World J Surg

https://doi.org/10.1007/s00268-018-4477-1

SCIENTIFIC REVIEW

Depression Induced by Total Mastectomy, Breast Conserving

Surgery and Breast Reconstruction: A Systematic Review
and Meta-analysis
Chengjiao Zhang1 • Guangfu Hu3 • Ewelina Biskup5,6 • Xiaochun Qiu7 •

Hongwei Zhang4 • Haiyin Zhang1,2

Ó Société Internationale de Chirurgie 2018

Abstract
Background To carry out a systematic review and meta-analysis of the literature to determine whether different type
of surgery induces different depression occurrence in female breast cancer at mean time more than 1-year term
postoperatively.
Methods A systematic literature search of PubMed, Web of Science, EMBASE, OvidSP, EBSCO and Psy-
cARTICLES was conducted. Observational clinical studies that compared the depression incidence in different
surgery groups and presented empirical findings were selected.
Results Sixteen studies met the inclusion criteria, including 5, 4, 2 and 5 studies compared depression between total
mastectomy (TM) and breast conserving therapy (BCS), TM and breast reconstruction (BR), BCS and BR, or among
all three groups (TM, BCS and BR), respectively. Only 1 of 5 studies, which subjected to multivariate analysis of
depression in female breast cancer, reported a statistically significant effect of type of surgery on depression
occurrence. Our meta-analysis showed no significant differences among the three types of surgery, with BCS patients
versus TM patients (relative risk [RR] = 0.89, 95% confidence interval [CI] 0.78–1.01; P = 0.06), BR patients
versus TM patients (RR = 0.87, 95% CI 0.71–1.06; P = 0.16) and BCS patients versus BR patients (RR = 1.10;
95% CI 0.89–1.35; P = 0.37), respectively.
Conclusions Our study showed that there were no statistically significant differences concerning the occurrence of
depressive symptoms in breast cancer patients as a consequence of TM, BCS or BR at mean time more than 1-year
term postoperatively.

Introduction
Chengjiao Zhang and Guangfu Hu have contributed equally to this
work and are co-first authors.
Breast cancer is the most common malignancy among
Electronic supplementary material The online version of this women worldwide [1]. Advances in early detection and
article (https://doi.org/10.1007/s00268-018-4477-1) contains supple- evolving treatment options over recent decades lead to an
mentary material, which is available to authorized users.

& Hongwei Zhang 2

Department of Psychiatry, Shanghai Mental Health Center,
zhang.hongwei@zs-hospital.sh.cn Shanghai Jiao Tong University School of Medicine,
Shanghai, China
& Haiyin Zhang
3
haiyinz2001@126.com Department of Breast Surgery, Shanghai Huangpu District
Central Hospital, Shanghai, China
1
Department of Psychological Measurement, Shanghai Mental 4
Department of General Surgery, Zhongshan Hospital, Fudan
Health Center, Shanghai Jiao Tong University School of
University, Shanghai, China
Medicine, Shanghai, China

