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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.57 no.2 Campinas Mar./Apr. 2007
Surgery preoperative anxiety in surgeries of the breast: a comparative study between patients with suspected breast cancer and that undergoing cosmetic surgery*
Ansiedad en el período preoperatorio de cirugías de mama: estudio comparativo entre pacientes con sospecha de cáncer a ser sometidas a procedimientos quirúrgicos estéticos
Maria Luiza Melo AlvesI; Adriana Jucá PimentelII; Álvaro Antônio Guaratini, TSAIII; José Álvaro Marques MarcolinoIV; Judymara Lauzi Gozzani, TSAV; Ligia Andrade da Silva Telles Mathias, TSAVI
da Faculdade de Ciências Médicas da Universidade de Pernambuco;
Pós-Graduanda da Faculdade de Ciências Médicas da Santa
Casa de São Paulo
IIMédica Residente da Cabeça e Pescoço da Beneficência Portuguesa de São Paulo
IIIMédico Assistente, Hospital Central da ISCMSP; Mestre em Medicina; Doutorando da Faculdade de Ciências Médicas da Santa Casa de São Paulo; Co-responsável do CET-SBA, ISCMSP
IVMédico Assistente, Hospital Central da ISCMSP; Professor Adjunto de Psiquiatria da Faculdade de Ciências Médicas da Santa Casa de São Paulo
VMestre em Biologia Molecular; Doutora em Medicina; Responsável pelo Grupo de Dor da ISCMSP
VIDiretora do Serviço e Disciplina de Anestesiologia, ISCMSP e Faculdade de Ciências Médicas da Santa Casa de São Paulo; Responsável pelo CET-SBA, ISCMSP
OBJECTIVES: Evaluation of anxiety is not part of the routine pre-anesthetic
evaluation (APA). Therefore, special situations in which patients might present
altered mood will go unnoticed by the anesthesiologist. The objective of this
study was to compare, at the moment of the outpatient basis APA, the risk factors,
severity, and prevalence of anxiety in patients with suspected breast cancer
and those undergoing cosmetic surgery of the breast.
METHODS: After approval by the Ethics Committee, 114 patients, ASA I or II, 14 years or older, were studied at the APA clinic; they were divided in two groups: GMAMA patients with suspected breast cancer; GPLAST patients undergoing cosmetic surgery. After signing the informed consent, patients answered the anxiety evaluation test (STAI State-Trait Anxiety Inventory) before the preanesthetic evaluation. The following parameters were analyzed: socio-demographic data; prior experience with surgical procedures; number and percentage of patients with low, moderate, or high anxiety (STAI I and II); and median of the STAI I and II scores.
RESULTS: Both groups were homogenous regarding the socio-demographic data and prior experience with surgical procedures. There was a significant difference in the levels and prevalence of anxiety-state (STAI I). No risk factors for anxiety-state and anxiety-trait were identified.
CONCLUSIONS: Patients with suspected breast cancer scheduled for nodulectomy or removal of breast tissue for diagnosis, had higher levels and prevalence of anxiety-state than patients undergoing mammaplasty; the levels and prevalence of anxiety-trait were similar in both groups; no risk factors for anxiety-state and anxiety-trait were identified.
Key Words: PREANESTHETIC EVALUATION: psychological status; SURGERY, Gynecologic, Plastic: breast.
JUSTIFICATIVA Y OBJETIVOS:
La evaluación de la ansiedad no forma parte de la rutina de la evaluación
preanestésica (APA), lo que hace que situaciones especiales en que el
estado emocional de los pacientes pueda estar alterado pasen desapercibidas
por el anestesiólogo. Este estudio quiso comparar al momento de la APA
ambulatorial, factores de riesgo, intensidad y prevalencia de ansiedad en pacientes
con sospecha de cáncer de mama a ser sometidas a procedimientos quirúrgicos
estéticos de mama.
MÉTODO: Después de la aprobación por el Comité de Ética, fueron estudiadas en el ambulatorio de APA, 114 pacientes, ASA I o II, edad > 14 años, divididas en los grupos: GMAMA - pacientes con sospecha de cáncer de mama; GPLAST - pacientes a ser sometidas a cirugía plástica estética. Después del consentimiento aclarado, las pacientes respondieron al la prueba de evaluación de ansiedad (IDATE - Inventario de Ansiedad Trazo-Estado) antes de la evaluación preanestésica. Se analizaron: datos sociodemográficos; experiencia con procedimientos quirúrgicos anteriores; número y porcentaje de pacientes con ansiedad baja, moderada y alta (IDATE I y II); promedio de los puntajes de las escalas IDATE I y II.
RESULTADOS: Los grupos fueron homogéneos en relación a los datos sociodemográficos y experiencia con procedimientos quirúrgicos anteriores. Se observó diferencia significativa de los niveles y prevalencia de ansiedad-estado (IDATE I). No fueron identificados factores de riesgo para ansiedad-estado y ansiedad-trazo.
