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Letter to the Editor - Year2017 - Volume32 - Issue 4

Dear Editor:

Recently, Alves et al.1 published a cross-sectional study evaluating the effect of breast reconstruction on the quality of life and self-esteem of 59 women who underwent mastectomy. The authors observed no significant differences between the evaluated groups at 30 days after surgery, and offered possible explanations for similar outcomes between the groups1.

However, we believe that some methodological problems may have contributed to the unexpected results of the study, including the small sample size and the random selection of patients. Of note is the selection bias related to the use of questionnaires by the support team, despite the availability of internationally validated instruments. Furthermore, considering the psychological effect of a breast cancer diagnosis and invasive surgery, the effectiveness of psychosocial assessment in the postoperative period is questionable.

In Goiás, a case-control study of 167 women found greater dissatisfaction with body image among breast cancer patients, particularly those who underwent mastectomy. Moreover, self-esteem was negatively affected in women dissatisfied with body image2. Despite the methodological differences, this study reinforces the hypothesis that mastectomy without breast reconstruction jeopardizes self-esteem and quality of life in these women3.

Therefore, this letter adds some considerations for critical evaluation of the study by Alves et al.1, and reinforces the need to understand the psychological process after surgical treatment of breast cancer.


1. Alves VL, Sabino Neto M, Abla LEF, Oliveira CJR, Ferreira LM. Avaliação precoce da qualidade de vida e autoestima de pacientes mastectomizadas submetidas ou não à reconstrução mamária. Rev Bras Cir Plást. 2017;32(2):208-17.

2. Prates ACL, Freitas-Junior R, Prates MFO, Veloso MF, Barros NM. Influence of Body Image in Women Undergoing Treatment for Breast Cancer. Rev Bras Ginecol Obstet. 2017;39(4):175-83.

3. Dauplat J, Kwiatkowski F, Rouanet P, Delay E, Clough K, Verhaeghe JL, et al.; STIC-RMI working group. Quality of life after mastectomy with or without immediate breast reconstruction. Br J Surg. 2017;104(9):1197-206.

Hospital das Clinicas, Universidade Federal de Goiás, GO, Brazil

Institution: Universidade Federal de Goiás, Goiânia, GO, Brazil.

Corresponding author:
Leonardo Ribeiro Soares
1ª Avenida, s/n, Setor Universitário
Goiânia, GO, Brazil - Zip Code 74605-050

Article received: August 3, 2017.
Article accepted: September 23, 2017.

Conflicts of interest: none.


Dear authors,

You indicated that the present study included 59 volunteers. However, 89 patients were enrolled. In addition, we suggest continuing the research.

With regard to methodological issues, it would be important to use the QLQ-BR23 questionnaire, because it specifically evaluates the quality of life in patients with breast cancer, whereas the QLQ-C30 evaluates the quality of life of cancer patients. The use of the former allows the assessment of possible changes in the quality of life and self-esteem of study participants in the postoperative period (1 month).

I agree that it is important to increase the number of participants in the study. Furthermore, the participants need to be evaluated at the time of cancer diagnosis; during chemotherapy and radiotherapy; immediately after mastectomy; at 1, 3, 6, and 12 months after mastectomy; after breast reconstruction and symmetrization. For this reason, we suggest continuing the research.

However, after reading your article, I observed that the methodology and inclusion criteria were different from those proposed in the present study. You evaluated patients on chemotherapy, and some studies indicate that the side effects of chemotherapy may interfere with self-esteem, quality of life, and personal image. In addition, the instrument used in your study specifically evaluates personal image, whereas the study by Alves et al. did not evaluate personal image or patients on chemotherapy. Therefore, the effect of breast reconstruction may have varied, precisely because of the undesirable effects of chemotherapy. For this reason, it is necessary to continue the study using the three instruments, increasing the number of participants, and designing the time points to evaluate these possible changes.

Regional considerations and religious beliefs are also relevant, but were not addressed in these two studies. In our practice in São Paulo, we have observed that the first thought that comes to the patient's mind is "DEATH," until she realizes that her prognosis may be better than she imagines. In addition, life values change, and affected women recognize that the condition of not having breasts is temporary, and is part of the process of coping with the disease. However, these data also need to be analyzed in the population described previously to determine the influence of beliefs, State, and other factors, and whether or not these factors apply. In addition, this analysis will allow health professionals to recommend treatments that maximize the expected results and thus improve the quality of life, self-esteem, and personal image.

I read your article "Influence of body image in women undergoing treatment for breast cancer" (Rev Bras Ginecol Obstet. 2017), and I believe we should continue the research and better define these two study populations (Alves et al. and Prates et al.).

Vanessa Lacerda Alves 1
1 Universidade Federal de São Paulo, São Paulo, SP, Brasil.


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