Assessment of Quality of Life of Breast Cancer Survivors Post 5 Years from Surgery: Study from a Community Hospital in India

Assessment of Quality of Life of Breast Cancer Survivors Post 5 Years from Surgery: Study from a Community Hospital in India | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Assessment of Quality of Life of Breast Cancer Survivors Post 5 Years from Surgery: Study from a Community Hospital in India Vasundhara Mathur, Niranjana Swaminathan, Neha Gupta, Priyansh Nathani, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4194565/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Breast cancer is the most common cancer afflicting women with an estimated 2.1 million new cases diagnosed globally every year. Breast cancer and its treatment significantly impair the patient’s physical mental health and thereby affect their overall quality of life (QOL). Our aim was to identify differences in long-term QOL between breast conservative surgery (BCS) and modified radical mastectomy (MRM) for early breast cancer among sociodemographic and clinical subgroups of patients. Methods: This prospective observational cohort study was conducted at Bhabha Atomic Research Centre (BARC) hospital under Universal Health Coverage scheme. We recruited patients who were surgically treated for breast cancer between 2010 to 2015 and were continuing further treatment or follow-up. Their QOL scores were measured using the 37-item Functional Assessment of Cancer Therapy- Breast, Version 4 (FACT-B) questionnaire andwere analysed using Mann-Whitney U test. P value <0.05 was considered statistically significant. Results: Among the 86 patients (46 with BCS and 41 with MRM) included in the study, the mean age was 59 ± 11.5 years with a mean follow-up period of 6.9 years. Functional well-being was significantly better for the BCS group (P<0.01). However, the QOL scores corresponding to physical, social, and emotional well-being as well as body image and attractiveness scores for BCS and MRM at the end of the follow-up period were comparable (p>0.05). Conclusion: Functional well-being was the only component of QOL that was noted to be higher for BCS for our study population. Future work on understanding the behavioural and cognitive components of body image in this patient population is warranted. Breast cancer Quality of life Modified Radical Mastectomy (MRM) Breast Conservation Surgery (BCS) Background Breast cancer is the most common cancer in women with an estimated 2.1 million new cases being added globally each year and represents a quarter of all cancer diagnoses affecting women.[ 1 ] India has documented high breast cancer burden with a prevalence of 25.8 and mortality of 12.7, per 100,000 women respectively.[ 2 ] Early detection and improved treatment facilities for breast cancer have increased patient survival, resulting in a greater emphasis on survival ship issues and ‘Quality of Life' (QOL) outcomes, globally as well as in India.[ 3 , 4 ] Surgery remains the mainstay treatment in patients with breast cancer and two surgical options exist - modified radical mastectomy (MRM) and breast conservation surgery (BCS). MRM and BCS with postoperative radiotherapy have shown equivalent survival in many long-term follow-up studies.[ 5 , 6 ] Since BCS has equivalent survival and is a less extensive and disfiguring procedure, it is often preferred over MRM, especially in high-income countries (HICs). Many long-term studies have documented better QOL in BCS patients from these HICs.[ 7 , 8 ] Bhat et al have also documented better QOL in BCS group at the end of five years at a tertiary centre in India.[ 9 ] Yet many patients in India and other low-and-middle-income countries (LMICs) lack access to radiotherapy (RT) making BCS a less common option. However, healthcare centres providing universal health coverage offer a unique setting, where BCS and RT can be offered at no extra cost or accessibility barriers. QOL outcomes then may override the affordability and feasibility concerns and become important factors driving the clinical decision-making process for patients with early breast cancer. The QOL issues among breast cancer survivors, within a setting of universal care, is likely to gain more importance in the Indian context as India moves towards universal health care with the Ayushman Bharat (Prime Minister’s) health scheme.[ 10 ] Much of the existing literature on impact of surgery on QOL is set in HICs and the Indian perspective in particular, is limited.[ 11 , 12 ] Moreover, most have recorded QOL at 5 years after surgery or even shorter duration, maximum studies recording QOL at 1 year post surgery. Patients defaulting follow-ups and incomplete records during follow-ups are main challenges in conducting long-term studies in India.[ 13 , 14 ] Therefore, we undertook this study to compare the long-term changes in QOL outcomes for BCS and MRM at a community hospital in patients receiving breast cancer treatment under universal health coverage scheme. This enabled a follow up of patients at no added cost in a robust healthcare system. Methods Study design This prospective observational study was conducted in 2020 and patients operated between 2010 and 2015 were included. Patients with metastatic disease were excluded. Context and setting We conducted this study in the Department of Surgery, Bhabha Atomic Research Centre (BARC) hospital, a multi-specialty government funded community hospital which provides universal health coverage. Under this scheme, treatment is provided equitably and free of cost and the choice of treatment is unaffected by the economic status of patients, thereby making this centre a preferable setting for the study. The details of this community hospital, universal health coverage system and the patient cohort are described in detail in our previous manuscript that describes the trends in QOL scores over first five years after surgery.