123

increase in breast cancer survival rates. Moreover, an
important issue of psychological health, and thus quality of
life (QOL), has received sufficient attention. A number of
data have shown that breast cancer patients suffer from
persisting psychological problems, including bad body
image, lower QOL and varied emotional disorders [2].
Depression is the best-investigated psychological disorder
in women with breast cancer [3].
Nowadays, depending on the stage of the breast cancer,
curative surgery is still one of the primary management
steps. It is recognized that body disfigurement caused by
the surgery will affect the psychological state of the female
breast cancer patients, mostly rendering them depressive
[4, 5]. A number of studies have investigated the differ-
ences in depression between women with a total mastec-
tomy (TM) and women treated by breast conserving
therapy (BCS) or breast reconstruction (BR), respectively.
Nevertheless, the question remains controversial whether
the different surgery types are relevantly reducing or
inducing depressive symptoms in female breast cancer
patients [6].
BCS has been introduced as an alternative to TM; being
much less invasive and aggressive, it is potentially less
straining on patients and thus might prevent considerable
depression consequences demonstrated in women treated
by TM [7–9]. Recently, research focused on direct com-
parison of depression occurrence in TM and BCS patients.
Although most studies have shown that there is a lower
depression morbidity in BCS patients than in TM patients,
there are no firm meta-analyses that would prove the sta-
tistical differences between these two different surgery
groups to be significant. Moreover, some studies have
reported opposite results, stating that more patients suffer
from depression after a BCS surgery than a TM at more
than 1/2- or 1-year term postoperatively [10, 11].
BR often represents another acceptable option for
women who require a TM [12]. It has been suggested that
BR may be regarded as a ‘‘reverse mastectomy,’’ offering
the most effective means for restoring psychological well-
being after a TM [13]. Some authors have concluded that
BR patients have less depressive symptoms than TM
patients [14, 15], while some authors indicated that BR
fails to provide substantial psychosocial advantages for
patients [16–18]. Some studies have been specifically
conducted to compare the effect of BCS and BR on the
5
Shanghai University of Medicine and Health Sciences,
Shanghai, China
6
Department of Internal Medicine, University Hospital of
Basel, University of Basel, Basel, Switzerland
7
Medical School Library, Shanghai Jiao Tong University
School of Medicine, Shanghai, China
123
World J Surg
depression in women with early breast cancer [19, 20].
However, no statistical differences in depression scores
have been described and compared so far.
In addition, most of the studies were single-center
studies and could not accurately assess the impact of dif-
ferent type of surgery on depression in women with breast
cancer due to a small number of patients included and
event rates reported. Up to now, there are no systematic
reviews or meta-analyses of the impact of different surgical
techniques for the depression occurrence in breast cancer
patients. Moreover, the previous studies were involved in
different terms from surgery to depression screening. Our
study was statistically powered to answer the primary
question of whether different type of surgery induces dif-
ferent depression occurrence in women with breast cancer
at mean time more than 1-year term postoperatively. Our
findings have a direct and meaningful translation to the
clinic, allowing us to offer patients the best individual
surgery option, especially for young and psychologically
vulnerable patients.
Materials and methods
Search strategies
Two psychologists, two breast surgeons and a medical
statistician formed the panel to develop the search, selec-
tion and review strategies, based on guidelines of the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) [21, 22]. We conducted a lit-
erature search using the following databases: PubMed,
Web of Science, EMBASE, OvidSP, EBSCO and Psy-
cARTICLES for English-language studies that were pub-
lished between January 1, 2000, and August 9, 2017. The
search was conducted using Medical Subject Headings
(MeSH) or keywords, and, when appropriate, search terms
(Boolean search criteria and included): (1) ‘‘Breast Neo-
plasms,’’ ‘‘Breast Carcinoma,’’ ‘‘Breast Cancer,’’ ‘‘Breast
Tumor*’’; (2) ‘‘Depression,’’ ‘‘Depressive Disorder,’’
‘‘Major Depressive Disorder,’’ ‘‘Depressive Symptom*’’;
(3) ‘‘Mastectomy, Simple,’’ ‘‘Mastectomy,’’ ‘‘Modified
Radical Mastectomy,’’ ‘‘Mastectomy, Modified Radical’’;
(4) ‘‘Mastectomy, Segmental,’’ ‘‘Breast conserving sur-
gery,’’ ‘‘Breast-conserving surgery,’’ ‘‘Breast Conservative
Surgery,’’ ‘‘Partial Mastectomy,’’ ‘‘Lumpectomy,’’ ‘‘Local
Excision Mastectomy’’; (5) ‘‘Mammoplasty,’’ ‘‘Breast
Reconstruction*,’’ ‘‘Breast Reconstructive Surgery.’’ The
