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 Table of Contents  
ORIGINAL RESEARCH REPORT
Year : 2022  |  Volume : 19  |  Issue : 1  |  Page : 35-44

Postmastectomy breast reconstruction awareness and attitudes in Nigerian women with breast cancer: A descriptive, cross sectional survey


1 Department of Plastic, Reconstructive and Aesthetic Surgery, University College Hospital; Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
2 Department of Plastic, Reconstructive and Aesthetic Surgery, University College Hospital, Ibadan, Oyo State, Nigeria
3 Department of Radiation Oncology, University of Ibadan, Ibadan, Oyo State, Nigeria
4 Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria

Date of Submission23-Jul-2021
Date of Acceptance31-Dec-2021
Date of Web Publication07-Mar-2022

Correspondence Address:
Dr. Afieharo I Michael
Department of Surgery, College of Medicine, University of Ibadan, Queen Elizabeth Road, Ibadan, Oyo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_28_21

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  Abstract 


Introduction: Sub-Saharan Africa has a high burden of breast cancer and very low rates of breast reconstruction. This study aimed to determine the awareness of and attitude to breast reconstruction among women with breast cancer who had mastectomy. Methods: A cross-sectional study of women with breast cancer who underwent mastectomy was done. Participants were recruited from September 2020 to January 2021 from the surgical oncology and radio-oncology outpatient clinics of the University College Hospital, Ibadan. A multivariate logistic regression was used to determine predictors of awareness and attitudes to breast reconstruction. P ≤ 0.05 was considered statistically significant. Results: Fifty-one women participated in the study. The mean age was 54.76 (+9.94) years. Most, 30 (58.8%) of them had tertiary level of education, were working, 39 (76.5%) and were married, 41 (80%). Funding for the mastectomies was mainly out-of-pocket 34 (66.7%). Most 37 (72.5%) were not aware that the breast could be reconstructed before their surgery and only one (1.96%) of the women had breast reconstruction. The reason most proffered for declining breast reconstruction was not wanting another surgery 13 (33.3%). The age (odds ratio [OR] 0.02, 95% confidence interval [CI] 0.001–0.33), P = 0.006 of the participants and the educational status (OR 12.50, 95% CI 1.86–84.26), P = 0.009 were significant predictors of awareness of breast reconstruction. None of the variables were significant predictors of positive attitudes to breast reconstruction. Conclusion: There is a very low level of awareness of breast reconstruction. Younger age and tertiary education were significant predictors of awareness of breast reconstruction.

Keywords: Attitude, awareness, breast cancer, breast reconstruction, mastectomy


How to cite this article:
Michael AI, Olawoye OA, Ademola SA, Ugwu EO, Sarimiye FO, Ayandipo OO, Aderibigbe RO, Iyun AO, Oluwatosin OM. Postmastectomy breast reconstruction awareness and attitudes in Nigerian women with breast cancer: A descriptive, cross sectional survey. J Clin Sci 2022;19:35-44

How to cite this URL:
Michael AI, Olawoye OA, Ademola SA, Ugwu EO, Sarimiye FO, Ayandipo OO, Aderibigbe RO, Iyun AO, Oluwatosin OM. Postmastectomy breast reconstruction awareness and attitudes in Nigerian women with breast cancer: A descriptive, cross sectional survey. J Clin Sci [serial online] 2022 [cited 2022 May 28];19:35-44. Available from: https://www.jcsjournal.org/text.asp?2022/19/1/35/339147




  Introduction Top


The vital role of breast reconstruction in the management of breast cancer has been substantiated by different authors, with improvement in the quality of life of these women as the central theme.[1],[2],[3] Psychological benefits of postmastectomy breast reconstruction include re-established psychological well-being, improved body image and self-esteem, as well as strengthening the affective and sexual relationship of couples.[1],[2],[3],[4] Breast reconstruction is one of the most important determinants of long-term health and well-being among breast cancer survivors.[5]

