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“Going Flat” After Mastectomy: Patient-Reported Outcomes by Online Survey

Annals of Surgical Oncology volume 28, pages 2493–2505 (2021)Cite this article

Abstract

Background

The Going Flat movement aims to increase awareness and acceptance of mastectomy alone as a viable option for patients. Little is known about motivations and satisfaction with surgical outcomes in this population.

Methods

An online survey was administered to 931 women who had a history of uni- or bilateral mastectomy for treatment of breast cancer or elevated breast cancer risk without current breast mound reconstruction. Satisfaction with outcome and surgeon support for the patient experience were characterized using 5-level scaled scores.

Results

Mastectomy alone was the first choice for 73.7% of the respondents. The top two reasons for going flat were desire for a faster recovery and avoidance of a foreign body placement. Overall, the mean scaled satisfaction score was 3.72 ± 1.17 out of 5. In the multivariable analysis, low level of surgeon support for the decision to go flat was the strongest predictor of a satisfaction score lower than 3 (odds ratio [OR], 3.85; 95% confidence interval [CI], 2.59–5.72; p < 0.001). Dissatisfaction also was more likely among respondents reporting a body mass index (BMI) of 30 kg/m2 or higher (OR, 2.74; 95% CI, 1.76–4.27; p < 0.001) and those undergoing a unilateral procedure (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 surgeon with a specialized breast surgery practice (OR, 0.56; 95% CI, 0.38–0.81; p = 0.002).

Conclusions

Most patients undergoing mastectomy alone are satisfied with their surgical outcome. Surgeons may optimize patient experience by recognizing and supporting a patient’s decision to go flat.

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Acknowledgment

The authors thank the following patient advocates for their assistance with survey development and pre-distribution review as well as with dissemination of the survey: Kimberly Bowles, Catherine Guthrie, AnneMarie Mercurio, and Alicia Staley. We also thank everyone who shared and participated in the survey.

Author information

Authors and Affiliations

  1. Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA

    Jennifer L. Baker MD, Carlie K. Thompson MD, Minna K. Lee MD, Maggie L. DiNome MD & Deanna J. Attai MD

  2. Brown University and the Lifespan Cancer Institute, Providence, RI, USA

    Don S. Dizon MD

  3. Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA

    Cachet M. Wenziger MPH & Elani Streja PhD

  4. UCLA Health Burbank Breast Care, Burbank, CA, USA

    Deanna J. Attai MD

Authors
  1. Jennifer L. Baker MD
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  2. Don S. Dizon MD
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  3. Cachet M. Wenziger MPH
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  4. Elani Streja PhD
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  5. Carlie K. Thompson MD
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  6. Minna K. Lee MD
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  7. Maggie L. DiNome MD
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  8. Deanna J. Attai MD
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Correspondence to Deanna J. Attai MD.

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Appendix

Appendix

Survey questionnaire

We thank you for taking the time to participate in this survey. Please review the questions carefully and answer as best possible (Fig. 4).

Fig. 4
figure 4

Cohort construction

Full size image

“Going Flat” refers to mastectomy (breast removal) without breast mound reconstruction, one side or both sides

Breast mound reconstruction refers to procedures that aim to completely “rebuild” after mastectomy to give the appearance of a pre-surgical breast, not just fill in areas on an otherwise flat chest

  1. 1.

    Did you have a mastectomy (removal of one or both breasts)?

    • Yes

    • No ≥ disqualified

  2. 2.

    Did you have breast mound reconstructive surgery at the time of or after mastectomy (one side or both sides)?

    • I had breast mound reconstruction and I still have the reconstruction ≥ disqualified

    • I had breast mound reconstruction, but then I decided to have the reconstruction removed: skip to Q3

    • I had breast mound reconstruction, but then I had to have the reconstruction removed: skip to Q3

    • I did not have breast mound reconstruction: skip to Q5

  3. 3.

    If you had breast mound reconstruction at the time of or after your mastectomy surgery (even if the reconstruction has been removed), what type did you have? Please read the choices carefully and choose the one that best fits your situation:

    • Tissue expander with eventual implant placement or plan for implant placement

    • Direct to implant (no tissue expander)

    • Flap using your own body fat and/or muscle including DIEP, TRAM, latissimus flap and other

    • Combination of tissue expander/implant + flap

    • Fat injections only

    • “Goldilocks” using only skin

  4. 4.

    Why did you decide to go flat after reconstruction? Please check all that apply:

    • Problem with implant: pain, rupture, or other problems

    • Development of implant-associated cancer or other illness

    • Concern of implant-associated cancer or other illness

    • Problem with fat/muscle flap, such as pain

    • Loss of fat/muscle flap (also known as flap failure) due to infection, poor blood supply, or other problems

    • Not happy with appearance of reconstruction

  5. 5.