[ 15 ] This manuscript analyses QOL scores beyond the five year period after surgery, during a long-term follow-up. All patients receiving care under this health plan were encouraged to choose between the two surgical alternatives for treatment (BCS and MRM), after being informed that BCS requires postoperative radiation. Depending on the surgical modality each patient underwent, a standardised protocol for treatment based on guidelines. This uniform treatment protocol, the hospital’s robust electronic medical records system and a breast cancer registry enabled the retrieval of accurate data on demography, clinical notes, investigations, management protocols and details of every follow-up visit. Data collection Data was collected using a validated questionnaire during the routine follow-up visits in the out-patient department, after obtaining written, valid informed consent from the study participants. Those who were unable to read and write in English, were interviewed by the trainee doctor in vernacular languages. The data collected contained demographic characteristics including age, sex, education level, menstrual status, family history and marital status at the time of diagnosis as well as their tumour characteristics and the QOL scores. Study tool The QOL was measured using the Functional Assessment of Cancer Therapy- Breast, Version 4 (FACT-B) questionnaire, which is validated for Indian women. It is a 37-item scale that assesses a patient's emotional status, functional capability, social well-being, and physical well-being. Additionally, the FACT-B trial outcome index (FACT-B TOI), FACT-B Total Score (FACT-B TS), Breast Cancer Subscale (BSS), and FACT-G (global) score were noted. The Functional Assessment for Chronic Illnesses Therapy (FACIT) measuring system was employed to assess the FACT-B questionnaire responses. (Supplementary Table 1) Statistical methods The data was analysed using SPSS version 20.0 (SPSS Inc, Chicago, IL, USA) statistical software. The categorical variables were described as frequency and percentages and chi square test or Fisher’s exact test was used for association analysis. The continuous variables were represented as mean (with standard deviation) and changes in QOL were tested using Mann-Whitney U test. P value of < 0.05 was considered as statistically significant. Results 140 patients were operated on at BARC hospital between 2010–2015, of which 35 (21 metastatic disease + 14 deaths) were excluded. Of the 105 remaining, 21 were lost to follow-up, 4 had other associated cancers, 2 had poor general condition and 1 refused participation, who were excluded. Thus, 86 patients were included in the final cohort for this questionnaire-based study, of which 45 were operated for BCS and 41 underwent MRM. Table 1 describes the characteristics of the participants and their association with type of surgery (BCS and MRM). The mean age of patients was 59 ± 11.5 years and the follow-up period ranged between 5 to 10 years with a mean of 6.9 years. Over half (52.9%) of post-menopausal women showed preference for MRM, whereas 70.7% of women with higher education and 58.3% of those who had partners demonstrated preference for BCS. BCS was also the preferred choice of surgery for 85.7% of those with a family history of breast cancer. 70% had Stage 2 disease, however it was not associated with the preference of surgery. Table 1 Characteristics of cohort and FACT B score comparison between BCS and MRM patients Demographics and oncology variables BCT MRM Grand Total P value Count 45 41 86 Age (Mean + SD) 54.2 + 9.6 65.1 + 10.9 59.4 + 11.5 0.000 Menopausal Status, N (%) Pre-menopausal 12 (75) 4 (25) 16 0.044 Post-menopausal 33 (47.1) 37 (52.9) 70 Married Status, N (%) Married 42 (58.3) 30 (41.7) 72 0.011 Widowed 3 (21.4) 11 (78.6) 14 Educational Status, N (%) Illiterate 3 (42.9) 4 (57.1) 7 0.004 Primary/Secondary level 13 (34.2) 25 (65.8) 38 Educated (Graduation above) 29 (70.7) 12 (29.3) 41 Family History of Breast Cancer, N (%) No 33 (45.8) 39 (54.2) 72 0.006 Yes 12 (85.7) 2 (14.3) 14 Tumour Size*, N (%) T1 11 (64.7) 6 (35.3) 17 0.530 T2 27 (51.9) 25 (48.1) 52 T3 3 (30) 7 (70) 10 T4 3 (60) 2 (40) 5 Stage*, N (%) 1 11 (73.3) 4 (26.7) 15 0.360 2 28 (47.5) 31 (52.5) 59 3 5 (55.6) 4 (44.4) 9 4 0 1 1 Chemotherapy, N (%) No 15 (40.5) 22 (59.5) 37 0.057 Yes 30 (61.2) 19 (38.8) 49 Radiotherapy # , N (%) No 4 (12.5) 28 (87.5) 32 0.000 Yes 40 (80) 10 (20) 50 Hormonal Therapy # , N (%) No 11 (42.3) 15 (57.7) 26 0.211 Yes 32 (57.1) 24 (42.9) 56 Survival Status, N (%) BCT MRM NA Total Died Survived 5 (35.7) 5 (35.7) 4 (28.6) 14 56 (44.4) 66 (52.4) 4 (3.2) 126 Note: * for two patients records were missing, # for four patients’ data were missing. Stage: Records of 2 patients were missing, RT & HT: Records of 4 patients each were missing) The QOL scores for both groups in physical well-being (PWB), social well-being (SWB), emotional well-being (EWB) and breast specific domains as well as total scores were comparable at the end of the follow-up period (p > 0.05). However, based on the FACT-B score, the functional well-being (FWB) scores were better for BCS as compared to MRM ( Table 2 ). Table 2 Comparison of QOL Scores between BCS and MRM groups. Domain BCT MRM P value Physical Well Being (PWB) 26.9 (1.5) 26.9 (2.1) 0.755 Social Well Being (SWB) 27.2 (3.1) 26.1 (4.4) 0.202 Emotional Well Being (EWB) 22.2 (2.4) 22.4 (2.2) 0.638 Functional Well Being (FWB) 26.9 (1.6) 24.9 (3.9) 0.002 Breast Cancer Subscale (BSS) 32.8 (1.9) 31.8 (3.8) 0.12 FACT-B Trial Outcome Index (PWB + FWB + BCS score) 86.6 (3.9) 83.4 (8.2) 0.021 FACT-G Total Score (PWB + SWB + EWB + FWB score) 102.9 (6.2) 100.3 (8.9) 0.105 FACT-B Total score (PWB + SWB + EWB + FWB + BCS score) 135.8 (7.0) 132.1 (11.4) 0.072 Note: All scores presented as Mean (Standard Deviation)</p Discussion Our study revealed that QOL scores in all domains were similar in BCS and MRM groups after long-term follow-up, except in the functional wellbeing (FWB) domain, which was higher for women undergoing BCS. We also documented that women who were younger, had a history of breast cancer in the family, had formal education, were married and were pre-menopausal preferred BCS over MRM. Functional wellbeing (FWB) is a measure of an individual's capacity to perform tasks of daily work, socialize and enjoy life. It also measures whether the woman is content with her life and accepted her illness.[ 16 ] The better functional scores in the BCS subgroup in our study may be attributed to only a minimal disfigurement and disruption of body form after surgery, leaving women free to focus on function and life rather than physical form, shape and image. This explanation can also be extrapolated to the higher scores of FACT B TOI in BCS patients in our study. This outcome index is a sum of functional, physical and breast subscale scores that additionally includes questions regarding arm pain and oedema, body shape and form, comfort in dressing and feeling of being attractive. This combined outcome index reflects the woman's overall confidence and comfort about herself, resulting in better functional outcomes. Bhat et al. reported better acceptance of disease, body image and coping with cancer in BCS groups, during a follow up period of 2.5 years.