In the United States of America, the Women's Health and Breast Cancer Rights Act in 1998[5] ensured that all women who were health-care payers enjoyed coverage for breast reconstruction after mastectomy. Consequent on the implementation of the Breast Cancer Patient Education Act in 2015, there was an increase in the access of breast reconstruction, particularly among racial and ethnic minority groups in the USA.[6],[7] The New York State Provider Discussion Law mandates all physicians to discuss breast reconstruction with breast cancer patients and expedite plastic surgery referral following breast cancer diagnosis.[8]

Sub-Saharan Africa has a high burden of breast cancer and very low rates of breast reconstruction. One unique characteristic of women with breast cancer from this region is the comparatively younger age of occurrence of the disease, similar to African–American women.[7],[9],[10],[11] Its management has over the years being marred by late presentation, funding limitations, and the complex interplay of religion and myths about breast cancer.[12],[13] This late presentation has made breast-conserving surgeries impractical and mastectomies the norm.[14] A recent survey of surgeons in West Africa identified cost, lack of awareness, and inadequate skill sets as barriers to the uptake of breast reconstruction.[15] We aimed to determine the awareness and attitudes of breast reconstruction among women who had underwent mastectomy.


  Methods Top


Study design/setting/participants

The study was approved by the joint University College Hospital (UCH)/University of Ibadan review board. The study was a cross-sectional study. Consenting postmastectomy female patients with breast cancer presenting to the surgical oncology and radio-oncology outpatient clinics of the UCH, Ibadan, were recruited from September 2020 to January 2021

Study instrument/sample size

A 45-item structured questionnaire was self-administered. It included a Likert scale for assessment of attitude to breast reconstruction. The study size was estimated using the Leslie Kish sample size formula for single proportion. A minimum sample size of 37 participants was obtained.

Data analysis

The responses were coded and entered into the IBM Statistical Package for the Social Sciences (SPSS) version 20.0. Chicago, Illinois. The mean attitude score was computed. The association between sociodemographic characteristics and other variables with the level of awareness of and attitude to breast reconstruction was analyzed using Chi-square and Fisher's exact test. Variables that are statistically significant at P < 0.5 during the bivariate analysis will be used to run a logistic regression model to determine independent predictors of respondents' attitudes to breast reconstruction.

P ≤ 0.05 were considered statistically significant.


  Results Top


Sociodemographic and clinical details of the participants

Fifty-one women participated in the study. The mean age was 54.76 (+9.94) years. Larger portion of them had tertiary level of education 30 (58.8%), were working 39 (76.5%), married 41 (80%), and had at least one child 48 (94.2%). The sociodemographic characteristics are shown in [Table 1]. Almost three-fifths of the women 30 (58.8%) did not know the stage of their breast cancer. However, more than half 29 (56.9%) of the participants had mastectomy at a hospital different from the hospital of study. Nearly all of these women 50 (98.0%) had one mastectomy done and oftentimes, on the left 27 (52.9). The funding for the mastectomies was majorly out-of-pocket 34 (66.7%). Only 3 (5.9%) had full funding with health insurance. Most of the women were <1-year postmastectomy 29 (59.2%). Thirty-one (60.8%) women were using improvised material to mimic the shape of the breast. While 22 (71.0%) regarded this method as convenient for them, 10 (32.3%) reported they had had embarrassing moments with the use of the material. The clinical information of the women is shown in [Table 2]. Majority of the women 44 (86.3%) did not belong to a support group for women who had had mastectomy. Of all, only one (1.96%) woman had received breast reconstruction.
Table 1: Sociodemographic information of the study participants (n=51)

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Table 2: Clinical information of the participants (n=51)

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Awareness of breast reconstruction