    Which scenario best fits your situation?

    • Mastectomy was my first operation ≥skip to question 7

    • I had one or more lumpectomy surgeries for treatment of cancer before my mastectomy (lumpectomy may also be referred to as partial mastectomy, surgical biopsy, or excisional biopsy).

  6. 6.

    If you initially had lumpectomy (also known as partial mastectomy or surgical biopsy or excisional biopsy) as your first surgery, why did you have a mastectomy? Please read the choices carefully and choose the one that best fits your situation:

    • Positive margins or could not get clear margins

    • Did not like the appearance after lumpectomy

    • Did not want to do radiation

    • Had radiation before and could not do it again

    • Other, please specify

  7. 7.

    Please select the best description of why you had mastectomy surgery. Please read the choices carefully and choose the one that best fits your situation:

    • I did not have cancer. Surgery was performed as preventative/prophylactic due to genetic mutation, high risk, or family history

    • I had cancer (may include stage 0/DCIS) in one breast

    • I had cancer (may include stage 0/DCIS) in both breasts (either at the same or at different points in time)

    • Gender confirmation (female to male or female to neutral transition)

    • Other, please specify

  8. 8

    Please read the options carefully and choose the one that best fits your situation. Please report on your current state, even if you had the surgeries at different times:

    • Single–one side removed for cancer

    • Double–one side removed for cancer and the other for prophylaxis/prevention

    • Double–both sides removed for cancer

    • Double–both sides removed for prophylaxis/prevention

  9. 9.

    Regarding the discussions with your surgeon about your options for surgery, please check all of the choices that your surgeon presented to you:

    • Breast conservation (lumpectomy, partial mastectomy, excisional biopsy, surgical biopsy)

    • Mastectomy without breast mound reconstruction (going flat)

    • Mastectomy with breast mound reconstruction using a tissue expander and/or implant

    • Mastectomy with breast mound reconstruction using muscle and/or fat from your own body including DIEP, TRAM, latissimus flap, and other)

    • Mastectomy with breast mound reconstruction using a combination of implant and flap

  10. 10.

    What was your first choice for surgery?

    • Breast conservation (lumpectomy, partial mastectomy, excisional biopsy, surgical biopsy)

    • Mastectomy without breast mound reconstruction (going flat)

    • Mastectomy with breast mound reconstruction using a tissue expander and/or implant

    • Mastectomy with breast mound reconstruction using muscle and/or fat from your own body including DIEP, TRAM, latissimus flap, and other)

    • Mastectomy with breast mound reconstruction using a combination of implant and flap

    • Other, please specify

  11. 11.

    Do you feel you had adequate information about all of your surgical options so that you could make the right decision for you?

    • Yes

    • No

  12. 12.

    Please describe your reasons for going flat. Please check all that apply:

    • Shorter recovery

    • Direct cost of procedure. An example of a direct cost is medical bills and co-pays for the procedure.

    • Indirect cost of procedure. An example of indirect cost is lost wages due to time off work

    • Lower complication rate

    • Lower health risks

    • Breasts are not important for my body image

    • Don’t want procedure on another body area (abdominal flap, etc.)–not related to cost

    • Don’t want a foreign object in my body (tissue expander or implant)–not related to cost

    • Influence of family, friends, or other source, or knowledge of others’ experience with reconstruction or going flat

    • Doctor’s advice or recommendation

    • Didn’t have an option–reconstruction didn’t work, or I couldn’t have reconstruction

  13. 13.

    Of the list above, what are your top two reasons for going flat:

  14. 14.

    Do you feel your surgeon respected and supported your decision to “go flat”?

    • Yes

    • No

  15. 15.

    During a mastectomy surgery, the breast is removed, and the skin is closed. Usually the same surgeon does both parts of the procedure. In your situation, which of the following best describes the surgeon who did the skin closure for the going flat procedure?

    • Breast surgeon (only performs breast surgery)

    • General surgeon (performs breast and other body area surgeries)

    • Plastic/reconstructive surgeon

    • I don’t know or don’t remember

  16. 16.

    Was the surgeon who performed the skin closure for the flat procedure female or male?

    • Female

    • Male

    • I don’t remember

  17. 17.

    What year did you have your mastectomy surgery? If you do not remember exactly, please use your best estimate:

    • Year entry

  18. 18.

    How old were you when you had your mastectomy surgery? If you had more than one mastectomy surgery, please indicate your age at the first procedure:

  19. 19.

    Did you have any additional surgery to revise or redo the scar area?

