The impacts of breast conserving treatment and mastectomy on the quality of life in early-stage breast cancer patients

Breast Cancer Vol. 2 No. 1 April 1995

Original Article

The Impacts of Breast Conserving Treatment and Mas- tectomy on the Quality of Life in Early-stage Breast Cancer Patients KOJIRO SHIMOZUMA*L HIROSHI S O N O 0 .1, KIYOSHI ICHIHARA .2, KAZUMASA MIYAKE*' , JUNICHI KUREBAYASH1.1, KIKUKO OTA*L AND TOKUHIKO KIYONO .1

The quali ty of life (QOL) in 55 early-stage breast cancer patients after surgery was prospectively assessed using a newly developed Japanese QOL questionnaire: The QOL Questionnaire for Cancer Patients Treated with Anticancer Drugs (QOL-ACD). The impacts of breast conserving treatment (BCT) (22 cases) and modified radical mastectomy (MRM) (33 cases) on the QOL in those subjects were compared. The overall QOL scores were evaluated during four periods (before surgery, 0-2, 3-12, and 13-24 months after surgery). The mean scores of the four categories of the QOL- ACD (activity, physical condi t ion, psychological condi t ion, and social relationships) were also compared.

The results demonstrated that a significant improvemen t was observed in the overall QOL scores among the three periods after surgery (0-2, 3-12, and 13-24 months) only in the BCT group (P<0 .05) . There were no significant differences between the two groups in the overall QOL scores dur ing any of the three periods after surgery, and the mean score of the 'psychological condition' during 0-2 months period in the BCT group was significantly lower than that in the MRM group ( P < 0.05).

These results suggest that BCT does not always improve the patients' QOL more than MRM does, and that the patients receiving BCT require more psychological support than those receiving MRM dur ing the early postoperative period.

Breast Cancer 2:35-43, 1995

Key words: Quality of life (QOL), Breast cancer, Breast conserving treatment, Radiotherapy, Informed consent

Encouraged by the reports which demonstrated the equivalent survival of conventional mastectomy and segmental mastectomy l-a) for primary breast cancer, physicians have been fre-

*1Division of Endocrine Surgery and *2Department of Clinical Pathology, Kawasaki Medical School. Reprint requests to Kojiro Shimozuma, Division of Endocrine Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki 701 -01, Japan.

Abbreviations: ADM:Doxorubicin; BCT:Breast conserving treatment; CPA: Cyclophosphamide; 5FU:5 - Fluorouracil; GHQ:General Health Questionnaire; MRM:Modified radical mastectomy; POMS:Profile of Mood States; PS:Performance status; QOL: Quality of life; QOL-ACD:QOL Questionnaire for Cancer Patients Treated with Anticancer Drugs; TMD:Total Mood Disturbance; UFT:Tegafur'uracil

Received June 10, 1994; accepted November 2, 1994

quently choosing breast conserving treatment (BCT) for early-stage breast cancer patients. One of the major advantages of BCT is that BCT can save breast contours and functions. We expect that this new therapy should reduce psychological distress and the time required for physical rehabilitation of the patients and consequently could improve the 'quality of life (QOLy of the patients receiving BCT.

To date, there have been many reports about the effect of BCT and mastectomy on the QOL of patients in Western countries 4 10), but few reports in Japan lm2). Kiebert et al TM reported in their review article of 18 English papers that, contrary to their expectation, there was no solid proof of a better psychological adjustment after BCT and that there were no substantial differences among

35

Shimozuma K, el al hnpact of Breast Conservation o n Q()L

the t r ea tmen t modal i t ies in changes of life pat- terns and the degree of fears and concerns. However , the resul ts with respect to body image and sexual funct ioning favored the use of BCT.

In Japan, where the h is tory of BCT is still short, little a t ten t ion has been paid to the issue. Although BCT is now being applied widely, we should conf i rm its ac tual benefi ts to the pat ient

and reveal possible negat ive consequences that have not been repor ted with convent iona l mas- tec tomy. For tha t purpose, we prospec t ive ly assessed the OOL in ea r l y - s t age breas t cancer

pat ients using a newly developed Japanese 0 O L ques t ionnai re ~'~s) (The QOL Quest ionnai re for Cancer Pat ients T r e a t e d with Ant icancer Drugs [QOL-ACD]). T h e impacts of BCT and mas-

t ec tomy of the QOL in the subjects were inves-

t igated at var ious periods before and a f te r surgery.