reference lists of retrieved articles were manually checked
to retrieve other studies that might be eligible for the
review. Detailed search methods are summarized in Sup-
plementary Table S1–S4.
World J Surg
Eligibility criteria
Two trained reviewers (i.e., C.Z. and G.H.) independently
screened all retrieved abstracts and titles to determine
articles that were ‘‘potentially relevant’’ and ‘‘relevant.’’
The two reviewers then independently reviewed full arti-
cles, according to the following inclusion criteria: (1) ret-
rospective or prospective observational clinical study; (2)
focusing on female breast cancer patients post-surgery (as
cancer management); (3) comparing depression with dif-
ferent surgery types at mean time more than 1-year term
postoperatively; (4) presenting empirical findings. Study
was excluded if (1) a single case report, a regular review or
systematic review; (2) a clinical trial associated with
interventions; (3) investigating metastatic breast cancer or
other cancers. Discrepancies were systematically resolved
by consensus discussion.
Quality assessment
Two reviewers (i.e., J.Z. and G.H.) independently con-
ducted the quality assessment of studies using the New-
castle–Ottawa Scale (NOS) [23, 24]. The NOS was
developed to assess the quality of case–control and cohort
studies, using three parameters: (1) selection; (2) compa-
rability; and (3) exposure assessment. Studies that achieved
five or more points were considered to be of high quality.
Any discrepancies between reviewers were addressed by a
joint reevaluation of the original article. In addition, pub-
lication bias was assessed using the technique of the funnel
plot [25, 26].
Extracted information
We systematically extracted the following data from
included studies: first author’s name, publication year,
sample number and demographics, time from surgery to
survey and screening tools used to diagnose depression,
and further information about the type of surgery, inci-
dence of depression among the patients, P values of rele-
vant findings concerning depression. Data were
extrapolated from graphs, tabulated proportions of events
or from subgroup analyses. If the studies did not present
sufficient data, we contacted authors to request the required
information. Whenever possible, multivariate analysis
concerning depression was extracted from each study.
Meta-analysis strategies
Meta-analyses were performed between two out of the
three groups of patients with depression occurring after
specific surgeries, TM, BCS and BR, respectively. The X2
test and I2 statistic were performed to assess the statistical
heterogeneity of the depression occurrence in different
surgery groups. Values of P \ 0.10 and I2 \ 50% sug-
gested that the observed heterogeneity might be accepted
for a meta-analysis. The relative risk (RR), with a 95%
confidence interval (CI), was used to estimate the effect of
different surgeries on the occurrence of depression.
P value \ 0.05 was defined as statistically significant for
the meta-analysis. All statistical analyses were conducted
using the RevMan version 5.3.5 statistical software pack-
age (Cochrane Collaboration, RevMan software, Oxford,
UK).
Results
Review results
A total of 479 studies were detected through a compre-
hensive literature search. After reviewing the titles and
abstracts, 262 duplicates and 119 irrelevant studies were
excluded, leaving 98 potentially eligible studies. Out of
these 98 references, 51 were identified through a full-text-
read as relevant by both reviewers. Finally, 16 studies met
the inclusion criteria for this review [10, 16–20, 27–36]
(Fig. 1).
The 16 studies included 7679 participants, who had been
diagnosed with breast cancer and had undergone breast
cancer surgery in the period from 1991 to 2012. Table 1
provides a summary of included studies and patients’
characteristics. The surgery type, total number of patients
and the number of identified depressive patients in each
surgery group and results (P value) in the included 16
studies are summarized in detail in Table 2. We also
extracted multivariate analysis of depression in women
coping with breast cancer from 5 [10, 16, 30, 31, 33] of the
included 16 studies in Table 3. Besides the type of surgery,
further factors related to depression in female breast cancer
patients were analyzed, including demographic and
socioeconomic factors, disease- and treatment-related fac-
tors, psychiatric history and medical comorbidity. Only 1
[10] of the 5 studies reported a statistically significant
effect of type of surgery on depression in breast cancer
patients.
Studies quality
The results of quality assessment according to the NOS are
given in Supplementary Table S5. In total, the detailed
search strategies yielded 16 cohort studies, and 100 percent
of the studies were assessed as high quality: 2 studies
[20, 34] had a NOS score of six, 5 studies
[10, 19, 27, 29, 35] had a NOS score of seven, 5 studies
[17, 28, 31–33] had a NOS score of eight and 4 studies
123