    • Yes

    • No ≥ skip to Q 21

  20. 20

    Who performed the additional surgery to revise the scar area?

    • Same surgeon who did my initial mastectomy (breast surgeon)

    • Same surgeon who did my initial mastectomy (general surgeon)

    • Same plastic/reconstructive surgeon who did the initial skin closure

    • Different breast surgeon

    • Different general surgeon

    • Different plastic/reconstructive surgeon

    • I don’t know or don’t remember

  21. 21.

    Did the final results of the surgery (appearance of the chest area) match your expectations?

    • Yes

    • No

  22. 22.

    For each of the statements below regarding satisfaction after surgery, please indicate the extent to which you agree or disagree:

     

    Strongly disagree

    Somewhat disagree

    Neither agree nor disagree

    Somewhat agree

    Strongly agree

    My doctor performed the surgery we agreed upon

    		     

    My doctor offered me the option to go flat

    		     

    My doctor was supportive of me going flat

    		     

    The recovery time from surgery matched my expectations

    		     

    I did not have any surgical complications

    		     

    I am pleased with the appearance of my chest

    		     

    I feel confident about my body

    		     

    Overall, I am satisfied with my surgical outcome

    		     
  23. 23.

    Have you had radiation therapy to the breast or chest, on the side of mastectomy? Please read the choices carefully and choose the one that best fits your situation:

    • I had radiation before my mastectomy for previous breast cancer

    • I had radiation after my mastectomy due to breast cancer

    • I had radiation for Hodgkin’s lymphoma or other medical condition before my mastectomy

    • I had radiation for Hodgkin’s lymphoma or other medical condition after my mastectomy

    • I have not had radiation to the breast or chest

  24. 24.

    Did you receive chemotherapy? Please do not consider endocrine therapy such as tamoxifen or aromatase inhibitors (anastrozole/arimidex, letrozole/femara, exemestane/aromasin) in answering this question. Please read the choices carefully and choose the one that best fits your situation:

    • I received chemotherapy before my mastectomy surgery, for previous breast or non-breast cancer

    • I received chemotherapy before my mastectomy surgery, for my current breast cancer

    • I received chemotherapy after my mastectomy surgery, for my current breast cancer

    • I received chemotherapy after my mastectomy surgery, for non-breast cancer

    • I have not received chemotherapy

  25. 25.

    What was your original (before surgery) bra cup size? Please choose the most appropriate size:

    • A/AA cup

    • B cup

    • C or D cup

    • DD through E cup

    • F cup or larger

  26. 26.

    How much do you weigh in pounds? If you measure your weight in kilograms or stone, please use this calculator to convert to pounds:

  27. 27.

    What is your height in feet and inches? Please enter numbers only. If you measure your height in meters, please use this calculator to convert to feet and inches:

  28. 28.

    How old are you?

  29. 29.

    What is your marital or relationship status?

    • Single, never married

    • Married

    • Long-term relationship

    • Divorced or separated

    • Widowed

  30. 30.

    What is the highest level of education or degree that you received?

    • Did not attend high school

    • Attended some high school but did not receive a degree

    • High school or graduate equivalency degree (GED)

    • Some college but no degree

    • Associate degree

    • Bachelor degree

    • Graduate degree

  31. 31.

    In what country was your surgery performed?

    • Dropdown menu of all countries

    • If answer is U.S., go to Q32

    • If answer is non-U.S. country: skip to Q33

  32. 32.

    In what state was your surgery performed?

    Dropdown menu of U.S. states

  33. 33.

    What best describes your racial/ethnic background?

    • American Indian or Alaska native

    • Asian

    • Black or African American

    • Hispanic, Latino or Spanish origin

    • Native Hawaiian or Pacific Islander

    • White

    • Other, please specify

  34. 34.

    What type of insurance did you have at the time of your mastectomy surgery?

    • Private insurance–individual policy, not from employer

    • Private insurance–group policy from employer

    • Medicare with or without a secondary insurance

    • Medicaid

    • National Health Service

    • I don’t know or I don’t remember

  35. 35.

    What is your sex (please list sex at birth):

    • Female

    • Male

      The following questions are optional:

  36. 36.

    Please list the gender with which you best identify:

    • Female

    • Male

    • Gender variant/non-binary/nonconforming

    • Decline to state

  37. 37.

    Please enter any other comments you might have for the research team:

Thank you for your time and participation! We value your opinions.

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Baker, J.L., Dizon, D.S., Wenziger, C.M. et al. “Going Flat” After Mastectomy: Patient-Reported Outcomes by Online Survey. Ann Surg Oncol 28, 2493–2505 (2021). https://doi.org/10.1245/s10434-020-09448-9

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