CONCLUSIONES: Las pacientes con sospecha de cáncer de mama a ser sometidas a la retirada de nódulo o tejido mamario para diagnóstico presentaron niveles y prevalencia de ansiedad-estado alta mayores que las pacientes a ser sometidas a mamoplastías; los niveles y la prevalencia de ansiedad-trazo fueron similares en los de los grupos y no fueron identificados factores de riesgo para ansiedad-estado y ansiedad-trazo.
There are several factors responsible for the anxiety connected with anesthesia/surgery: concern about lesions that might be incurred during the procedure, fear of postoperative pain, separation from the family, loss of independence, fear of becoming disabled, not waking up any more, waking up in the middle of the surgery, the diagnosis, and complications 1-4.
High preoperative anxiety levels were associated with the nature of prior experience with anesthesia, history of cancer, smoking, psychiatric disorders, negative outlook about the future, moderate to severe symptoms of anxiety, and presence of moderate or severe pain 5-7.
Regarding patients with breast cancer, there are several reports in the literature on the emotional status of patients before, during, and after the clinical and/or surgical treatment 8-11. However, we did not find in the literature any studies on anxiety of patients with suspected breast cancer at the time of the preanesthetic evaluation (APA), before the biopsy, when concerns about femininity, maternity, and sexuality might be present, since the breast is full of symbolism for women 12-14.
Another group of patients that might show a high incidence of temporary or lasting psychological disturbances are those undergoing cosmetic surgeries of the breast, and the associated factors include: young patient, male, unreal expectations about the procedure, and history of depression, anxiety, or personality disorders 15,16.
Those studies did not discuss the emotional status of patients undergoing cosmetic surgeries of the breast or patients with suspected breast cancer at the time of the preanesthetic evaluation. The objective of this study was to compare the severity and prevalence of anxiety at the time of the outpatient basis APA, and the risk factors for anxiety in those patients.
After approval by the Ethics Committee of the Universidade de Pernambuco, patients of the APA clinic with suspected breast cancer scheduled for diagnostic nodulectomy or removal of breast tissue, and patients scheduled for cosmetic breast surgery were included in this comparative, prospective study during an 18-month period.
Patients were female, ASA physical status I or II, 14 years or older. Criteria for exclusion included: patients with severe visual or hearing deficiencies; illiterate or those that did not understand Portuguese; those with intellectual disturbances; taking psychoactive drugs; with central nervous system disorders (neurological or psychiatric); with recurrent breast tumor; and those scheduled for breast reconstruction after mastectomy.
Patients were divided in two groups: GMAMA patients with suspected breast cancer undergoing nodulectomy or removal of breast tissue for diagnosis; GPLAST patients undergoing cosmetic breast surgery.
The State-Trait Anxiety Inventory (STAI) 17 was used to evaluate anxiety. It is composed of two scales: scale of anxiety-state, STAI I, with 20 affirmations that indicate how individuals feel at a specific moment; and scale of anxiety-trait, STAI II, also with 20 affirmations that describe how individuals usually feel. Each item of the two scales receives a score from 1 to 4, and the total score varies from 20 (minimum) to 80 (maximum) 17-19.
Patients signed an informed consent at the time of the outpatient basis preanesthetic evaluation. They answered the STAI and a preanesthetic evaluation form composed of two parts, to be filled by the patient and the anesthesiologist. Afterwards, patients were submitted to the APA. Every procedure of the study was performed only by the anesthesiologist responsible for the study.
The cutting points to consider a patient as having mild, moderate, or severe anxiety were, according to the literature 2,17,19-21: severe anxiety > 75th percentile; moderate anxiety: between the 75th and 25th percentiles; and mild anxiety < 25th percentile.
Socio-demographic data (age, marital status, current occupation), prior surgical experience, and the scores of the STAI I and II were analyzed.
Non-paired test t Student was used to compare the results regarding age. The other variables were analyzed by the Fisher Exact test, Chi-square test for tables greater than 2 × 2, and the Mann-Whitney test. A p < 0.05 was considered statistically significant. The tests used are part of the Statistical Package for the Social Sciences (SPSS) for Windows 14.
The final study population was composed of 114 patients in the preoperative period; 53 (46.5%) were suspected of having breast cancer (GMAMA) and 61 (53.5%) were scheduled for cosmetic surgeries of the breast (GPLAST).
Table I shows the socio-demographic data (age, marital status, and occupation) and those regarding previous surgical experience, as well as the results of the statistical tests.
Both groups were homogenous regarding the demographic data and past experience with surgical procedures.
According to the criteria established by the protocol 2,17,22,21, the cutting points were:
- STAI I: mild anxiety: < 35; moderate anxiety: 36 to 46; severe anxiety: > 47.
- STAI II: mild anxiety: < 32; moderate anxiety: 33 to 41; severe anxiety: > 42.
