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 exercised. 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 will 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. Cancer 1992; 69:2111-2115.