Original article

Factors influencing patient decision-making between simple

mastectomy and surgical alternatives
W. Q. Lee1 , V. K. M. Tan2,3 , H. M. C. Choo1 , J. Ong1 , R. Krishnapriya1 , S. Khong2 , M. Tan2 ,
Y. R. Sim2 , B. K. Tan3,4 , P. Madhukumar2,3 , W. S. Yong2,3 and K. W. Ong2,3
1 Yong Loo Lin School of Medicine, National University of Singapore, 2 Division of Surgical Oncology and 3 Singhealth Duke-NUS Breast Centre,

National Cancer Centre Singapore, and 4 Department of General Surgery, Singapore General Hospital, Singapore
Correspondence to: Ms V. K. M. Tan, Division of Surgical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, Singapore 169610
(e-mail: [email protected])

Background: Despite similar survival rates, breast-conserving therapy (BCT) remains a distant second
choice after simple mastectomy for patients with early-stage breast cancer in Singapore. Uptake of
reconstruction after mastectomy is also low (18 per cent). The aim of this study was to explore the
factors influencing a patient’s choice for mastectomy when eligible for BCT, and why patients decline
reconstruction after mastectomy.
Methods: Patients from the National Cancer Centre Singapore, who were eligible for BCT but chose
mastectomy without reconstruction, between December 2014 and December 2015 were included. An
interviewer-administered questionnaire focusing on patients’ reasons for choosing mastectomy over BCT
and not opting for immediate breast reconstruction after mastectomy was used. Tumour characteristics
were retrieved from medical records. Spearman’s rank correlation coefficient, Mann–Whitney U and
Kruskal–Wallis tests were used to analyse the correlation between the patient’s self-rated influential
factors and variables. Statistical significance was taken as P < 0⋅050.
Results: Ninety-one patients were included (90⋅1 per cent response rate). The main reasons for choosing
mastectomy over BCT were: fear of cancer recurrence (considered very important in 74 per cent), the
perception that health outweighs breast retention (49 per cent) and the possibility of second surgery
for margins (40 per cent). Key factors for rejecting immediate reconstruction after mastectomy were:
patient-perceived ‘old age’ (very important in 53 per cent), concern about two sites of surgery (42 per
cent) and financial cost (29 per cent). Given a second chance, 19⋅8 per cent of patients would undergo
BCT instead of mastectomy.
Conclusion: This study has identified the considerations that women in Singapore have when deciding
on breast cancer surgery. Some perceptions need to be addressed for women to make a fully informed
decision, especially as one-fifth regret their initial choice.
Funding information
No funding

Paper accepted 21 August 2018

Published online 8 October 2018 in Wiley Online Library (www.bjsopen.com). DOI: 10.1002/bjs5.50105

Introduction fact that the majority of breast cancers are diagnosed in

Singapore at an early stage (32⋅7 per cent stage I and 38⋅5
Breast-conserving therapy (BCT) for early-stage breast
per cent stage II)10 , and access to radiotherapy is readily
cancer has been shown to have similar, if not better, overall
survival rates compared with mastectomy1 – 3 . Indeed, BCT available throughout the small city state.
is the preferred locoregional treatment in most western Among women in Singapore who chose to have a mas-
countries, with reported rates ranging from 65 to 70 per tectomy, only 18 per cent underwent reconstruction after
cent3,4 . In parts of Asia, rates of BCT range between 60 and mastectomy11 . This again differs from the West and other
65 per cent5,6 . In comparison, uptake of BCT in Singapore parts of Asia, where reported rates of reconstruction after
is much lower at 30–40 per cent7 – 9 . This is despite the mastectomy are approximately 60 per cent3 – 6,11 .

© 2018 The Authors. BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd BJS Open 2019; 3: 31–37
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
32 W. Q. Lee, V. K. M. Tan, H. M. C. Choo, J. Ong, R. Krishnapriya, S. Khong et al.