Majority, 37 (72.5%), were not aware that the breast could be reconstructed before their surgery. More of the information on breast reconstruction was obtained from the Internet 7 (30.4%) and the hospital 7 (30.4%). Before the explanation on breast reconstruction in the questionnaire, only 12 (23.5%) were interested in having a breast reconstruction. Examples of reasons proffered for desiring a new breast included “to feel good and make clothing fit” 4 (33.3%), for better breast symmetry 2 (16.7%) and to prevent discomfort with silicone brassiere 2 (16.7%). The reason most proffered for declining breast reconstruction was not wanting another surgery 13 (33.3%) [Table 3].
Table 3: Awareness of and willingness for breast reconstruction among participants (n=51)

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Following the explanation on breast reconstruction in the questionnaire, there was only a small increase of 17 (33.3%) in the desire for breast reconstruction. Of the patients who wished to have breast reconstruction, most 11 (58.7) admitted they would have preferred implant-based reconstruction and the preferred timing of reconstruction was fairly similar between immediate 8 (47.1%) and delayed 7 (41.2%) reconstruction [Table 4]. When asked how awareness on breast reconstruction could be created, most of the women preferred education and counseling of women with breast cancer before surgery [Figure 1].
Figure 1: Suggested ways of creating awareness of breast reconstruction

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Table 4: Willingness for breast reconstruction after explanation on breast reconstruction (n=51)

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Factors associated with awareness of breast reconstruction

A statistically significant association was found between the participants awareness of breast reconstruction and age (P < 0.001), level of education (P < 0.001), employment status (P = 0.024), age of last child (P = 0.024), and period since mastectomy (P = 0.016). Awareness of breast reconstruction was not associated with marital status (P = 0.154), number of children (P = 0.237), hospital where surgery was performed (P = 0.645) and usage of material or device to maintain breast shape [P = 0.244; [Table 5]].
Table 5: Factors associated with awareness of breast reconstruction

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Notably, participants in the lowest age category had the highest level of awareness of breast reconstruction 12 (80.0%), while those aged 60+ years had the lowest level of awareness 1 (6.3%). The level of awareness was the highest among participants with tertiary education 20 (66.7%) and lowest among those who attained below secondary education 1 (10.0%). The level of awareness was higher among participants who were currently employed 21 (53.8%) than those who had no current employment 2 (16.7%). Sixty-two percent (n = 18) of women who had a mastectomy within a year before the study were aware of breast reconstruction compared to 23% (n = 3) of those who had theirs 1–2 years before the study and 14% (n = 1) among those who had theirs over 2 years before the study [Table 5].

The multivariate logistic regression showed that the age of the participants and the educational status were significant predictors of awareness of breast reconstruction. Participants aged 50–59 years (odds ratio [OR] = 0.24) and 60+ years (OR = 0.02) were very less likely to be aware of breast reconstruction, compared to those aged 35–49 years. Participants with tertiary education were significantly more likely to be aware of breast reconstruction than those who attained below tertiary education (OR = 12.5). Participants who had their mastectomy in a hospital different from the study institution were less likely to be aware of breast reconstruction (OR = 0.73) [Table 6].
Table 6: Multivariate analysis of factors associated with awareness of breast reconstruction

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Factors associated with willingness for breast reconstruction

The findings [illustrated in [Table 7]] revealed that none of the participants sociodemographics such as age (P = 0.407), level of education (P = 0.557), occupational status (P = 0.294), marital status (P = 1.00), and age of last child (P = 0.279) had a significant association with their willingness to have breast reconstruction. None of the participant's clinical information had a statistically significant relationship with their acceptance of breast reconstruction. Despite no statistical significance, the result showed that the level of willingness for breast reconstruction was higher among participants who were aware of breast reconstruction (39%) than those with no awareness (29%).
Table 7: Factors associated with willingness for breast reconstruction

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The multivariate analysis revealed that participants in the older age group, 50–59 years (OR = 0.48) and 60 + years (OR = 0.38), were less likely to accept breast reconstruction. Participants with tertiary education were equally as likely as those who attained below tertiary education (OR = 1.03) to accept breast reconstruction. Participants who had their surgery in a hospital outside UCH were nearly twice as likely as those who had surgery within UCH (OR = 1.67) to accept breast reconstruction. Participants who used improvised material or devices to maintain breast shape were less likely to accept breast reconstruction (OR = 0.84). Participants who were aware of breast reconstruction were more likely than others to accept it (OR = 1.11) [Table 8].
Table 8: Multivariate analysis of factors associated with willingness for breast reconstruction