[ 9 ] Similarly, a recent meta-analysis that included 18 studies assessing QOL scores in patients with BCS, reconstruction and mastectomy documented a better global, and component scores in BCS when compared to MRM.[ 17 ] Our group previously reported that all QOL scores, including FWB, showed no statistical difference in BCS and MRM groups at 5 years of follow-up.[ 15 ] Thus, longer follow-up, such as in the current study, may help unmask persisting insufficiencies of functional ability, acceptance of the disease and disfigurement among MRM patients.[ 5 ] This highlights the need for long-term support and coping strategies for breast cancer patients. In our cohort, we reported significant differences in patients’ preference of surgical options for breast cancer. Younger, premenopausal, educated and patients with partners preferred less disfigurement and morbidity. This is in agreement with other reports of patients-preference being dependent on factors such as age, educational status, and family history.[ 18 , 19 ] Since MRM is the most performed surgery for breast cancer in India, this study highlights the need of long-term support to patients undergoing MRM. It also emphasises on offering BCS, whenever feasible oncologically and socioeconomically, to women in India. Long-term follow-up of our cohort is a unique strength of this study. Most Indian studies have addressed QOL scores during short-term follow-up less than five years.[ 9 , 13 , 20 ] The setting of the universal health care system, allowing equitable and free of cost healthcare delivery, freeing them to choose between BCS and MRM, is a strength of this study. This mimics an ideal situation without socioeconomic barriers. While the uniqueness of the setting may limit generalisability of the study in India and can be currently viewed as a limitation, increasing implementation of UHC in India, positions this study in a new light. The FACT-B score is a quantitative method of assessing sensitive issues in breast cancer like sexuality, body image, and interpersonal relationships with family and friends. Although it provides a broad idea about breast specific concerns, it does not comprehensively explore the perceptual and cognitive aspects of body image. Conclusion In summary, we documented that, on long-term follow-up, functional wellbeing was better in women whose breasts were conserved. To better understand the underlying causes of these results, additional large sample quantitative and other qualitative studies to analyse the cognitive, behavioural, and affective components of QOL are required. These may offer a more granular understanding of QOL in breast cancer patients. Abbreviations MRM- Modified Radical Mastectomy BCS- Breast Conservation Surgery RT- Radiotherapy QOL- Quality of Life PWB- Physical well-being SWB- Social well-being FWB- Functional well-being EWB- Emotional well-being FACT-B- Functional Assessment of Cancer Therapy- Breast Declarations Ethical considerations- The study was approved by the Institutional Ethics Committee of BARC hospital (IEC number BHMEC/DNB/21/18). Consent for Publication- All authors have consented for the publication of this report. Availability of data and materials- The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests- The authors do not declare any financial or non-financial competing interests. Funding- This is a non-funded study. Authors’ contribution- The authors Vasundhara Mathur, Niranjana Swaminathan, Priyansh Nathani, and Bhakti Sarang have contributed in the writing of the manuscript. The author Prashant Bhandarkar has contributed in the statistical analysis and writing the results in the manuscript. The authors Anita Gadgil and Nobhojit Roy have contributed in the conceptualisation, writing and review of the manuscript. Acknowledgements- The authors would like to acknowledge WHO collaborating Centre for Research in Surgical Care Delivery, India. Also, due credit to be given to Breast Cancer Consortium, WHOCC, India for the regular meetings and guidance. Statement Of Declaration- All authors acknowledge that they are not affiliated to or a part of any group or organization that has a financial or non-financial involvement in the subject or materials addressed in this manuscript. References Ghoncheh M, Pournamdar Z, Salehiniya H. Incidence and Mortality and Epidemiology of Breast Cancer in the World. Asian Pac J Cancer Prev APJCP . 2016;17(S3):43-46. doi:10.7314/apjcp.2016.17.s3.43 Malvia S, Bagadi SA, Dubey US, Saxena S. Epidemiology of breast cancer in Indian women: Breast cancer epidemiology. Asia Pac J Clin Oncol . 2017;13(4):289-295. doi:10.1111/ajco.12661 Yfantis A, Sarafis P, Moisoglou I, et al. How breast cancer treatments affect the quality of life of women with non-metastatic breast cancer one year after surgical treatment: a cross-sectional study in Greece. BMC Surg . 2020;20(1):210. doi:10.1186/s12893-020-00871-z World Heath Organization. The World Health Organization Quality of Life User Manual. Published March 2012. Accessed August 27, 2023. https://www.who.int/tools/whoqol Arndt V, Stegmaier C, Ziegler H, Brenner H. Quality of life over 5 years in women with breast cancer after breast-conserving therapy versus mastectomy: a population-based study. J Cancer Res Clin Oncol . 2008;134(12):1311-1318. doi:10.1007/s00432-008-0418-y Poggi MM, Danforth DN, Sciuto LC, et al. Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer Institute Randomized Trial. Cancer . 2003;98(4):697-702. doi:10.1002/cncr.11580 Janni W, Rjosk D, Dimpfl Th, et al. Quality of Life Influenced by Primary Surgical Treatment for Stage I-III Breast Cancer?Long-Term Follow-Up of a Matched-Pair Analysis. Ann Surg Oncol . 2001;8(6):542-548. doi:10.1007/s10434-001-0542-2 Curran D, van Dongen JP, Aaronson NK, et al. Quality of life of early-stage breast cancer patients treated with radical mastectomy or breast-conserving procedures: results of EORTC trial 10801. Eur J Cancer . 1998;34(3):307-314. doi:10.1016/S0959-8049(97)00312-2 Bhat V, Roshini AP, Ramesh R. Does Quality of Life Among Modified Radical Mastectomy and Breast Conservation Surgery Patients Differ? A 5-Year Comparative Study. Indian J Surg Oncol . 