Singapore is a relatively small country and its healthcare required to rate each reason on a three-point Likert scale
is based on a co-payment system with government subsi- (ranging from not important to very important).
dies for breast cancer surgery, breast reconstruction and The questionnaire also asked the patients who they con-
adjuvant radiotherapy. Common factors that limit use of sidered had influenced their decision-making. The last part
BCT, such as geographical access to adjuvant radiother- assessed satisfaction following simple mastectomy, includ-
apy and affordability of healthcare, are not expected to ing asking patients whether they would make a different
be major problems in this population. Furthermore, the choice if they could choose again.
expertise for BCT and reconstruction after mastectomy, Tumour characteristics such as tumour size, stage, loca-
both autologous and implant-based, is also readily avail- tion and receptor status were retrieved from patients’ med-
able. It is therefore surprising that simple mastectomy is ical records.
the preferred operation in this population. Patients in this study were counselled before surgery that
This study aimed to explore the reasons why women who the radiotherapy regimen for BCT consisted of 15–20
could have BCT choose to undergo mastectomy, and why daily fractions lasting 10 min each session. They were
these women decline reconstruction after mastectomy. informed about common side-effects such as skin changes
and rare but important complications such as cardiotoxicity
and radiation-induced sarcoma. Patients were also coun-
Methods selled that BCS has a 10–20 per cent possibility of requir-
ing re-excision for involved margins (intraoperative frozen-
The study had Institutional Ethics Review Board approval. section examination of margins is not done at NCCS).
Women with breast cancer were identified from the clinics
of five consultant breast surgeons at the National Cancer
Centre Singapore (NCCS), between December 2014 and Statistical analysis
December 2015. Patients who were documented to have R statistical software v3.3.2 (R Foundation for Statistical
had preoperative discussions that offered them the choice Computing, Vienna, Austria) was used for data analysis.
between BCT and mastectomy by their primary breast Spearman’s rank correlation coefficient, Mann–Whitney
surgeon, but who chose to undergo a simple mastectomy, U and Kruskal–Wallis tests were used to analyse the cor-
were recruited. relation between the patient’s self-rated influential factors
An interviewer-administered face-to-face questionnaire and variables such as demographics, tumour characteris-
was conducted. The interview was conducted in English tics and decision-making-related factors. Statistical signif-
or Mandarin in a single 15-min session during the patient’s icance was taken as P < 0⋅050.
follow-up visit at NCCS. The questionnaire consisted of
five parts (Appendix S1, supporting information).
Results
The first part recorded the patient demographics, such
as age at mastectomy, race, highest level of education, A total of 101 women were approached, with a response
marital status and whether they were working at the point rate of 90⋅1 per cent (91 patients). Demographic data are
of diagnosis. shown in Table 1. The median age of the women at the
The second part of the questionnaire examined rea- point of mastectomy was 60 (range 25–83) years. The
sons for choosing mastectomy over BCT. The reasons survey was performed a median of 48 (0–205) months
included in the survey were based on similar studies done in after mastectomy. The racial mix of the participants was
other countries12 – 14 , such as patient’s age, family history of proportionate to the resident population of Singapore. The
breast cancer, existing co-morbidities, fear of cancer recur- majority of patients who chose simple mastectomy (without
rence, concerns about radiotherapy, avoiding risk of sec- reconstruction) over BCT were married (74 per cent) and
ond surgery for margins, cost, sexuality, the perception that had a secondary school education or lower (79 per cent).
health is more important than retaining a breast, and length Almost half of the women (46 per cent) were working at
of time away from work. In the third part, patients’ reasons the time of diagnosis of breast cancer.
for not undergoing breast reconstruction after mastectomy Table 2 lists the tumour characteristics of the patients
were explored. Factors such as the woman’s subjective per- included in the study. In keeping with the criterion that
ception of her age, marital status, cost, longer hospital stay, the patient must have been eligible for both mastec-
undesirable cosmetic outcome with reconstruction, con- tomy and BCT, the majority of tumours were early-stage
cerns about two surgery sites (one for donor site) and sexu- (93 per cent were stage I–II) and almost all (97 per cent)
ality were listed. For both parts 2 and 3, respondents were of the tumours were 50 mm or less in size. The majority

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BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd
Patient decision-making between simple mastectomy and surgical alternatives 33

Table 1 Patient demographics Table 2 Tumour characteristics

No. of patients* (n = 91) No. of patients (n = 91)