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Attitude to breast reconstruction

Most of the participants, 33.2 (65%), had a positive attitude to breast reconstruction. However, neither the age (P = 0.070), level of education (P = 0.170), current employment status (P = 0.231), and marital status (P = 0.447) were significantly associated with a positive attitude towards breast reconstruction. The proportion of participants who showed a positive attitude towards breast reconstruction was higher among unmarried (80%) than married (61%) women. The hospital where mastectomy was performed had no significant association with attitude toward breast reconstruction (P = 0.678). Usage of material or device to maintain breast shape was likewise not significantly associated with attitude level (P = 0.217). Awareness of breast reconstruction was also not significantly associated with the level of attitude toward it (P = 0.603) [Table 9].
Table 9: Factors associated with attitude toward new breast reconstruction

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The multilogistic regression [Table 10] revealed that participants of older age were more likely to exhibit a positive attitude toward breast reconstruction than younger participants in the age group 35–49 years; 50–59 (OR = 1.23) and 60 + years (OR = 8.41). Participants who had attained a tertiary education were less likely to show a positive attitude towards breast reconstruction, as compared to those who had below tertiary education (OR = 0.41). Participants who were aware of breast reconstruction were thrice as likely as others to show a positive attitude toward it (OR = 3.51).
Table 10: Multivariate analysis of factors associated with attitude toward new breast reconstruction

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  Discussion Top


Most of the women who participated in the study were young, married, had tertiary education and were working. The majority of them had no idea of the stage of their breast cancer. Unilateral mastectomies were predominant and most of the women had paid out of pocket for their surgeries. The majority of these women were not aware of breast reconstruction before their mastectomies. Being of a younger age and having tertiary education were determinants of awareness of breast reconstruction amongst women who were aware of breast reconstruction at the time of the study. Most of the participants were not interested in receiving breast reconstruction. Recurring reasons both before and after explanation of breast reconstruction were not wanting another surgery and a feeling of being too old. Only one of the 51 participants had received breast reconstruction. Although more participants had a positive attitude to breast reconstruction, none of the sociodemographic variables were predictors of this positive attitude.

It was revealing from this study that most of the women were not able to say what stage of breast cancer they were diagnosed with. This was irrespective of educational status. Considering that from their response's survival was more important to them than breast reconstruction, they were seemingly ignorant of this information that had a bearing on survival. It is possible that the lack of understanding of the breast cancer disease by women in our setting is contributory to late presentation and loss to follow-up as previously reported.[15],[16] This knowledge gap identified in this study and the significant gaps in knowledge about breast cancer amongst health care workers both at the tertiary care and community level as identified by Pruitt et al.[17] calls for a review of how information is given during breast cancer awareness programs in our region. This has also been buttressed by Wogu et al.[18] who identified that only a fifth of the women in their study received awareness on breast cancer through the media and knowledge gaps were evident amongst the women studied in Southeastern Nigeria.

Only one patient in this cohort of women had received breast reconstruction. This prevalence of 2% is abysmally low. A study from Kenya also reported a very low rate of breast reconstruction of 2.88% over a 5-year period.[10] Over 70% of the women in this study were not aware of the options of breast reconstruction prior to the mastectomy they received. A survey of West African surgeons also revealed that despite most of the surgeons admitting that breast reconstruction was essential, the referral rate for breast reconstruction was <30%.[15] They alluded to cost constraints and lack of skill sets as some of the barriers to referrals for breast reconstruction. This present situation in West Africa on breast reconstruction is similar to the situation reported by Alderman et al. over a decade ago in the USA, where over 70% of women were not informed of breast reconstruction by their general surgeons.[19] It was this recurring situation that led to the enactment of laws in the USA to ensure that every woman with breast cancer is informed on breast reconstruction and can access the procedure under cover of health insurance. Subsequently, increased uptake of breast reconstruction was realized.[7],[20]

