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In 1952, Renneker and Cutler published the results of a distinguished group of surgeons and psychoanalysts. In examining the psychosomatic aspects of breast cancer, they found a typical postmastectomy depression in most patients.1 Sutherland and Orbach reported that a majority of women who had undergone a radical mastectomy experienced significant depression, anxiety, and low self-esteem, along with extended impairments in physical and sexual functioning.2 Follow-up studies have affirmed that approximately 25% of women who undergo radical or modified radical mastectomies experience significant psychological distress in the year following surgery3,4 In the last half century, considerable clinical and research attention has been placed on the psychosocial effects of breast cancer and the various and evolving surgical treatments, reconstruction options, and combination therapies.5,6

There have been numerous studies that have addressed the psychosocial aspects of mastectomy from the woman's perspective,7 the man's viewpoint,8 and the impact on the family.9 Issues such as loss, changes in self-esteem, sexuality, body image and fears of disfigurement, mood and anxiety, suicidal ideation, sleep disturbances, and quality of life have been studied in the context of the treatments offered at the time.10,11 Wellisch and associates noted that in their sample of 31 men that sexuality and intimacy were "severely stressed and often negatively altered after mastectomy." Men were also polarized about the surgeon—some viewing the surgeon as an adversary, some as an ally.8

Jamison and associates called attention to depression and suicidal thoughts after a mastectomy. In their study, one-fourth of women had considered suicide for reasons they associated with their mastectomies or to depression.7 This same group of patients had previously rated their pre-mastectomy sexual satisfaction significantly higher than the other women. Klein wrote of the adverse psychological effects of mastectomy on the family—the husband's feelings of inadequacy to protect his wife and children's worries about their mother's survival transforming into depression and anxiety.9

The role of the surgeon has been noted to be central to a patient's psychosocial journey. Surgeons' attributes in this process have included the importance of honesty, providing appropriate hope and involvement of the patient's partner, and timely referral for counseling and rehabilitation.12 Baile and colleagues noted that training physicians in giving bad news and improving communication techniques was an important component of medical education and was helpful to patients' recovery.13 The doctor–patient relationship and the trust the patient puts in the surgeon remain core values in cancer care. Physician suggestions and preferences; how the surgeon communicates with the patient, partner, and family; and treatment team dynamics are of consummate importance. In a busy practice, with complicated and complex issues and a high level of stress for patients, attending to the psychosocial needs of patients and families can take a significant amount of time and effort, often without reimbursement. Melding medical and psychosocial treatment to meet the needs of the patient ...

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