[16, 18, 30, 36] had a NOS score of nine. Furthermore,
funnel plots for the comparison of depression of women
with breast cancer following TM, BCS and BR included in
the meta-analysis did not suggest any publication bias
(Supplementary Fig. S1–S3).
Meta-analysis results
Meta-analysis of the relation between depression occur-
rences in BCS patients versus TM patients is shown in
Fig. 2. Five studies [18, 30, 32, 33, 36] with a mean time
from surgery to depression screening above 12 months
were selected to conduct the meta-analysis. The pooling
detected 5399 depressive patients with no evidence of a
statistical heterogeneity (P = 0.37, I2 = 7%). The pooled
depression occurrence rates in the selected studies were
determined as follows: 417 of 1941 (21.48%) BCS patients
and 840 of 3458 (24.29%) TM patients. Thus, the pooled
estimate suggested that there was no significant psycho-
logical benefit of conducting a BCS instead of a TM in
terms of later depression occurrence (RR = 0.89, 95% CI
0.78–1.01; P = 0.06).
Fig. 1 PRISMA flow diagram detailing the strategy adopted for the
literature search described in this article
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World J Surg
Meta-analysis of the relation between depression
occurrences in BR patients versus TM patients is shown in
Fig. 3. The numbers of total and depressive patients in BR
and TM groups were extracted from 6 [16–18, 29, 35, 36]
of the included studies and were therefore included in
pooling. Examining the effect of BR on the depression
occurrence was performed by a pooled analysis in the
remaining 6 studies. Statistical heterogeneity was not sig-
nificant by test (P = 0.15, I2 = 38%). Among all together
1578 patients, depression occurred in 109 of 642 (16.97%)
BR patients and in 214 of 936 (22.86%) TM patients. The
pooled analysis for depression occurrence, however, sug-
gested no statistical significance of BR patients versus TM
patients (RR = 0.87, 95% CI 0.71–1.06; P = 0.16).
Meta-analysis of the relation between occurrences of
depression in BCS patients versus BR patients was con-
ducted based on 3 studies [18, 19, 36] and is shown in
Fig. 4. Among the 1871 included patients, the depression
occurrence rate was 308 of 1398 (22.03%) BCS patients
versus 89 of 473 (18.81%) BR patients. Significant statis-
tical heterogeneity of depression occurrence was not
observed (P = 0.19, I2 = 39%), and thus, pooling was
performed. There was no significant psychological benefit
on depression occurrence between the two groups
(RR = 1.10, 95% CI 0.89–1.35; P = 0.37).
Discussion
Negative results and possible explanations
In opposition to a general conviction, we had seen that
overall, BCS and BR seemed not to differ in the influence
on developing depressive symptoms in breast cancer
patients at least mean time of 1 year after surgery. As BCS
and BR became more widely available, the real benefits of
these types of surgery may not be prominent in psycho-
logical, but rather in cosmetic and physical terms.
BCS is considered to be the least disfiguring; however,
esthetic outcomes vary widely, and the majority of women
report breast asymmetry after BCS [37]. Many BCS
patients require multiple excisions of their disease, as well
as radiation therapy, which can lead to poor esthetic results
[38]. Finally, providers should be aware of the effect of
breast asymmetry on psychosocial functioning and provide
early referral of BCS patients with poor esthetic outcome
for supportive counseling, breast prosthetics and recon-
structive techniques [39]. In view of possible clinical
consequences of BR, such as longer operative times,
lengthier hospitalizations, risks of complications or the
need of additional surgery, data should be available
regarding the advantages of these surgical techniques,
including the influence on depression risk [16, 39, 40].
 World J Surg