2019;10(4):643-648. doi:10.1007/s13193-019-00962-1 About Pradhan Mantri Jan Arogya Yojana (PM-JAY). Accessed September 2, 2023. https://nha.gov.in/PM-JAY Shimozuma K, Sonoo H, Ichihara K, et al. The impacts of breast conserving treatment and mastectomy on the quality of life in early-stage breast cancer patients. Breast Cancer . 1995;2(1):35-43. doi:10.1007/BF02966894 Warm M, Gatermann C, Kates R, et al. Postoperative Sense of Well-Being and Quality of Life in Breast Cancer Patients Do not Depend on Type of Primary Surgery. Onkologie . 2008;31(3):99-104. doi:10.1159/000113540 Gangane N, Khairkar P, Hurtig AK, San Sebastián M. Quality of Life Determinants in Breast Cancer Patients in Central Rural India. Asian Pac J Cancer Prev APJCP . 2017;18(12):3325-3332. doi:10.22034/APJCP.2017.18.12.3325 jhajharia S, Verma S, Kumar R. Quality of Life in Breast Cancer Survivors in India: Factors and Importance. Int J Cancer Res . 2017;13(2):36-40. doi:10.3923/ijcr.2017.36.40 Deepa KV, Gadgil A, Löfgren J, Mehare S, Bhandarkar P, Roy N. Is quality of life after mastectomy comparable to that after breast conservation surgery? A 5-year follow up study from Mumbai, India. Qual Life Res . 2020;29(3):683-692. doi:10.1007/s11136-019-02351-1 The Australian Institute of Health and Welfare’s Metadata Online Registry - Functional Wellbeing. Accessed August 27, 2023. https://meteor.aihw.gov.au/content/524403#:~:text=The%20ability%20of%20a%20person,to%20carry%20out%20social%20roles. Zehra S, Doyle F, Barry M, Walsh S, Kell MR. Health-related quality of life following breast reconstruction compared to total mastectomy and breast-conserving surgery among breast cancer survivors: a systematic review and meta-analysis. Breast Cancer . 2020;27(4):534-566. doi:10.1007/s12282-020-01076-1 Bapsy PPP, Maurya P, Dhande S, et al. What decides breast conservation versus mastectomy in the background of diverse sociocultural environment, an Indian study. Ann Oncol . 2016;27:vi48. doi:10.1093/annonc/mdw364.17 Gumus M, Ustaalioglu BO, Garip M, et al. Factors that Affect Patients’ Decision-Making about Mastectomy or Breast Conserving Surgery, and the Psychological Effect of this Choice on Breast Cancer Patients. Breast Care . 2010;5(3):164-168. doi:10.1159/000314266 Kaur N, Gupta A, Sharma AK, Jain A. Survivorship issues as determinants of quality of life after breast cancer treatment: Report from a limited resource setting. The Breast . 2018;41:120-126. doi:10.1016/j.breast.2018.07.003 Additional Declarations No competing interests reported. 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India","fulltext":[{"header":"Background","content":"\u003cp\u003eBreast cancer is the most common cancer in women with an estimated 2.1\u0026nbsp;million new cases being added globally each year and represents a quarter of all cancer diagnoses affecting women.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] India has documented high breast cancer burden with a prevalence of 25.8 and mortality of 12.7, per 100,000 women respectively.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Early detection and improved treatment facilities for breast cancer have increased patient survival, resulting in a greater emphasis on survival ship issues and \u0026lsquo;Quality of Life' (QOL) outcomes, globally as well as in India.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Surgery remains the mainstay treatment in patients with breast cancer and two surgical options exist - modified radical mastectomy (MRM) and breast conservation surgery (BCS). MRM and BCS with postoperative radiotherapy have shown equivalent survival in many long-term follow-up studies.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Since BCS has equivalent survival and is a less extensive and disfiguring procedure, it is often preferred over MRM, especially in high-income countries (HICs). Many long-term studies have documented better QOL in BCS patients from these HICs.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Bhat et al have also documented better QOL in BCS group at the end of five years at a tertiary centre in India.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Yet many patients in India and other low-and-middle-income countries (LMICs) lack access to radiotherapy (RT) making BCS a less common option.\u003c/p\u003e \u003cp\u003eHowever, healthcare centres providing universal health coverage offer a unique setting, where BCS and RT can be offered at no extra cost or accessibility barriers. QOL outcomes then may override the affordability and feasibility concerns and become important factors driving the clinical decision-making process for patients with early breast cancer. The QOL issues among breast cancer survivors, within a setting of universal care, is likely to gain more importance in the Indian context as India moves towards universal health care with the Ayushman Bharat (Prime Minister\u0026rsquo;s) health scheme.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eMuch of the existing literature on impact of surgery on QOL is set in HICs and the Indian perspective in particular, is limited.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Moreover, most have recorded QOL at 5 years after surgery or even shorter duration, maximum studies recording QOL at 1 year post surgery. Patients defaulting follow-ups and incomplete records during follow-ups are main challenges in conducting long-term studies in India.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Therefore, we undertook this study to compare the long-term changes in QOL outcomes for BCS and MRM at a community hospital in patients receiving breast cancer treatment under universal health coverage scheme. This enabled a follow up of patients at no added cost in a robust healthcare system.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e \u003cp\u003eThis prospective observational study was conducted in 2020 and patients operated between 2010 and 2015 were included. Patients with metastatic disease were excluded.\u003c/p\u003e \u003cp\u003eContext and setting\u003c/p\u003e \u003cp\u003eWe conducted this study in the Department of Surgery, Bhabha Atomic Research Centre (BARC) hospital, a multi-specialty government funded community hospital which provides universal health coverage. Under this scheme, treatment is provided equitably and free of cost and the choice of treatment is unaffected by the economic status of patients, thereby making this centre a preferable setting for the study. The details of this community hospital, universal health coverage system and the patient cohort are described in detail in our previous manuscript that describes the trends in QOL scores over first five years after surgery.