10.1046/j.1365-2648.2001.01865.x

Harcourt, D. and Rumsey, N. (2004), Mastectomy patients' decision-making for or against immediate breast reconstruction. Psycho-Oncology, 13: 106–115. doi: 10.1002/pon.711

Lee, R. F. (2000). Sexual satisfaction and self-image after post-mastectomy TRAM flap breast reconstruction. Gonzaga University). ProQuest Dissertations and Theses, , 102-102 p. Retrieved from http://ezproxy.lib.utexas.edu/login?url=http://search.proquest.com/docview/230622476?accountid=7118