Table II shows the mean, standard deviation median, 25th and 75th percentiles of STAI 1 and STAI II scores of GMAMA and GPLAST, and the results of the Mann-Whitney test.
There were statistically significant differences between Gmama and Gplast (p = 0.0406) when the scores of the STAI I were compared (Mann-Whitney test).
Table III shows the total number and percentage of patients with moderate, mild, and severe anxiety (STAI I and II) of both groups and the Mann-Whitney test.
There was a statistically significant difference (p = 0.043) in the prevalence of the different levels of anxiety-state (STAI I) between Gmama and Gplast (Mann-Whitney test).
There were no statistically significant differences (p = 0.776) in the prevalence of the different levels of anxiety-trait (STAI II) between both groups (Mann-Whitney test).
Each socio-demographic data and prior experience with surgical procedures in both groups were analyzed to determine the presence of risk factors for severe anxiety-state (STAI I). There were no statistically significant differences regarding the prevalence of severe anxiety-state for anyone of the variables analyzed in both groups.
"Fear of the unknown" 2,22,24 has been deemed the greatest source of anxiety among patients at the outpatient basis preanesthetic evaluation. However, the specific evaluation of anxiety, as a separate item, is not part of the routine outpatient and inpatient basis APA. Therefore, special situations in which the mood of the patients might be altered, by the disease and/or other reasons (family problems, pre-school age children, possibility of mutilation) go unnoticed by the anesthetic-surgical team 2,4,25-27.
The STAI was chosen in this study due to the quality of the tool (self-evaluation and easily understood by the lay person), and because it is considered the golden standard 20,21,23,28-37.
The mean values of anxiety state and trait (STAI I and II) found in the present study are close to the values reported in the literature, in studies carried on in the preoperative period, but not at the time of the APA 2,6,38.
In this study, the prevalence of moderate and severe anxiety was 89.1% in GMAMA and 62.3% in GPLAST, which are elevated in both groups, reflecting the importance of the APA, close to the surgery. It also demonstrated, as it was identified in the statistical analysis, that the prevalence of severe anxiety was higher in GMAMA than in GPLAST, suggesting that the imminence of a cancer diagnosis induces more frequently a high level of anxiety than a cosmetic surgery.
The results did not show any difference in anxiety-trait in both groups, as would be expected, since it reflects a stable tendency of the individual regarding anxiety, which is less sensible to changes regarding environmental situations 39.
Follow-up studies with breast cancer patients who underwent mastectomy reported abnormal anxiety levels in 20% to 25% of the patients 40,41.
Magalhães Filho et al. 7 found a 40.6% prevalence of anxiety in patients with different types of cancer evaluated by the hospital anxiety and depression scale (HAD) at the APA.
The results obtained in the present study in the group of patients with suspected breast cancer, regarding the prevalence of anxiety, are within the range of values reported in the literature, using several methods, for cancer patients undergoing clinical treatment and patients with and without cancer in the preoperative period; it is also important to stress that neither one of those studies evaluated patients at the time of the outpatient basis APA 2,6,12.
The study of Yumi et al. 42 comparing the state of anxiety in patients who underwent removal of a breast tumor, demonstrated that patients who repressed their preoperative anxiety showed a higher level of anxiety, depression, and confusion after receiving the diagnosis of cancer than the group of patients who openly expressed their emotions. The present study did not evaluate the level of anxiety of the patients after the diagnosis of cancer, which leaves space for further studies.
There were no comparative data in the literature regarding the group of patients scheduled for cosmetic surgery.
Smith et al. 43 verified that the anxiety-trait, more than the anxiety-state, affects the intraoperative anesthetic needs and suggested that anesthesiologists should base anesthetic induction on the preoperative anxiety level of the patients. Those aspects were not evaluated in this study.
It was not possible to identify risk factors for severe anxiety. These results do not coincide with those found in the literature that report higher prevalence of anxiety in younger patients, with low schooling, higher income, and without a partner 6,44-48. However, the data in the literature refers to the comparison among patients with and without anxiety and the present study compares different levels of anxiety.
We need a new APA model, more concerned with the psychosocial dimensions of the patients and, therefore, allowing for better diagnosis and treatment of anxiety disorders. The advantage of a broad and early approach of the patient in the preoperative period is that it allows us to detect individuals with anxiety disorders, whose consequences can be seen both in the intra- and postoperative periods. The approach and treatment of those patients should be further studied, since the clinical treatment can be greatly improved by detecting the emotional concerns of the patients.
This study demonstrated the importance of adding the evaluation of the degree of anxiety to the preanesthetic evaluation of patients with suspected breast cancer.
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Dra. Lígia Andrade da Silva Telles Mathias
Alameda Campinas, 139/41
01404-000 São Paulo, SP
Submitted em 10
de abril de 2006
Accepted para publicação em 08 de dezembro de 2006
* Received from Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP), São Paulo, SP