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] This manuscript analyses QOL scores beyond the five year period after surgery, during a long-term follow-up.\u003c/p\u003e \u003cp\u003eAll patients receiving care under this health plan were encouraged to choose between the two surgical alternatives for treatment (BCS and MRM), after being informed that BCS requires postoperative radiation. Depending on the surgical modality each patient underwent, a standardised protocol for treatment based on guidelines. This uniform treatment protocol, the hospital\u0026rsquo;s robust electronic medical records system and a breast cancer registry enabled the retrieval of accurate data on demography, clinical notes, investigations, management protocols and details of every follow-up visit.\u003c/p\u003e \u003cp\u003eData collection\u003c/p\u003e \u003cp\u003eData was collected using a validated questionnaire during the routine follow-up visits in the out-patient department, after obtaining written, valid informed consent from the study participants. Those who were unable to read and write in English, were interviewed by the trainee doctor in vernacular languages. The data collected contained demographic characteristics including age, sex, education level, menstrual status, family history and marital status at the time of diagnosis as well as their tumour characteristics and the QOL scores.\u003c/p\u003e \u003cp\u003eStudy tool\u003c/p\u003e \u003cp\u003eThe QOL was measured using the Functional Assessment of Cancer Therapy- Breast, Version 4 (FACT-B) questionnaire, which is validated for Indian women. It is a 37-item scale that assesses a patient's emotional status, functional capability, social well-being, and physical well-being. Additionally, the FACT-B trial outcome index (FACT-B TOI), FACT-B Total Score (FACT-B TS), Breast Cancer Subscale (BSS), and FACT-G (global) score were noted. The Functional Assessment for Chronic Illnesses Therapy (FACIT) measuring system was employed to assess the FACT-B questionnaire responses. (Supplementary Table\u0026nbsp;1)\u003c/p\u003e \u003cp\u003eStatistical methods\u003c/p\u003e \u003cp\u003eThe data was analysed using SPSS version 20.0 (SPSS Inc, Chicago, IL, USA) statistical software. The categorical variables were described as frequency and percentages and chi square test or Fisher\u0026rsquo;s exact test was used for association analysis. The continuous variables were represented as mean (with standard deviation) and changes in QOL were tested using Mann-Whitney U test. P value of \u0026lt;\u0026thinsp;0.05 was considered as statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e140 patients were operated on at BARC hospital between 2010\u0026ndash;2015, of which 35 (21 metastatic disease\u0026thinsp;+\u0026thinsp;14 deaths) were excluded. Of the 105 remaining, 21 were lost to follow-up, 4 had other associated cancers, 2 had poor general condition and 1 refused participation, who were excluded. Thus, 86 patients were included in the final cohort for this questionnaire-based study, of which 45 were operated for BCS and 41 underwent MRM.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e describes the characteristics of the participants and their association with type of surgery (BCS and MRM). The mean age of patients was 59\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5 years and the follow-up period ranged between 5 to 10 years with a mean of 6.9 years. Over half (52.9%) of post-menopausal women showed preference for MRM, whereas 70.7% of women with higher education and 58.3% of those who had partners demonstrated preference for BCS. BCS was also the preferred choice of surgery for 85.7% of those with a family history of breast cancer. 70% had Stage 2 disease, however it was not associated with the preference of surgery.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of cohort and FACT B score comparison between BCS and MRM patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDemographics and oncology variables\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eBCT\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eMRM\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eGrand Total\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge (Mean\u0026thinsp;+\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.2\u0026thinsp;+\u0026thinsp;9.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.1\u0026thinsp;+\u0026thinsp;10.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59.4\u0026thinsp;+\u0026thinsp;11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMenopausal Status, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-menopausal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.044\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-menopausal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (47.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (52.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMarried Status, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (58.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (41.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (78.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEducational Status, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary/Secondary level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (34.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (65.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEducated (Graduation above)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (70.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eFamily History of Breast Cancer, N (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (45.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (54.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (85.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTumour Size*, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (64.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (35.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.530\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (51.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (48.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eStage*, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.360\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (47.