Age at mastectomy (years)† 60 (25–83) Tumour stage

Height (cm)† 154⋅5 (132⋅0–173⋅5) I 39 (43)
Weight (kg)† 57 (36⋅4–88⋅6) II 45 (50)
BMI (kg/m2 )† 23⋅9 (16⋅6–36⋅4) III 6 (7)
Time after mastectomy (months)† 48 (0–205) Missing 1
Ethnicity Tumour size (mm)
Chinese 79 (89) ≤ 20 47 (53)
Malay 6 (7) 21–50 39 (44)
Indian 2 (2) > 50 2 (2)
Other 2 (2) Missing 3
Missing 2
Tumour location
Highest education level
Upper outer quadrant 40 (47)
None 7 (8)
Lower outer quadrant 10 (12)
Primary 25 (28)
Upper inner quadrant 8 (9)
Secondary (O-level) 39 (43)
Lower inner quadrant 6 (7)
Tertiary (A-level) 6 (7)
Central 22 (26)
Diploma 8 (9)
Missing 5
University 5 (6)
Cancer focality
Missing 1
Unifocal 63 (72)
Marital status
Single 17 (19) Multifocal 25 (28)
Married 67 (74) Missing 3
Divorced 2 (2) Nodal status
Widowed 4 (4) N0 67 (74)
Missing 1 N1 17 (19)
Working at the point of diagnosis N2 4 (4)
Yes 41 (46) N3 2 (2)
No 48 (54) Missing 1
Missing 2 Hormone receptor status
Previous contralateral mastectomy Triple negative (ER/PR−, HER-2−) 16 (21)
Yes 3 (3) Luminal ‘A’ (ER/PR+, HER-2−) 38 (49)
No 88 (97) Luminal ‘B’ (ER/PR+, HER-2+) 15 (19)
HER-2-enriched (ER/PR−, HER-2+) 8 (10)
*With percentages in parentheses unless indicated otherwise; †values are Missing 14
median (range). Preoperative breast MRI
Yes 4 (4)
No 87 (96)
(72 per cent) were unifocal cancers, with 28 per cent mul-
tifocal and none multicentric, as would be expected in Values in parentheses are percentages. ER, oestrogen receptor; PR,
progesterone receptor; HER-2, human epidermal growth factor
a cohort offered BCS. Most cancers (68 per cent) were
receptor 2.
hormone-positive, 10 per cent were HER-2-enriched, and
21 per cent were triple-negative.
Patients’ ratings of the importance of various factors in (53 per cent), concern about two sites of surgery (42 per
their decision to choose mastectomy over BCT are shown cent) and cost of treatment (29 per cent) (Table 4).
in Table 3. The top three factors that influenced the choice Correlation between patients’ self-rated influential
of mastectomy were: fear of cancer recurrence (74 per factors and clinicopathological factors showed that the
cent), the perception that health was more important than older a patient was, the more influential her age was in
retaining a breast (49 per cent), and wishing to avoid the influencing her decision (r S = 0⋅61, P < 0⋅001). In addition,
risk of a second surgery for margins (40 per cent). the more educated the patient, the stronger her concern
Patient demographics and tumour characteristics about two sites of surgery for an autologous flap recon-
were not significantly correlated to these top three struction (r S = 0⋅22, P = 0⋅047). Concern regarding cost of
patient-ranked factors. Hormone receptor status treatment was not correlated with any patient or tumour
(P = 0⋅173) and nodal status (P = 0⋅957) showed no characteristic.
correlation with patients’ fear of cancer recurrence. Some 97 per cent of women indicated that their
The top three factors cited by patients for declin- own viewpoint was the most important in choos-
ing breast reconstruction after mastectomy were ing a mastectomy over BCT (Table 5), followed by
patient-perceived ‘old age’ at the time of mastectomy their surgeon’s viewpoint as the next most influential

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BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd
34 W. Q. Lee, V. K. M. Tan, H. M. C. Choo, J. Ong, R. Krishnapriya, S. Khong et al.

Table 3Patient self-rated importance of factors in the decision to Table 6 Patients’ reflections after mastectomy
choose mastectomy over breast-conserving surgery
Yes No
Very Somewhat Not
Is your quality of life worse after mastectomy? 17 (19) 74 (81)
important important important
Was having the mastectomy what you 81 (89) 10 (11)
Fear of cancer recurrence 67 (74) 11 (12) 13 (14) expected from descriptions from your
Health is more important than 44 (49) 45 (51) 0 (0) surgeon or breast care nurse?
retaining a breast If you could choose between the two 18 (20) 73 (80)
No risk of second surgery for 36 (40) 20 (22) 35 (38) procedures again, would you choose
margins breast-conserving surgery instead?
Concern about radiotherapy 32 (36) 13 (15) 44 (49) Do you wish you had had a breast 2 (2) 88 (98)
Age 29 (32) 18 (20) 43 (48) reconstruction at the time of surgery?
Family history of breast cancer 15 (16) 11 (12) 65 (71) Would you consider a breast reconstruction 3 (3) 88 (97)
now or in the future?
Existing co-morbidities 12 (13) 10 (11) 68 (76)
Cost of treatment 9 (10) 17 (19) 64 (71) Values in parentheses are percentages.
Time away from work 8 (9) 7 (8) 75 (83)
Sexuality 2 (2) 11 (12) 77 (86)