Patients and Methods

R e c r u i t m e n t and Charac ter i s t i cs o f P a t i e n t s For the past seven years in our clinic, pa t ients

with s tage I ~6) breas t cancer at a d is tance of more than 3 cm f rom the nipple have chosen their

own t r ea tmen t option between BCT ( lumpectomy or segmenta l m as t ec to m y fol lowed by radio therapy) and modif ied radical m a s t e c t o m y (MRM) (Patey or Auchincloss operat ion). Moreover , f rom April 1994, the pat ients with s tage II b reas t

cancer have also chosen their t r ea tmen t option, if the tumor was 3 cm or less in d iamete r and the

dis tance between the tumor and the nipple was

Table 1. Patient Characteristics (1) Before Surgery

Factor BCT (N 8) MRM (N=15) (Mean+SD) (Mean+SD) Mann Whitney test

Age 52.0_+ 12.2 57.4 _+ 10.9 not significant Body weight (kg) 49.4_+ 8.7 54.4 + 8.6 not significant

Fisher's exact Factor No. of patients No. of patients probability test

Stage Tis 0 0 not significant

I 7 8 in every combination II 1 7

All the patients were in PS '0', and in hospitalized state. None of the patients received adjuvant therapy. Two out of 8 patients in the BCT group underwent lumpectomy a week before radical surgery.

0 -2 Months after Surgery BCT (IX" 10) MRM (N 16)

Factor (Mean + SD) (Mean_+ SD) Mann-Whitney test

Months after surgery 0.4_+ 0.5 0.8_+ 0.5 not significant Age 52.3 +_ 10.7 53.2 _+ 8.6 not significant Body weight (kg) 49.5 + 7.6 56.8_+ 8.9 P < 0.05



I 7 6 in every combination II 3 7

PS 0 10 13 not significant 1 0 3

Hospitalization Hospitalized 8 6

P < 0.05 Not hospitalized 2 10 Adjuvant therapy

Chemotherapy 0 6 } ] Endocrine therapy 0 1 Chemoendocrine 0 4 Any therapy 9 0 with radiotherapy

None 1 5

P<0.01

P<0.01

BCT:Breast conserving treatment; MRM:Modified radical mastectomy; t)S:Perfornlance status.

36

Breast Cancer Vol. 2 No, 1 April 1.995

more than 3 cm. A total of 73 b reas t cancer pat ients have actu-

ally chosen their own t r ea tmen t opt ion f rom F e b r u a r y 1991 to Sep tember 1994. F i f ty - f ive out of 73 were asked to enter this s tudy f rom Febru- ary 1993 to Sep tember 1994 a f te r being in formed of its purpose, and none refused it. T h e remain ing 18 phtients were not reques ted to enter this s tudy for reasons of double cancer in 1, con t r a l a t e ra l

b reas t cancer in 4, cr i t ical o ther diseases or compl ica t ions in 9, and our overs ight in 4. T w e n t y - t w o (18 in s tage I and four in s tage II)

out of 55 pat ients unde rwen t BCT and the remain ing 33 (three in Tis, 21 in s tage I and 9 in s tage II) unde rwen t MRM. All 55 subjects had been notif ied tha t thei r disease was cancer , and received in fo rmat ion about their prognosis . T h e y were also well in formed of the advan tages and d i sadvan tages of the two types of t rea tment : ie, BCT could save b reas t con tour and funct ions co m p a red with MRM, but would usual ly be fol- lowed by r ad io th e r ap y to the residual b reas t to

cont ro l the possible local recurrence . T h e y chose their own t r e a tm en t option, excep t for cases in

Table 2. Patient Characteristics (2) 3-1 2 Months after Surgery

BCT (N 11) MRM (N-17) Factor (Mean • SD) (Mean • SD) Mann-Whitney test

Months after surgery 5.7 • 3.5 4.8_+ 2.7 not significant Age 51.1• 9.6 53.8_+ 8.7 not significant Body weight (kg) 50.8 • 9.9 57.6 • 10.4 not significant


Stage Tis 0 4 not significant I 10 8 in every combination II 1 5

PS 0 11 16 not significant 1 0 1

Adjuvant therapy Chemotherapy 4 6 Endocrine therapy 4 2 not significant Chemoendocrine 2 6 in every combination Any therapy 0 0

with radiotherapy None i 3

None of the pa t ients were in hospi ta l ized state.