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (52.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eChemotherapy, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (40.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (59.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (61.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (38.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eRadiotherapy\u003csup\u003e#\u003c/sup\u003e, N (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eHormonal Therapy\u003csup\u003e#\u003c/sup\u003e, N (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (42.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (57.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.211\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurvival Status, N (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eBCT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMRM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eDied\u003c/p\u003e \u003cp\u003eSurvived\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66 (52.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNote: * for two patients records were missing, # for four patients\u0026rsquo; data were missing. Stage: Records of 2 patients were missing, RT \u0026amp; HT: Records of 4 patients each were missing)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe QOL scores for both groups in physical well-being (PWB), social well-being (SWB), emotional well-being (EWB) and breast specific domains as well as total scores were comparable at the end of the follow-up period (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, based on the FACT-B score, the functional well-being (FWB) scores were better for BCS as compared to MRM \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of QOL Scores between BCS and MRM groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDomain\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBCT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMRM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePhysical Well Being (PWB)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26.9 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.9 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.755\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSocial Well Being (SWB)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27.2 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.1 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEmotional Well Being (EWB)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.2 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.4 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.638\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFunctional Well Being (FWB)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26.9 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.9 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBreast Cancer Subscale (BSS)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32.8 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.8 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFACT-B Trial Outcome Index\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(PWB\u0026thinsp;+\u0026thinsp;FWB\u0026thinsp;+\u0026thinsp;BCS score)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86.6 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83.4 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFACT-G Total Score\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(PWB\u0026thinsp;+\u0026thinsp;SWB\u0026thinsp;+\u0026thinsp;EWB\u0026thinsp;+\u0026thinsp;FWB score)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102.9 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.3 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFACT-B Total score\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(PWB\u0026thinsp;+\u0026thinsp;SWB\u0026thinsp;+\u0026thinsp;EWB\u0026thinsp;+\u0026thinsp;FWB\u0026thinsp;+\u0026thinsp;BCS score)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e135.8 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e132.1 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003cp\u003eNote: All scores presented as Mean (Standard Deviation)\u003c/p \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study revealed that QOL scores in all domains were similar in BCS and MRM groups after long-term follow-up, except in the functional wellbeing (FWB) domain, which was higher for women undergoing BCS. We also documented that women who were younger, had a history of breast cancer in the family, had formal education, were married and were pre-menopausal preferred BCS over MRM.\u003c/p\u003e \u003cp\u003eFunctional wellbeing (FWB) is a measure of an individual's capacity to perform tasks of daily work, socialize and enjoy life. It also measures whether the woman is content with her life and accepted her illness.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] The better functional scores in the BCS subgroup in our study may be attributed to only a minimal disfigurement and disruption of body form after surgery, leaving women free to focus on function and life rather than physical form, shape and image. This explanation can also be extrapolated to the higher scores of FACT B TOI in BCS patients in our study. This outcome index is a sum of functional, physical and breast subscale scores that additionally includes questions regarding arm pain and oedema, body shape and form, comfort in dressing and feeling of being attractive. This combined outcome index reflects the woman's overall confidence and comfort about herself, resulting in better functional outcomes. Bhat et al. reported better acceptance of disease, body image and coping with cancer in BCS groups, during a follow up period of 2.5 years.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Similarly, a recent meta-analysis that included 18 studies assessing QOL scores in patients with BCS, reconstruction and mastectomy documented a better global, and component scores in BCS when compared to MRM.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Our group previously reported that all QOL scores, including FWB, showed no statistical difference in BCS and MRM groups at 5 years of follow-up.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Thus, longer follow-up, such as in the current study, may help unmask persisting insufficiencies of functional ability, acceptance of the disease and disfigurement among MRM patients.