Carcinoma of the breast is the most frequently diagnosed cancer in females, ranking as the second leading cause of death according to the estimates. 1 In South Asia, Pakistan has the highest number of cases and notably one in nine women have experienced this illness at some point in their lives. 2 The standard surgical treatment for breast cancer is mastectomy and breast conservation surgery. Complications arising from breast cancer treatment are currently the focus of attention. Phantom Breast Syndrome (PBS) is one of the conditions that can occur following a mastectomy. 34 The incidence reported in the literature varies, ranging from around 30% to as high as 80% of patients following mastectomy. 5 Phantom Breast Syndrome (PBS) is a condition in which patients have a sensation of having residual mammary tissue which includes both non-painful sensations as well as phantom breast pain. 6 Phantom breast pain is a painful sensory perception of an already removed breast, whereas painless phantom breast sensation is a feeling of the presence of a removed breast. 7 PBS does not receive much attention and is often overlooked. PBS might persist for years after surgery. 8 It has a significant impact on the quality of life as a result of physical disability and emotional distress. 9 As existing studies on persistent pain after breast cancer surgery are limited and there is considerable uncertainty, this study aims to determine the prevalence of phantom breast syndrome in patients following mastectomy and the impact of phantom breast syndrome on patients suffering from depression following mastectomy.

The current research is a cross-sectional questionnaire-based study. The study was conducted at Liaquat National Hospital in Karachi. All the patients with mastectomy without reconstruction who visited the Breast clinic of Liaquat National Hospital Karachi constituted the population of the study.

The sample size was calculated through Wan Nor Arifin's Sample Size Calculator (Available at https://wnarifin.github.io/ssc/ss1prop.html), considering the prevalence of PBS =22.9%10 and a margin of error of 5%. The total calculated sample size was 272.

Inclusion Criteria -All those patients who underwent mastectomy or modified radical mastectomy without reconstruction. -Only those patients who have been postoperative for 60 days and onwards.

Exclusion Criteria All those patients: -who have been postoperative for less than 60 days -who have undergone breast conservation surgery -who have a diagnosis of a preexisting muscular disorder

This study included 272 women who underwent mastectomy without breast reconstruction for breast cancer and were at least 2 months post-surgery. They were all the patients who visited the outpatient clinics of the Breast Surgery Department of Liaquat National Hospital and Medical College and were asked to take part in the study during one of their postoperative appointments. All participants provided written and informed consent for their participation. To avoid discrepancies in Phantom Breast syndrome (PBS) caused by different surgical strategies, only patients who underwent the same type of surgery-mastectomy without reconstruction-were included to ensure adequate wound healing and prevent confusion between phantom sensations and wound-related sensations in patients with less than a month postoperatively were excluded from the study. All these patients received appropriate chemotherapy, Anti Her 2, Radiation, and hormonal therapy as needed by their stage and biology of the disease. l.

A structured questionnaire adopted from a Danish study 9 (translated both into Urdu and English) was used for the assessment of the feeling of having a mastectomy-removed breast, either in its entirety or in part. A clear division was established between postoperative pain and phantom breast pain or sensations, including burning, itching, etc. Depression among those patients was assessed using the Hamilton Depression Scale. 10 The provoking and relieving factors that were asked were i. Emotional states (e.g. sadness, occasional weeping, frequent weeping, extreme symptoms) ii. Feelings of guilt (delusion and hallucination of guilt) iii. Insomnia iv. Work and interests (loss of interest, decreased productivity, absence from work) v. Retardation (slowness of thought, speech and activity, apathy, and stupor vi. Agitation vii. Anxiety. Each item on the questionnaire was scored on a 3 or 5-point scale and the total score was compared to the corresponding descriptor.

was used to analyze the data. For quantitative data, the mean and standard deviation were calculated, whereas frequency and percentage were provided for qualitative variables. Fisher's exact test and Chi-square were used to examine any associations between the qualitative variables. Odd ratios were computed using univariate binary logistic regression. P-values with less than 0.05 were regarded as significant.

There were 272 female participants in the current study with an average age of 54.43±10.46 years. Most of the females (86%) were housewives. In addition, 3.3% of the female population were from rural areas, while 96.7% were from urban areas. Of the 272 females, 137 (or 50.4%) reported having discomfort in the axilla, side of the thorax, breast, or arm on the side of the operation. Of the 137 female participants, 52.6% experienced discomfort in the breast region, 24.8% on the side of the thorax, 37.2% in the axilla, and 36.5% in the arm. The average severity of the pain was 3.66±1.92. Out of 272 females, 27.7% reported almost everyday pain, 22.6% reported pain 1-3 times a week and 49.6% reported less frequent pain.