Values in parentheses are percentages. on the perioperative information and counselling provided
by their breast surgeon or breast care nurse (Table 6). Some
19 per cent felt their quality of life was worse after the
Table 4 Patient self-rated importance of factors in the decision to
choose simple mastectomy over mastectomy with breast simple mastectomy, and 20 per cent would choose BCT if
reconstruction given another chance. These two groups of patients tended
to be those who had their mastectomy done earlier (at 71⋅7
Very Somewhat Not
and 82⋅6 months of follow-up respectively), compared with
important important important
the other patients in the study (57⋅8 months’ follow-up).
Age 44 (53) 14 (17) 25 (30)
Only two women (2 per cent) wished they had undergone
Concern about two sites of 35 (42) 13 (16) 35 (42)
surgery immediate breast reconstruction, and three (3 per cent)
Cost of treatment 24 (29) 13 (16) 46 (55) would consider a delayed breast reconstruction. Of these
Longer hospital stay 22 (27) 11 (13) 50 (60) patients, only one woman felt that she would choose BCT
Undesirable cosmetic outcome 18 (22) 18 (22) 47 (57)
with reconstruction surgery
if given a second opportunity.
Cosmesis 17 (21) 16 (20) 49 (60)
Marital status 14 (17) 20 (24) 49 (59)
Sexuality 1 (1) 8 (10) 74 (89) Discussion

Values in parentheses are percentages. This is the first study in Singapore to explore the fac-
tors that influence women with breast cancer to choose
Table 5 Patient self-rated importance of stakeholders in the a mastectomy over BCT, as well as their perceptions of
decision to choose mastectomy over breast-conserving surgery their choice of surgery. The respondents in this study were
Very Somewhat Not
largely aged over 50 years, of Chinese ethnicity, and of sec-
important important important ondary school level of education and below. The demo-
graphic profile of the recruited patients was similar to that
Self 88 (97) 3 (3) 0 (0)
Surgeon 46 (51) 19 (21) 26 (29) of patients who chose to undergo mastectomy in other
Spouse (married) 23 (32) 14 (19) 35 (49) studies12 – 16 .
Breast care nurse 23 (25) 18 (20) 50 (55) The fear of cancer recurrence was the main reason why
Primary care physician 22 (25) 8 (9) 59 (66)
the women chose a mastectomy over BCT, followed closely
Internet 0 (0) 76 (88) 10 (12)
by the perspective that ‘health is more important than
Values in parentheses are percentages. retaining a breast’. This attitude was pervasive, despite all
patients receiving counselling and printed materials that
perspective. However, the surgeon’s viewpoint was rated indicated that BCT was an effective treatment with similar
as very important by only 51 per cent of women. Breast survival to mastectomy. During the survey, patients would
care nurses (25 per cent) and primary care physicians (25 explain that they wanted to have the lowest possible risk
per cent) were almost as influential as patients’ spouses (32 of a locoregional recurrence, even if such a recurrence
per cent) in the decision-making process. might not compromise survival. Conceptually, the women
Most respondents (89 per cent) felt that the outcome of felt that undergoing mastectomy removed not only the
the simple mastectomy matched their expectations as based cancer, but also the organ from which the cancer arose,