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] This highlights the need for long-term support and coping strategies for breast cancer patients.\u003c/p\u003e \u003cp\u003eIn our cohort, we reported significant differences in patients\u0026rsquo; preference of surgical options for breast cancer. Younger, premenopausal, educated and patients with partners preferred less disfigurement and morbidity. This is in agreement with other reports of patients-preference being dependent on factors such as age, educational status, and family history.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSince MRM is the most performed surgery for breast cancer in India, this study highlights the need of long-term support to patients undergoing MRM. It also emphasises on offering BCS, whenever feasible oncologically and socioeconomically, to women in India.\u003c/p\u003e \u003cp\u003eLong-term follow-up of our cohort is a unique strength of this study. Most Indian studies have addressed QOL scores during short-term follow-up less than five years.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] The setting of the universal health care system, allowing equitable and free of cost healthcare delivery, freeing them to choose between BCS and MRM, is a strength of this study. This mimics an ideal situation without socioeconomic barriers.\u003c/p\u003e \u003cp\u003eWhile the uniqueness of the setting may limit generalisability of the study in India and can be currently viewed as a limitation, increasing implementation of UHC in India, positions this study in a new light. The FACT-B score is a quantitative method of assessing sensitive issues in breast cancer like sexuality, body image, and interpersonal relationships with family and friends. Although it provides a broad idea about breast specific concerns, it does not comprehensively explore the perceptual and cognitive aspects of body image.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, we documented that, on long-term follow-up, functional wellbeing was better in women whose breasts were conserved. To better understand the underlying causes of these results, additional large sample quantitative and other qualitative studies to analyse the cognitive, behavioural, and affective components of QOL are required. These may offer a more granular understanding of QOL in breast cancer patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMRM- Modified Radical Mastectomy\u003c/p\u003e\n\u003cp\u003eBCS- Breast Conservation Surgery\u003c/p\u003e\n\u003cp\u003eRT- Radiotherapy\u003c/p\u003e\n\u003cp\u003eQOL- Quality of Life\u003c/p\u003e\n\u003cp\u003ePWB- Physical well-being\u003c/p\u003e\n\u003cp\u003eSWB- Social well-being\u003c/p\u003e\n\u003cp\u003eFWB- Functional well-being\u003c/p\u003e\n\u003cp\u003eEWB- Emotional well-being\u003c/p\u003e\n\u003cp\u003eFACT-B- Functional Assessment of Cancer Therapy- Breast\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical considerations- \u003c/strong\u003eThe study was approved by the Institutional Ethics Committee of BARC hospital (IEC number\u0026nbsp;BHMEC/DNB/21/18).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication-\u003c/strong\u003e All authors have consented for the publication of this report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials-\u003c/strong\u003e\u0026nbsp;The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests-\u003c/strong\u003e The authors do not declare any financial or non-financial competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding- \u003c/strong\u003eThis is a non-funded study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution-\u003c/strong\u003e The authors Vasundhara Mathur, Niranjana Swaminathan, Priyansh Nathani, and Bhakti Sarang have contributed in the writing of the manuscript. The author Prashant Bhandarkar has contributed in the statistical analysis and writing the results in the manuscript. The authors Anita Gadgil and Nobhojit Roy have contributed in the conceptualisation, writing and review of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements-\u003c/strong\u003e\u0026nbsp;The authors would like to acknowledge WHO collaborating Centre for Research in Surgical Care Delivery, India. Also, due credit to be given to Breast Cancer Consortium, WHOCC, India for the regular meetings and guidance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatement Of Declaration-\u003c/strong\u003e All authors acknowledge that they are not affiliated to or a part of any group or organization that has a financial or non-financial involvement in the subject or materials addressed in this manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGhoncheh M, Pournamdar Z, Salehiniya H. Incidence and Mortality and Epidemiology of Breast Cancer in the World. \u003cem\u003eAsian Pac J Cancer Prev APJCP\u003c/em\u003e. 2016;17(S3):43-46. doi:10.7314/apjcp.2016.17.s3.43\u003c/li\u003e\n\u003cli\u003eMalvia S, Bagadi SA, Dubey US, Saxena S. Epidemiology of breast cancer in Indian women: Breast cancer epidemiology. \u003cem\u003eAsia Pac J Clin Oncol\u003c/em\u003e. 2017;13(4):289-295. doi:10.1111/ajco.12661\u003c/li\u003e\n\u003cli\u003eYfantis A, Sarafis P, Moisoglou I, et al. How breast cancer treatments affect the quality of life of women with non-metastatic breast cancer one year after surgical treatment: a cross-sectional study in Greece. \u003cem\u003eBMC Surg\u003c/em\u003e. 2020;20(1):210. doi:10.1186/s12893-020-00871-z\u003c/li\u003e\n\u003cli\u003eWorld Heath Organization. The World Health Organization Quality of Life User Manual. Published March 2012. Accessed August 27, 2023. https://www.who.int/tools/whoqol\u003c/li\u003e\n\u003cli\u003eArndt V, Stegmaier C, Ziegler H, Brenner H. Quality of life over 5 years in women with breast cancer after breast-conserving therapy versus mastectomy: a population-based study. \u003cem\u003eJ Cancer Res Clin Oncol\u003c/em\u003e. 2008;134(12):1311-1318. doi:10.1007/s00432-008-0418-y\u003c/li\u003e\n\u003cli\u003ePoggi MM, Danforth DN, Sciuto LC, et al. Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer Institute Randomized Trial. \u003cem\u003eCancer\u003c/em\u003e. 2003;98(4):697-702. doi:10.1002/cncr.11580\u003c/li\u003e\n\u003cli\u003eJanni W, Rjosk D, Dimpfl Th, et al. Quality of Life Influenced by Primary Surgical Treatment for Stage I-III Breast Cancer?Long-Term Follow-Up of a Matched-Pair Analysis. \u003cem\u003eAnn Surg Oncol\u003c/em\u003e. 2001;8(6):542-548. doi:10.1007/s10434-001-0542-2\u003c/li\u003e\n\u003cli\u003eCurran D, van Dongen JP, Aaronson NK, et al. Quality of life of early-stage breast cancer patients treated with radical mastectomy or breast-conserving procedures: results of EORTC trial 10801. \u003cem\u003eEur J Cancer\u003c/em\u003e. 1998;34(3):307-314. doi:10.1016/S0959-8049(97)00312-2\u003c/li\u003e\n\u003cli\u003eBhat V, Roshini AP, Ramesh R. Does Quality of Life Among Modified Radical Mastectomy and Breast Conservation Surgery Patients Differ? A 5-Year Comparative Study. \u003cem\u003eIndian J Surg Oncol\u003c/em\u003e. 2019;10(4):643-648. doi:10.1007/s13193-019-00962-1\u003c/li\u003e\n\u003cli\u003eAbout Pradhan Mantri Jan Arogya Yojana (PM-JAY). Accessed September 2, 2023. https://nha.gov.in/PM-JAY\u003c/li\u003e\n\u003cli\u003eShimozuma K, Sonoo H, Ichihara K, et al. The impacts of breast conserving treatment and mastectomy on the quality of life in early-stage breast cancer patients. \u003cem\u003eBreast Cancer\u003c/em\u003e. 1995;2(1):35-43. doi:10.1007/BF02966894\u003c/li\u003e\n\u003cli\u003eWarm M, Gatermann C, Kates R, et al. Postoperative Sense of Well-Being and Quality of Life in Breast Cancer Patients Do not Depend on Type of Primary Surgery. \u003cem\u003eOnkologie\u003c/em\u003e. 2008;31(3):99-104. doi:10.1159/000113540\u003c/li\u003e\n\u003cli\u003eGangane N, Khairkar P, Hurtig AK, San Sebasti\u0026aacute;n M. Quality of Life Determinants in Breast Cancer Patients in Central Rural India. \u003cem\u003eAsian Pac J Cancer Prev APJCP\u003c/em\u003e. 2017;18(12):3325-3332. doi:10.22034/APJCP.2017.18.12.3325\u003c/li\u003e\n\u003cli\u003ejhajharia S, Verma S, Kumar R. Quality of Life in Breast Cancer Survivors in India: Factors and Importance. \u003cem\u003eInt J Cancer Res\u003c/em\u003e. 2017;13(2):36-40. doi:10.3923/ijcr.2017.36.40\u003c/li\u003e\n\u003cli\u003eDeepa KV, Gadgil A, L\u0026ouml;fgren J, Mehare S, Bhandarkar P, Roy N. Is quality of life after mastectomy comparable to that after breast conservation surgery? A 5-year follow up study from Mumbai, India. \u003cem\u003eQual Life Res\u003c/em\u003e. 2020;29(3):683-692. doi:10.1007/s11136-019-02351-1\u003c/li\u003e\n\u003cli\u003eThe Australian Institute of Health and Welfare\u0026rsquo;s Metadata Online Registry - Functional Wellbeing. Accessed August 27, 2023. https://meteor.aihw.gov.au/content/524403#:~:text=The%20ability%20of%20a%20person,to%20carry%20out%20social%20roles.\u003c/li\u003e\n\u003cli\u003eZehra S, Doyle F, Barry M, Walsh S, Kell MR. Health-related quality of life following breast reconstruction compared to total mastectomy and breast-conserving surgery among breast cancer survivors: a systematic review and meta-analysis. \u003cem\u003eBreast Cancer\u003c/em\u003e. 2020;27(4):534-566. doi:10.1007/s12282-020-01076-1\u003c/li\u003e\n\u003cli\u003eBapsy PPP, Maurya P, Dhande S, et al. What decides breast conservation versus mastectomy in the background of diverse sociocultural environment, an Indian study. \u003cem\u003eAnn Oncol\u003c/em\u003e. 2016;27:vi48. doi:10.1093/annonc/mdw364.17\u003c/li\u003e\n\u003cli\u003eGumus M, Ustaalioglu BO, Garip M, et al. Factors that Affect Patients\u0026rsquo; Decision-Making about Mastectomy or Breast Conserving Surgery, and the Psychological Effect of this Choice on Breast Cancer Patients. \u003cem\u003eBreast Care\u003c/em\u003e. 2010;5(3):164-168. doi:10.1159/000314266\u003c/li\u003e\n\u003cli\u003eKaur N, Gupta A, Sharma AK, Jain A. Survivorship issues as determinants of quality of life after breast cancer treatment: Report from a limited resource setting. \u003cem\u003eThe Breast\u003c/em\u003e. 2018;41:120-126. doi:10.1016/j.breast.2018.07.003\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Breast cancer, Quality of life, Modified Radical Mastectomy (MRM), Breast Conservation Surgery (BCS)","lastPublishedDoi":"10.21203/rs.3.rs-4194565/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4194565/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Breast cancer is the most common cancer afflicting women with an estimated 2.1 million new cases diagnosed globally every year. Breast cancer and its treatment significantly impair the patient’s physical mental health and thereby affect their overall quality of life (QOL). Our aim was to identify differences in long-term QOL between breast conservative surgery (BCS) and modified radical mastectomy (MRM) for early breast cancer among sociodemographic and clinical subgroups of patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This prospective observational cohort study was conducted at Bhabha Atomic Research Centre (BARC) hospital under Universal Health Coverage scheme. We recruited patients who were surgically treated for breast cancer between 2010 to 2015 and were continuing further treatment or follow-up. Their QOL scores were measured using the 37-item Functional Assessment of Cancer Therapy- Breast, Version 4 (FACT-B) questionnaire andwere analysed using Mann-Whitney U test. P value \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAmong the 86 patients (46 with BCS and 41 with MRM) included in the study, the mean age was 59 ± 11.5 years with a mean follow-up period of 6.9 years. Functional well-being was significantly better for the BCS group (P\u0026lt;0.01). However, the QOL scores corresponding to physical, social, and emotional well-being as well as body image and attractiveness scores for BCS and MRM at the end of the follow-up period were comparable (p\u0026gt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eFunctional well-being was the only component of QOL that was noted to be higher for BCS for our study population. Future work on understanding the behavioural and cognitive components of body image in this patient population is warranted.\u003c/p\u003e","manuscriptTitle":"Assessment of Quality of Life of Breast Cancer Survivors Post 5 Years from Surgery: Study from a Community Hospital in India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-16 16:13:15","doi":"10.21203/rs.3.rs-4194565/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e8dea2d7-3476-4c59-a60a-09feb31fe619","owner":[],"postedDate":"April 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-17T16:57:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-16 16:13:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4194565","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4194565","identity":"rs-4194565","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}