Fear of recurrence, breast-conserving surgery, and the trade-off hypothesis

Fear of recurrence has been at the heart of the controversy between surgeons favoring mastectomy versus those advocating a less radical operation. Breast-conserving surgery is thought to result in a better body image, but patients are expected to worry more about a cancer recurrence because only a small part of the breast is excised. To assess survival rates after breast-conserving intervention, patients were randomized into the National Surgical Adjuvant Breast Project (NSABP) prospective clinical trial (Protocol B06) with three treatment groups: total mastectomy, lumpectomy, and lumpectomy followed by radiation therapy. A fourth group was created to include patients who had a recurrence after their first operation and thus underwent a subsequent total mastectomy. Differences appeared, not according to the type of treatment, but with respect to the number of surgical interventions. Patients with multiple operations reported a greater fear of cancer recurrence and a worse body image, similar to those that underwent total mastectomy. Contrary to the trade-off hypothesis, patients who underwent radical surgery did not manifest less fear of recurrence. These results show unequivocally that the expected trade-off between breast conservation and fear of cancer recurrence does not occur. Those who undergo lumpectomy do not more express more fear of cancer than do patients who undergo mastectomy.