Of the 272 females, 93 (or 34.2%) reported having discomfort or sensory abnormalities in the arm on the surgery side, the thoracic side, the breast area, or the axilla. Among the seventy-two percent of the ninetythree female patients who reported experiencing sensory disturbances or discomfort in the breast area:

19.4% on the thorax side, 40.9% in the axilla, and 24.7% in the arm had these symptoms. Each of the patients reported experiencing these symptoms in one of the four locations. According to Table 1, 7.4% of the female participants in our study reported having phantom sensations following surgery, and 64.7% reported having Phantom Breast Syndrome.

The mean Hamilton Rating Scale for Depression (HDRS) score was 7.551±4.875. Table 1 shows that out of 272 females, 43.4% had depression. Table 2 compares the items of the Hamilton Rating Scale for Depression (HDRS) in patients with and without Phantom breast syndrome. As shown in Table 3, we discovered a significant association between Phantom breast syndrome and age group (P=0.036), but not between residence (P=0.725) and depression (P=0.204).

Through univariate logistic regression, it was discovered that females under 45 have a higher likelihood of developing phantom breast syndrome compared to those over 45 (OR=2.012, P=0.038). Additionally, it was discovered that compared to females from urban regions, females from rural areas have a lower likelihood of phantom breast syndrome (OR=0.673, P=0.561).

In contrast to females without depression, those experiencing mild depression have a higher likelihood of encountering phantom breast syndrome (OR=1.250, P=0.411). Conversely, females dealing with depression have a higher likelihood of experiencing phantom breast syndrome compared to those without depression (OR=1.114, P=0.673). Detailed results of the odds are presented in Table 3.

Breast cancer survivors who underwent mastectomy often experience depressive and unmotivated feelings in their daily lives. The existence of phantom breast syndrome is an additional phenomenon that may worsen their suffering. 10 Due to the loss of their breast, each of them went through some level of mourning, and the cancer context was mentioned frequently in all their accounts of their experiences. 11 Our study aimed to find out its prevalence among post-mastectomy women and its effect on depression among them.

We found out that 64.7% of women were affected by phantom breast syndrome. Medina et al. conducted a study in which patients were observed in two different follow-up visits.

The first visit, which was done at 45 days, showed that 44.3% of the patients suffered from phantom breast syndrome (PBS). Mann-Whitney U test was applied. *Significant at 0.05 level.

However, the last follow-up, done at 2 years, indicated that only 18.2% were positive. 12 Likewise, another study in 2014 stated a very low prevalence of PBS among patients at 3 different intervals (6 weeks, 6 months, and 12 months). 13 A correlation was seen between phantom breast syndrome and depression in a study which revealed that women suffering from PBS scored higher on the depression scale, which signifies a correlation between PBS and depression. 14 Our study found 37.5% of them suffered from mild depression, whereas 5.1 were categorized as moderately depressed and only 0.7% of the patients fell under the category of severe depression. Another correlation was seen in a study in which a psychological examination was done and those women with PBS were found to have a highly distorted sense of body and diminished sexual performance as compared to those without PBS. 1516 Tasmuth et al. studied all those patients who underwent modified radical mastectomy and found out that after one year, one-fourth of them complained of phantom sensations, whereas 23% of them, along with these sensations, complained of pain as well. 17 Björkman et al. reported that women in their study found difficulty in localizing their phantom breast pain and sensations in comparison to their other body parts. 17 A case report on a post-mastectomy patient who presented 2 months postoperatively emphasized the importance of phantom breast pain and the need to get it acknowledged among physical medicine and rehabilitation physicians. 18 Here, in our study we can conclude that phantom breast syndrome is being observed significantly in post-mastectomy patients and depressive symptomatology has a correlation with phantom breast syndrome in females with mastectomy.

This is a single-center study and a multicenter study with long-term follow-up may give more insight into the change in the level of depression and phantom breast syndrome.

Females with depression have a higher likelihood of experiencing phantom breast syndrome compared to those without depression.

The study protocol was approved by the ethical review committee and research committee (0902-2023 LNH-ERC). Patient identification was kept confidential.