13-24 Months after Surgery

BCT (N-13) MRM (N=14) Factor (Mean + SD) (Mean-- SD) Mann-Whitney test

Months after surgery 15.3 +_ 2.6 16.2_+ 4.0 not significant Age 50.8 + 11.1 54.4 + 10.1 not significant Body weight (kg) 54.0 + 8.5 59.1 + 11.8 not significant



I 12 10 in every combination

II 1 0 Adjuvant therapy

Chemotherapy 6 5 Endocrine therapy 2 4 Chemoendocrine 2 3 Any therapy 0 0

with radiotherapy None 3 2

not significant in every combination

All the pat ients were in PS '0' and none were in hospi ta l ized state. BCT:Breast conserving t reatment ; MRM:Modified radica l mastectomy; PS:Performance status.

37

Shimozuma K, el a/ Impact of Breast Conservation on QOL

which there was a possibility of noninvasive carcinoma with scattered multiple microcal- cifications on mammography. Such cases were recommended to receive MRM.

As for the types of adjuvant therapy, all the patients in the BCT group except one received radiotherapy to the residual breast, usually for 6 weeks during 0-2 months after surgery. In the BCT group, 20 out of 22 patients received some types of medical adjuvant therapy during one or two years. Ten patients received chemotherapy alone; five patients received endocrine therapy alone; and five patients received chemoendocrine therapy. In the MRM group, 27 out of 33 patients received some types of medical adjuvant therapy during 6 months to 2 years. Eleven patients received chemotherapy alone; 7 patients received endocrine therapy alone; and 9 patients received chemoendocrine therapy. For orally administered drugs, tegafur.uracil (UFT) (300-600 mg for tegafur/day), tegafur (800 rag/day), doxifluridine (600-1200 rag/day), carmofur (300 mg/day), cyclophosphamide (CPA) (50-100 rag/day) were used for chemotherapy, and only tamoxifen (20 mg/ day) was used for endocrine therapy. For an intravenously administered drugs, doxorubicin

(ADM) and 5-fluorouracil (5FU) were given to two cases in the MRM group in the form of 6 cycle CAF therapy (CPA: 100 mg• days Iorallyl, ADM: 30 rag/body Iday 1,811, 5FU: 500 nag/body Eday 1, 8~, every four weeks).

The questionnaire was filled in every four weeks by each patient. As we intended to compare the QOL score during the divided four periods (before surgery, 0-2, 3-12, and 13-24 months after surgery), the data were adopted from the first questionnaires taken in each period. No data by the same patient were includ- ed in each period.

Characteristics of the patients from whom the data were taken in each period and the comparison of results of distributions in the two treatment groups using the Mann-Whitney test or the Fisher's exact probability test are listed in Tables 1 and 2. The clinical stage was preoper- atively determined by UICC TNM classifica- tions 16). Performance status (PS) was assessed by the ECOG-performance status 17) (PS). The types of adjuvant therapy indicated in Tables 1 and 2 were those given within one month prior to the questionnaire. During the 0-2 months period, there were significant differences in the distribu-

NAME: DATE : / /

AGE : - - SEX : 1. MALE 2. FEMALE B.W. : Kg

This quest ionnaire is being done to help us understand your present state,

Please read the questions and circle the number above the scale w h i c h best describes your state during the past several days.

(Your privacy will be strictly protected and there will be no negative inf luence on your medical treatment, so please answer these quest ions freely w i t h o u t concern. )

(dur ing the past several days)

I. Have you been able to perform normal dai ly life activit ies ?

2. Have you been able to go out bY yourself ?

3. Have you been able to go for a 30 minute walk ?

4. Has it been hard for you to walk even a short d is tance?

5. Have you been able to go Up and d o w n the stairs ?

6. Have you been able to take a bath by yourself ?

7. How well have you felt ?

8. Have you had a good appetite ?

g. Have you enjoyed your meals ?

I0 Have you experienced vom t ing ?

71. Have you lost weight ?

12. Have you slept wel l?

I 2 L ,

Completely Unable

1 2 L ,

Completely Unable

1 2

Completely Unable

5 4, L i

Not At All

1 2 L ,

Completely Unable

1 2

Completely Unable

I 2

Extremely Poor

I 2 l i

Extremely Pool

l 2 L I

Not At AI~

5 4

Not At All

5 4 i i

Not At All

1 2

Not At AI~

3 4 5 i = ,

Completely Ab4e

3 4 5 i i J

r e~y Able

3 4 5 i i J

Completely Able

3 2 1

A Great Deal

3 4 5 = i t

Completely Able

3 4 5 i J i

Completely AbFe

3 4 5

Extremely Welt

3 4 5 i i t

Extremely Good

3 4 5

A Great Deal

3 2 1

Very Often

3 2 I

A Great Deal

3 4 5

Ext temelv Well

(dur ing the past several days)

13. Have you been absorbed in a n y t h i n g ?

14. Have you coped well with everyday stress ?

15. Do YOU feel unable to concentrate ?

16. Are you encouraged by anyone or any th ing (family, friends, religion, hobbies, etc.)?

1T.