Table 1 Cohort characteristics of included studies

Study Year Country THC Total N Total depression Age, mean ± SD (range) Mean time from surgery Depression
morbidity N (%) to survey (range) screening tools

Raaff [16] 2016 The Netherlands 1999–2009 139 77 (48.20) NA More than 72 months BDI-13
Fang [27] 2014 Taiwan NA 193 NA 49.94 ± 7.84 (26–70) 19 months CES-D
Sun [28] 2014 Korea 2011/2010–2012/2005 407 NA 51.60 (28–70) 49 (24–104) months BDI
Eltahie [29] 2013 The Netherlands 2006–2010 137 7 (5.10) NA (26–78) 24.0–37.5 (5–52) after last operation HADS
Qiu [30] 2012 China 2008/2001–2009/2004 505 94 (20.19) 52.02 ± 4.55 (23–65) 17.6 (6–36) months BDI and HAMD
Dastan [31] 2011 Turkey NA 123 21 (17.07) 48.30 (24–63) 17.9 months HADS
Medeiros [19]c 2010 Brazil NA 75 25 (33.33) NA (18–65) At least 12 months BDI
Sackey [20] 2010 Sweden 1991–1999 162 NA 58.5 (44–77) 48–180 months after surgery HADS
Chen [32] 2009 USA 2002/2003–2006/2004 1400 364 (26.00) 53.7 ± 9.8 (NA) At 18 months post-diagnosis CES-D
Oudsten [10]b 2009 The Netherlands 2002/2009–2006/2009 114 32 (27.80) 58.7 ± 9.4 (NA) Pre-diagnosis, 1,3,6,12 months CES-D
Kim [33] 2008 Korea 1993–2002 1491 372 (24.9) 47.4 ± 9.3 (NA) 55 months BDI
Parker [34]a 2007 USA NA 258 68 (26.40) NA Pre-diagnosis, 1, 6,12,24 months CES-D
Rubino [35] 2007 Italy 2001/2004–2002/2004 66 9 (13.63) NA (32–64) 12 months after surgery HAMD
Harcourt [17]b 2003 UK NA 75 8 (10.66) 54.8 ± 11.35 (29–78) Pre-diagnosis, 6,12 months HADS
Rowland [18] 2000 USA 1994/2009–1995/2011 1957 491 (25.08) NA 12–60 months after BC diagnosis CES-D
Al-Ghazal [36] 2000 UK 1997/2006–1998/2010 577 42 (7.27) NA 39.5–51.2 months HADS
BC breast cancer, THC time horizon covered, BDI Beck depression index, CES-D center for epidemiologic studies depression scale, HADS hospital anxiety and depression scale, HAMD
Hamilton depression scale, NA not available, SD standard deviation
a
The depression morbidity was abstracted at pre-diagnosis
b
The depression morbidity was abstracted at 12 months after surgery
c
Have control group consisted women without breast cancer

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Table 2 Type surgery and depression morbidity of included studies
Study Type of surgery Total TM BCS BRe Outcomes
N Depression N Depression N Depression N Depression
morbidity N (%) morbidity N (%) morbidity N (%) morbidity N (%)