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BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd
Patient decision-making between simple mastectomy and surgical alternatives 35

thereby affording them a greater sense of security14,17 . In In the present study nearly one-fifth of women regret-
this study, this fear of a cancer recurrence was independent ted their decision to undergo mastectomy and felt that
of hormone receptor and nodal status of the tumour. they would choose BCT if they had the opportunity to
Previous studies have shown that, even with deliberate choose again. A similar proportion felt that their quality of
preoperative patient education regarding the similar sur- life after mastectomy had worsened. These findings were
vival rates of BCT and mastectomy, fear of recurrence was found despite 89 per cent of respondents indicating that
still a significant influential factor, with reasons given such they had been adequately prepared by their primary breast
as mastectomy being a more complete procedure14 and surgeon and breast care nurse about what to expect from a
having peace of mind by removing the breast4 . This fear simple mastectomy, and that the results of a simple mastec-
of cancer recurrence as a deciding factor for choosing mas- tomy matched their expectations. Despite optimal preop-
tectomy is similar to the findings of previous studies from erative preparation and managing expectations, living with
western countries4,14,18 , as well as in Hong Kong19 . Inter- a simple mastectomy clearly has its challenges, which may
estingly, a study performed in Malaysia12 found no sig- not be wholly anticipated before surgery. Fortunately, the
nificant difference in terms of fear of cancer recurrence majority do not regret their choice, possibly due to the fact
between women who chose mastectomy and those who that 97 per cent of the women felt they had made their own
chose BCT. decision. It is known that patients who are more indepen-
The possibility of requiring a second operation for dent in their decision-making have less regret, regardless
involved margins was the third most common reason cited of the eventual outcome25 .
for not choosing BCT. Re-excision rates for positive mar- Similar to previous studies16,26,27 , the main reasons for
gins after BCT range from 17 to 68 per cent20 . Previous patients in the present study to decline immediate breast
studies12,19 have had differing results regarding the impor- reconstruction were the patient’s perception of her age
tance of this factor to patients, with Lam and colleagues19 and concerns about two sites of surgery. Concern over
showing that ‘avoiding having further surgery in the future’ the financial costs of treatment is more apparent in Asian
was a key consideration in women who choose simple mas- studies26 , and was evident in the present study. In Singa-
tectomy over BCT, whereas Teh and co-workers12 reported pore, healthcare payment is a co-payment system whereby
otherwise. In the present study, this factor was shown to healthcare-related costs are subsidized partially by the gov-
play a prominent role. Unfortunately, the questionnaire ernment and the rest is borne by the consumer (patient).
was not designed to examine the underlying reason, for In addition, breast reconstruction could increase the time
example whether it was the fear of a second operation, the away from work, and almost half of the women interviewed
cost associated with it, or needing to bear the burden of were working at the time of cancer diagnosis. This is simi-
cancer for a prolonged duration. lar to a previous study from Hong Kong17 , in which women
Only four participants had preoperative MRI of the were concerned about the financial burden of cancer treat-
breast, and three patients had undergone a previous con- ment on themselves and their family, especially as breast
tralateral mastectomy. Therefore, the probability that these reconstruction after mastectomy is deemed non-medical.
patients opted for mastectomy based on results of preop- The main limitations of this study include it being retro-
erative breast MRI, or chose a second mastectomy after a spective, with its attendant element of recall bias, the rel-
previous one, was unlikely to have had a strong influence. atively small sample size, and recruitment of patients from
Another interesting finding was that a very high pro- a single institution. However, the NCCS does treat the
portion of women (97 per cent) felt they relied on them- majority of breast cancers diagnosed in Singapore, and the
selves to make the decision to undergo mastectomy. The findings probably reflect the Singapore population accu-
importance of the opinions of their breast surgeon and rately. Finally, patients who had a choice between mas-
spouse was a distant second (51 per cent) and third (32 tectomy and BCT but chose to undergo BCT were not
per cent) respectively. These findings mirror those of included in the study. Exploring reasons why patients select
other studies12 – 14,21 – 23 , which found that patients who BCT over simple mastectomy would provide the most
were given the freedom to choose tended to opt for comprehensive understanding of why patients make the
a mastectomy. Although this result differs from that of decisions they do.
a previous study of Asian American women in 200224 , The heterogeneity of reasons reported in the literature
where patients placed more importance on their doc- as to why women choose mastectomy over BCT when
tors’ recommendations, it may indicate the differences in given a choice between the two options indicates that
perceptions of Asian women across the decades, and in regional differences exist, and are most likely multifactorial
different countries. in nature. Overall, the results of this study differ from those

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BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd
36 W. Q. Lee, V. K. M. Tan, H. M. C. Choo, J. Ong, R. Krishnapriya, S. Khong et al.

of previous studies, even studies of Asian women. This may Publications-Cancer/cancer-registry-annual-report-2015_

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Supporting information
Additional supporting information can be found online in the Supporting Information section at the end of the
article.

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