18.

19.

20.

21.

22.

2 3 4

Not At All A Great Deal

2 3 4

Not At All Exlremelv Well

4 3 2

Not At All A G~eat Deal

2 3 4


Have you felt ill at ease about the condit ion of your d isease?

Have you felt unwil l ing to meet anyone other than your f a m i l y ?

How much trouble do you feel you give your family over your medical treatment ?

Are you anxious about your social life in the future?

Are YOU worried about the medical costs of your treatment ?

4 3 2

Not At All A Great Dea~

4 3 2


4 3 2

None A Great IDeal

4 3 2


4 3 2

Not At All A Great Deat

Please circle the number of the face expressing your state during the past . . . . . . I days. ~ ~ ~ ~ ~

5 4 3 2

At last, please confirm that you have answered all of the quest ions

[A column filled out by doctors or nurses]

a. 1.inpatient 2. outpatient I e. Remarks :

b. PS:

c B . W . : Kg

d. Date : / / Recorder :

Fig 1. 'The QOL Questionnaire for Cancer Patients Treated with Anticancer Drugs (QOL ACD)' (English edition).

38

Breast Cancer Vol. 2 No. 1 April 19.95

tion of the hospitalized state and the types of adjuvant therapy in the two groups (P <0.05, P < 0.01, respectively). That is, more patients in the BCT group were hospitalized than those in the MRM group. Nine patients out of 10 in the BCT group received radiotherapy, while none received it in the MRM group.

Questionnaire Evaluation The English edition of the 0OL-ACD used in

this study to evaluate the 0OL is shown in Fig 1. The 0OL-ACD is a patient-rated 0OL measure developed for Japanese cancer patients by a scientific group in the Ministry of Health and Welfare in Japan called 'The Research Group For Scientific Assessment Measures of Treat- ments with Anticancer Drugs' (April 1989 to March 1991, leader: M. Kurihara) and 'The Research Group for Scientific Assessment of Drug Treatments ' (April 1991 to March 1993, leader: M. Kurihara). The validity and reliability of this measure for Japanese cancer patients were verified during its development 14>.

The following is a brief description of the 0OL- ACD. It consists of 22 questions, which are divided into five categories: (1) six questions to evaluate activity, (2) five for physical condition, (3) five for psychological condition, (4) five for social relationships, and (5) one for overall aspects of the QOL as represented by a face scale, which includes five different faces selected from among the 20 faces in the original face scale by Lorish and Maisia TM. Patients are instructed to answer all questions by circling the number that best represents their state. The score for each question is summed to give an overall score, the minimum being 22 and the maximum being 110. A higher score represents a higher QOL. The mean scores were also calculated for four categories excluding that for evaluation of the global QOL by the face scale. Each score ranged from one to five.

Data Management and Statistical Methods A questionnaire with no more than two un-

answered questions among the 22 questions was judged valid. The unanswered questions, if any, were figured into the mean score for the rest of the questions. By this criterion, all the questionnaires taken in this study were valid (100%).

The Kruskal-Wallis test was used to investi- gate the improvement of the overall 0OL scores

over assessment times in each group, and the Mann-Whitney test was used to compare the overall QOL scores and the mean scores of the four categories.

Lotus 1-2-3 (Lotus Development Co) was used for accumulation of the data and calculation of the scores. The statistical analyses were carried out using general purpose statistical software, Stat Flex (View Flex Co, Tokyo).