In a study that interviewed women in Southwestern Nigeria on their life without a breast, one of the women volunteered that had she been aware of breast reconstruction before the mastectomy, she would have opted for it.[21] It indeed should no longer be acceptable for a mastectomy to be recommended for any woman without the options of breast reconstruction similarly discussed with her regardless of her sociodemographic or economic standing. Our study showed that women who were aware of breast reconstruction were more likely to accept breast reconstruction.

Retrouvey et al.[22] pointed out that barriers to breast reconstruction existed in all domains of the Pechansky and Thomas' access to care framework. These domains are availability, accessibility, accommodation, affordability, acceptability, and awareness. Improving access to breast reconstruction, therefore, requires an approach from different fronts. Olasehinde et al. identified fear of surgery as one of the emotions women had to go through in the decision-making for a mastectomy.[21] This fear of surgery has also been identified in African American women with breast cancer.[23],[24] Fear of surgery may be a component of the decision not to have another surgery by the women in this study. Other barriers to reconstruction such as lack of awareness, socioeconomic status, and accessibility to specialist care have been identified in different climes.[22],[25] Predictors of receiving breast reconstruction In the Kenyan study were age and the availability of insurance coverage. While most of the women in our study paid out of pocket for the mastectomy they received, the majority of the women in the Kenyan study were supported by health insurance.[10] Understandably, the women in our study may be unwilling to have to pay for another procedure. Immediate breast reconstruction in eligible women obviates the need to pay for a second procedure.

Breast reconstruction methods are largely of two types. Implant based and autologous reconstruction. While the later makes use of the patients own tissue, the former involves the use of artificial breast simulating materials. In a study looking at breast reconstruction among African Americans, a population akin to the women in our study, autologous breast reconstruction was the most frequent choice for breast reconstruction regardless of the coverage by health insurance for implant-based reconstruction.[26] Similarly, in a recent study from India, autologous breast reconstruction was preferred.[27] Implant-based reconstructions are generally more expensive. We found it surprising that most of the women in this study opted for implant-based reconstruction. It is at variance with the major reason proffered for not wanting reconstruction that is not wanting another surgery. It is possible that there was a misunderstanding of the question asked in the questionnaire. The women may have assumed that implant-based reconstructions being artificial did not require another surgery. Afuwape et al.[28] from our hospital reported on postmastectomy reconstruction in five patients with implants. The decision-making for implant-based reconstruction in these women was not elaborated on. Factors which have been identified as predictors of choice for implant-based reconstruction include younger age, shorter downtimes, and improved esthetic design of implants.[29]

Although late presentation amongst other factors plagues the management of breast cancer in our setting, a study done over a decade ago from our institution that looked at mastectomies for breast cancer reported that most of the patients had stage I and II disease.[14] These women were, therefore, candidates to receive breast reconstruction. General surgeons and plastic surgeons from our sub-region have reported on postmastectomy breast reconstruction using either autologous tissue[30] or implants,[28] suggesting that the expertise for these procedures may not be as limited as suggested in the study by Ranganathan et al.[15] Policies supporting breast reconstruction, robust breast cancer tumor boards that include plastic surgeons and provision of health insurance coverage for breast reconstruction in sub-Saharan Africa is overdue.

Community programs on breast reconstruction awareness as exist in other climes[31],[32] are needed in sub-Saharan Africa, so no woman with breast cancer is denied information on breast reconstruction regardless of her literacy level or socioeconomic status. The lack of a qualitative component is a weakness of the study.


  Conclusion Top


This study has provided a glimpse into the perspective of Nigerian women with breast cancer towards breast reconstruction. There is a very low level of awareness and acceptance of breast reconstruction.

Acknowledgment

We appreciate Miss. Marvelous Adeoye for her assistance with data collection and collation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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  [Full text]  
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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