Raaff [16] TM, BR 139 67 (48.20) 105 54 (51.42) – – 34 13 (38.23) P = 0.18

Fang [27] TM, BCS, BR 193 NA 103 NA 54 NA 36 NA P = 0.435
Sun [28] TM, BCS, BR 407 NA 122 NA 254 NA 31 NA P = 0.520
Eltahie [29] TM, BR 137 7 (5.10) 45 3 (6.66) 92 4 (4.34) P = NS
Qiu [30] TM, BCS 505 94 (20.19) 449 85 (18.93) 56 9 (16.07) – – P = 0.6, P = 0.8*
Dastan [31] TM, BCS 123 21 (17.07) 50 NA 73 NA – – P = 0.04
Medeiros [19]c BCS, BR 75 25 (33.33) – – 25 9 (36.00) 25 4 (16.00) P = 0.126
Sackey [20] BCS, BR 162 NA – – 115 NA 47 NA P = 0.48
Chen [32] TM, BCS 1400 364 (26.00) 1320 351(26.59) 33 4 (12.12) – – P = 0.195
Oudsten [10]b TM, BCS 114 32 (27.80) NA NA NA NA – – P = 0.017, P = 0.013*
Kim [33] TM, BCS 1491 372 (24.90) 976 256 (26.22) 479 105 (21.92) – – P = 0.040
Parker [34]a TM, BCS, BR 258 68 (26.40) 45 NA 104 NA 109 NA P [ 0.1 (all)
Rubino [35] TM, BR 66 9 (13.63) 33 7 (21.21) – – 33 2 (6.06) P = 0.0047
Harcourt [17]b TM, BR 75 7 (9.33) 40 2 (5.00) – – 35 5 (14.28) P = 0.424 (pre-diagnosis)
Rowland [18] TM, BCS, BR 1957 483 (24.93) 511 128 (25.04) 1119 280 (25.02) 327 80 (24.46) P = 0.963, P = 0.719*
Al-Ghazal [36]d TM, BCS, BR 577 42 (7.27) 202 20 (9.90) 254 19 (7.48) 121 5 (4.13) P = 0.09, P \ 0.01 (age C 39)
TM total mastectomy, BCS breast conservative surgery, BR breast reconstruction, NA not available
a
The depression morbidity was abstracted at pre-diagnosis
b
The depression morbidity was abstracted at 12 months after surgical treatment
c
Have control group consisted women without breast cancer
d
The depression morbidity was obtained by authors
e
Breast reconstruction means TM with reconstruction, including immediate or delayed reconstruction, patients reconstructed with pedicled or free transverse rectus abdominis myocuta-
neous flap or Becker’s permanent expander/implant
* P value based on logistic regression
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World J Surg

Table 3 Multivariate analysis for depression of included studies

Study Independent variables in MA Different type of surgery for depression

Raaff Demographic characteristics (age, type of household, children,
[16] etc.), clinical characteristics (type of operation, medication
use, therapy, etc.)
Qiu [30] Demographic characteristics (age, marriage status, occupation
status, education, monthly income, etc.), clinical
characteristics (months after surgery, types of operation, ER
and PR status, etc.)
Chen Socio-demographic (age, education, marital status, etc.) and
[31] clinical characteristics (menopausal
symptoms, Charlson comorbidity index, ER/PR status, TNM
stage), QOL scores
Oudsten Socio-demographic characteristics (children, partner, paid work,
[10] etc.), clinical characteristics (disease stage, types of surgery,
fatigue in Time-1, etc.), basic personality factors
Kim Socio-demographic variables (age, education, monthly income,
[33] etc.) clinical variables (stage of diagnosis, therapy,
comorbidities, etc.), symptom variables (pain, dyspnea,
insomnia, etc.)
BC breast cancer, MA multivariate analysis, QOL quality of life, TM total mastectomy, BCS breast conserving surgery, BR breast reconstruction,
ER estrogen receptor, PR progesterone receptor, BMI body mass index, NS not significant
NS; BR had no clear influence on depressive symptoms on the
long term
NS (P = 0.8); unmarried/separated/divorced/widowed
(P = 0.03), past psychiatric history (P = 0.00), within
12 months after surgery (P = 0.02), recurrence (P = 0.00)
had higher risk of depression in MA
NS; low income, marital status, comorbidity and low QOL scores
were independent predictors for depression in MA
P = 0.013; BCS scored low on agreeableness, scored high on
neuroticism or reported higher scores on depressive symptoms
or fatigue before diagnosis predicted depressive symptoms
NS; socio-demographic factors, comorbidity and symptom
characteristics rather than cancer- or treatment-related were
associated with depression