S c o r e B C T

100

75

5 0 '

S c o r e

u i i

O 0

�9 �9 O 0 �9 O 0

88 - * I * -

Q

a ## u I _ _ ## _ _ ,

i i n I

before 0 - 2 3 - 12 13- 24

surgery Months a f t e r s u r g e r y

MRM

100

75

5O

u i n

o o o o

OO

O 0 �9

OO0 O 0 �9 00 �9 I J f l

OO0

g o �9 : : .|

i I # _ _

#

l i

before 0- 2 3 - 12 surgery

i

o o o

o o o

J

1

u

1 3 - 2 4

Kruskal - Wallis test * P < 0.05 ** P < 0.01 Mann- Whitney test # P < 0.05 ## P < 0.01

Months af ter surgery

BCT: Breast conserving treatment M R M : Modified radical mastectomy The bar represents the mean of the score,

Fig 2. The overall QOL-ACD scores in the BCT group (above) and the MRM group (below). A significant improvement was observed in the scores among the three periods after surgery (0 2, 3-12, and 13 24 months) in the BCT group but, on the other hand, those for the same periods in the MRM group were not significantly improved. In the BCT group, the score during the 0-2 months period was significantly lower than that during the 3-12 and 13 24 months periods, while in the MRM group, the score during the 0-2 months period was significantly lower than that only during the 13 24 months period.

39

Shiinozuma K, et al Impact of Breast Conservation on QOL

Results

Overall QOL Score The overall QOL scores in the BCT group and

the MRM group are shown in Fig 2. A significant improvement was observed in the scores among the three periods after surgery (0-2, 3-12, and 13- 24 months) in the BCT group (P <0.05) and, on the other hand, those among the same periods in the MRM group were not significantly improved, although a significant improvement was observed in the scores among all the four periods and the three periods except the 13-24 months in the MRM group. In the BCT group, the score during the 0-2 months period was significantly lower than those during the 3-12 and 13-24 months

periods (P<0.01), while in the MRM group, the score during the 0-2 months period was significantly lower than that only during the 13-24 months period (P<0.05). There were no significant differences between the two groups in the overall QOL scores during any of the four periods.

The Mean Score of the Four Categories o f the QOL-ACD

The mean scores of the four categories are shown in Fig 3. The mean score of the 'psychological condition' before surgery in the BCT group was significantly higher than that in the MRM group (P < 0.05), and that during the 0-2 months period in the BCT group was significantly lower than that in the MRM group (P <0.05).

Score A c t i v i t y

surgery

m

13-24 (M)

Score

5

4

3

0 1

I

~;~ BCT

Physical condition [ I MRM

before surgery

I P/, 0-2

IT

3-

T-T

2 13-24 (M)

Psychological condition Score

5 - i J

0

before 0- 2 3 - 12

before 0- 2 3 - 12 surgery * : Mann - Whi tney

I

3- 24 (M) P < 0.05

Score

5

3

0 1

Social relationship

before 0- 2 surgery

l 3-1 2 13-24 (M)

BCT: Breast conserving treatment M R M : M o d i f i e d radical mastectomy

Hight of the bar represents the mean of the score and the span of the vertical l ine above it indicates the standard deviat ion (SD).

Fig 3. The mean scores of the four categories. The mean score of the 'psychological condition' before surgery in the BCT group was significantly higher than that in the MRM group, and that during the 0-2 months period in the BCT group was significantly lower than that in the MRM group.

40

Breast Cancer Vol. 2 No. 1 April 1.9.95

Discussion

A comparative study of treatment modalities using a QOL score requires consideration with regard to the issue of notification of cancer and the manner in which treatment modalities are chosen. Stechlin et a/19) pointed out that the diagnosis of cancer evoked a far greater distress than any other disease, regardless of its prognosis. In Japan the majority of cancer patients are not notified of the disease and its prognosis, although our previous study revealed that 88% of experimentally notified breast cancer patients subsequently approved the act of notification TM.

All the subjects in this study, however, were notified of their disease and prognosis. As for the issue of the manner in which t rea tment modalities are chosen, Kiebert et al TM pointed out that rational decision-making should be based on the theory and the empirical data with respect to the three end points: (1) the likelihood of local tumor control and survival; (2) the burden of the treatment to be experienced by patients and its effect on the QOL; (3) the cost of treatment. However, the availability of such information to patients or strong recommendation from physicians on treatment options may affect a patient' s psychological condition. Pozo et al 9) pointed out that the choice of surgical procedure resulted in higher levels of life satisfaction at three months after surgery. Inversely, Fallowfield et

al TM reported that patients who had a choice between mastectomy and breast conservation did not do any better psychologically than patients who did not have a choice. The present study was performed under such conditions that most of the subjects were allowed to freely choose their surgical procedures after being well informed of them.

