Plastic Surgery Research Council

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Post Traumatic Stress Disorder and Associated Risk in Breast Cancer Patients
Daniel J. Yoho, MD1, Elizabeth Ulrich, BA2, Christel Rushing, BA3, Dunya Atisha, MD1.
1Henry Ford Health System, Detroit, MI, USA, 2Wayne State University, Detroit, MI, USA, 3Duke University, Durham, NC, USA.

PURPOSE:
Post-traumatic stress disorder is a well-documented sequela of breast cancer. As treatment advances continue to improve breast cancer related survival, it is increasingly important to evaluate the long term health and psychological well-being of different treatment modalities. While, breast conservation surgery, mastectomy alone, and mastectomy with reconstruction are known to have equivalent oncologic outcomes, little is known about the impact of these procedures on PTSD rates or symptomatology in breast cancer patients.
METHODS: Women recruited from the Army of Women (AOW) with a history of breast cancer surgery took electronically-administered surgery-specific surveys including a background survey to collect patient, disease, and procedure specific factors as well as the PTSD Checklist-Civilian Version (PCL-C), a self-report symptom checklist that closely mirrors the diagnosis criteria in Diagnostic and Statistical Manual of Mental Disorders, Revision IV (DSM-IV). Descriptive statistics, univariate hypothesis testing, and regression analysis were used to compare the incidence of PTSD and the degree of PTSD symptoms between surgical groups.
RESULTS: 7,619 women completed all questionnaires (83%). 3,507 had a history of breast conservation surgery (43%), 1,269 had mastectomy (16.67%), 2,328 underwent breast reconstruction (BR) (30.6%), and 515 had a complex surgical history (6.8%). Linear regression demonstrated that compared to BCS, patients who had a complex surgical history reported the most PTSD symptoms. There was no difference in PTSD symptoms, or incidence, with other surgical procedures, including mastectomy alone and all the reconstruction subtypes. Factors associated with an increase in PTSD symptoms included stage III disease, chemotherapy, obesity, and minor. Logarithmic regression displayed an increased incidence of PTSD with minor complications and unemployment and a decreased incidence with increasing age at diagnosis and increased time since initial operation.
CONCLUSION: PTSD remains an underdiagnosed and undertreated comorbidity of breast cancer. This study demonstrates that a complex surgical history, chemotherapy, obesity, unemployment, and a history of higher stage disease may increase the risk for the development of PTSD or the experience of PTSD symptoms. Identifying patients at high risk and understanding the psychological ramifications of treatment options will allow earlier diagnosis and enhance patient counselling on their options.

Linear Regression
VariablesChange in PTSD Score95% CI Upper95% CI Lowerp-value
Complex Surgical History2.221.073.370.0002
Chemotherapy0.950.401.510.0008
Time Since Surgery-0.28-0.22-0.14<0.0001
Stage III1.941.042.83<0.0001
Minor Complication2.211.722.71<0.0001
Age-0.19-0.22-0.1<0.0001
BMI0.110.070.15<0.0001
Unemployed2.651.154.150.0005
Disabled8.747.3810.09<0.0001


Logistic Regression
VariableOdds Ration95% CI Lower95% CI Upperp-value
Time Since Surgery0.690.361.32<0.0001
Minor Complication1.251.121.38<0.0001
Age0.690.192.50<0.0001
Disabled3.622.485.30<0.0001


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