Fig. 2 A forest plot that details the depression occurrences in BCS patients versus TM patients. TM total mastectomy, BCS breast conservative
surgery. Note In Al-Ghazal [36], the depression morbidity was obtained by authors

With the constant improvements of the surgical techniques
and adjuvant therapies, in the future BCS or BR could
probably induce less depression than TM.
Related factors and study limitations
Prevalence estimates for depression in breast cancer sur-
vivors vary widely as a result of inconsistency in the use of
depression screening tools, such as BDI, CES-D, HADS,
HAMD, SDS, where cutoffs for clinically significant
depression are not clearly validated in breast cancer pop-
ulations [41]. In addition, there were differences in
methodological approaches, such as the choice of com-
parators from the general population. Therefore, the ref-
erences included in our study were subject to some
methodological limitations of measurement tools and
comparative approaches.
Another key factor is the mean time from surgery to
depression screening. The depression seems to be rather
caused by the diagnosis of breast cancer itself rather than
the mutilating effect of the surgical treatment in the first
year after diagnosis [42]. Certainly, the impact of addi-
tional therapies such as chemotherapy, radiation or endo-
crine therapy is having an influence in the first year after
diagnosis breast cancer. Thus, we conducted the system
review and meta-analyses of studies with a mean time from
surgery to survey above 1-year term when patients may
have recovered from the short-term, exhausting and detri-
mental side effects of the chemotherapy and radiation
therapy [43]. A rationale for the lower bound of the time

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Fig. 3 A forest plot that details the depression occurrences in BR patients versus TM patients. TM total mastectomy, BR breast reconstruction.
Note In Harcourt [17], the depression morbidity was abstracted at 12 months after surgical treatment; In Al-Ghazal [36], the depression
morbidity was obtained by authors

Fig. 4 A forest plot that details the depression occurrences in BCS patients versus BR patients. BCS breast conservative surgery, BR breast
reconstruction. Note In Al-Ghazal [36], the depression morbidity was obtained by authors

from surgery to survey is needed, but perhaps also
important is the upper bound. After some point (e.g., post-
2 years) if there are depressive symptoms, the attribution
should not be surgery type but recurrence of major
depressive disorder. In fact, the patients with recurrence
were almost excluded in our 16 detected studies.
It is crucial to consider other factors related to depres-
sion in women coping with breast cancer, including
demographic and socioeconomic factors, disease-related
factors, psychiatric history and medical comorbidity [44].
Several studies have concluded that depressive symptoms
in female breast cancer patients were not associated with
objective cancer-related factors, but most strongly linked to
many subjective psychosocial variables [45–47]. In addi-
tion, Lam et al. [48] indicated that if the patient had
decision-making difficulty of TM versus BCS or BR before
the surgery, she would often have a higher risk of
depression in a long time after the operation. The majority
of our studies were retrospective in nature, with significant
inherent limitations. Our meta-analysis was limited by the
fact that some patients’ data had to be extrapolated from
graphs, tabulated proportions of events, possibly resulting
in some human error.
Recommendations and clinical implications
In sum, our study proved that there were no statistically
significant benefits of TM, BCS and BR in terms of
resulting depressive symptoms in breast cancer patients at
mean time more than 1-year term postoperatively.
Depression is likely underrecognized and underestimated
in many female breast cancer patients [49, 50]. Thus, it
seems recommendable that primary care clinicians and/or
leading oncologists conduct regular assessments of patients
for depression, especially in patients that are more prone to
develop a depression. Last but not least, with the constant
improvements of the surgical techniques and adjuvant
therapies in the future, we hope the BCS or BR could
probably induce less depression than TM.
Acknowledgements Grant support for the research reported: Gen-
eral Scientific Research foundation of Shanghai Mental Health Center
Grants 2017-YJ-10; Youth Fundation of Zhongshan Hospital Grants
2016ZSQZ54.

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Compliance with ethical standards
Conflict of interest The authors declare that there are no conflicts,
either perceived or real, with respect to this article.
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