Some investigators 4,6) have reported that the surgical procedure for breast cancer had no influence on the QOL, while some reported the differences on the QOL depending on the assessment time after surgery 9'~~ In the present study, a significant improvement was observed in the overall QOL scores among the three periods after surgery in the BCT group. Moreover, the mean score of the 'psychological condition' during the 0-2 months period in the BCT group was significantly lower than that in the MRM group, although no significant differences were found in

the overall QOL scores between the two treatment groups during any of the periods.

The interpretation of our results is as follows. First, the radiotherapy which is usually performed after breast conserving surgery may affect the lower scores during the early postoperative period in the BCT group. Adverse effects of radiotherapy on the QOL of patients have been reported by many investigators 22-24). Ganz el a[ 1~

reported in their study during the year of follow- up using the POMS (The Profile of Mood States) and TMD (Total Mood Disturbance) that, although statistically not significant, patients receiving BCT appear to have greater distress at one month with continued improvement in mood over the remainder of the year, concomitant with a steep decline in the TMD score at the four- month assessment time. On the other hand, their MRM group had a lower TMD score at one month but did not show any improvement in TMD until six months later. Similar changes in the QOL over assessment times have also been reported by other investigators ~'8). Secondly, a prolonged hospitalized period due to radiotherapy after surgery in the BCT group might affect our results. Our previous study using multivar- iate analysis TM has revealed that the hospitalization had strong negative relation to the overall QOL score and all the four categories of the QOL- ACD in breast cancer patients after surgery. Thirdly, the lower mean score of the 'psychological condition' may be attr ibutable to a fear of recurrence. Actually, it has been pointed out 26'27) that some patients receiving mastectomy felt that the removal of the whole breast gives a greater protection against recurrence, although there have been other reports with conflicting results 5). In any case, we may say that women receiving BCT may require more intensive psychological support during the early postoperative period.

On the other hand, there have also been some reports 11'2s'29) referring to the advantages of BCT. McArdle et al TM reported using the General Health Questionnaire (GHQ) and the Leeds Scales for Anxiety and Depression that their MRM group had greater psychological distress than the BCT group at any assessment times (6, 9, and 12 months after surgery), but the difference was statistically significant only on the depression subscale of the GHQ. Vinokur et al TM also reported that patients who underwent BCT were significantly less concerned about body image

41

Shimozuma K, et a/ Impact of Breast Conservation on QOL

and their appearance than those who underwent mastectomy. Pozo el al 9) pointed out that the BCT patients reported a higher quality sex life at 6 and 12 months postsurgery than the MRM patients, and that they had fewer problems with clothing and body image judging from their rehabilitation needs. As shown above, it is also impor- tant to note that, despite the advantage of the

BCT in sexual function, body image and clothing problems, the general QOL measures have failed to reveal differences in QOL in the two t reatment groups. Our study did not demonstrate any appar-

ent differences in the overall QOL scores between the two t reatment groups either, although significant improvement of the QOL score during the postoperative period was shown only in the BCT group.

The failure to show significant differences in QOL score by general QOL evaluation may be

attr ibuted to the following reasons: First is the validity of the questionnaire evaluation. In the

case of our study, the QOL-ACD does not include enough questions about sexual function and body

image. Actually, the QOL-ACD was not origi- nally designed to evaluate the influence of surgical procedures on the QOL of postsurgical patients, but to evaluate the influence of anticancer drugs. This problem requires further investi-

gation using a more specific measure. Secondly, we also should consider how much emphasis the breast cancer patients actually put on such problems as sexual function and body image in their daily life. Patients in Japan tend to decline to answer such questions about sexual problems. The response to such questions may therefore depend on the cultural background of the patient.

At last, to interpret a significant difference observed in the mean score of the 'psychological condition' between the two groups before surgery (BCT > MRM), further investigation may be ne- cessary because of the small number of subjects,

especially in the BCT group before surgery. In conclusion, the results of the present study

suggest that BCT does not always improve the patients ' QOL more than MRM does, and that the

patients receiving BCT require more psychological support than those receiving MRM during the early postoperat ive period. This, however, does not mean that, based on the results of this study, that we necessarily discourage the use of BCT as a relevant t rea tment option for ear ly-s tage breast cancer patients. This issue requires fur-

ther investigation using a new measure focusing more specifically on the postsurgical status, under a longitudinal study with close monitoring of the QOL.

Acknowledgment

We wish to express our gratitude to Prof M. Kurihara of Showa University, and Emeritus Prof K. Sarai of Hiroshima University for their guidance.

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Breast Cancer Vol. 2 No. 1 April 1995

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The impacts of breast conserving treatment and mastectomy on the quality of life in early-stage breast cancer patients