A paradigm shift in U.S. breast reconstruction: Part 2. The influence of changing mastectomy patterns on reconstructive rate and method

New Deep Dermal ADM Incorporates Well in Case Series of Complex Breast Reconstruction Patients

Breast cancer patients with significant comorbidities present reconstructive challenges due to a predictably high complication rate. During expander-based breast reconstruction, human acellular dermal matrix (ADM) is often used to prevent pectoralis muscle retraction, facilitate early expansion, and improve cosmetic outcome. Device infection and chronic seroma have been correlated to the addition of the graft by some large database reports but not others. This study describes the first reported experience with a new deep dermal ADM, FlexHD® Pliable™ (MTF, Edison, NJ). Sixteen breasts in 10 consecutive patients identified retrospectively and followed prospectively had immediate expander-based breast reconstruction utilizing the new ADM. Patient comorbidities were catalogued, complications were recorded, and overall reconstructive success was assessed. At implant exchange, the ADM was examined for tissue ingrowth and biopsied for histologic examination. All 16 breasts had successful reconstructions. Two breasts (12.5%) developed device infection, requiring removal and later replacement of the expander. One breast (6.7%) developed chronic seroma, also requiring expander removal and later replacement. All the complicated patients had significant comorbidities, including obesity in all 3. At expander removal, the FlexHD Pliable showed near-complete visual tissue incorporation in 14 of 16 breasts (88%). This case series demonstrates significant reconstructive success in challenging patients utilizing a novel ADM. Visual and histologic assessment of tissue ingrowth into the graft suggests the high rate of complication may be due to patient comorbidities rather than addition of ADM. Additional experience is needed to confirm and the study is ongoing.

Tissue Expander versus Tissue Expander and Latissimus Flap in Morbidly Obese Breast Reconstruction Patients

Background:

Immediate postmastectomy breast reconstruction in morbidly obese patients represents a challenge because neither prosthetic nor abdominal-based options may be suitable.

Methods:

This study compared a previously published cohort of immediate prosthetic reconstruction of 346 patients (511 breasts) of whom 49 patients (67 breasts) were morbidly obese (defined as a body mass index > 35) with a morbidly obese patient population whose breasts were reconstructed immediately following postmastectomy with latissimus flap and tissue expander (21 patients and 22 breasts) in the same time period. The preoperative risk factors of mastectomy such as tobacco use, diabetes, and prior radiation and the postoperative complications of mastectomy such as skin necrosis, seroma, and prosthesis loss were examined. The explantation of the tissue expander provided a defined endpoint of reconstruction failure.

Results:

The average body mass index in the tissue expander/implant group and in the latissimus flap plus tissue expander/implant group was 40.9 and 40.1, respectively. The risk profile of diabetes and tobacco use was similar in both groups. Fifteen of the 67 breasts (22.3%) of the tissue expander/implant group and 15 of the 23 breasts (65.2%) of the latissimus flap group had received prior radiation. The prosthesis loss was 13 of 67 breasts (19.4%) that had tissue-expander–alone reconstruction and 1 of 22 (4.8%) in the latissimus group that had tissue expander reconstruction. Modification of donor-site incision and skin-island location in the latissimus group of patients can minimize scar deformity.

Conclusion:

The loss rate in immediate postmastectomy reconstruction in morbidly obese patients with latissimus flap plus tissue expander was substantially lower than the loss rate in those with breast reconstructed with tissue expander alone.

Surgical management for early-stage bilateral breast cancer patients in China

Background

The aim of this study was to investigate the current surgical management strategy for bilateral breast cancer (BBC) patients and to assess the changes in this strategy in China.

Methods

This is a retrospective review of all patients with early-stage BBC who underwent surgical treatment at the Fudan University Shanghai Cancer Center between June 2007 and June 2014.

Results

A total of 15,337 patients with primary breast cancer were identified. Of these patients, 218 (1.5%) suffered from synchronous bilateral breast cancer (sBBC), and 296 (2.0%) suffered from metachronous bilateral breast cancer (mBBC). Patients with a lobular carcinoma component, those with estrogen receptor-positive cancer, and those with an accompanying sclerosing adenosis in the affected breast tended to develop BBC. The rates of bilateral mastectomy, breast conserving therapy, reconstruction, and combined surgeries were 86.2%, 6.4%, 3.7%, and 3.7%, respectively, for patients with sBBC and 81.1%, 4.4%, 3.0%, and 11.5%, respectively, for patients with mBBC. The interval between bilateral cancers, age at first diagnosis of breast cancer, histopathological type, and stage have significant impacts on the choice of surgery for patients with BBC.

Conclusions

Bilateral mastectomy was the dominant surgical management for patients with BBC in China, despite the increased application of breast reconstruction surgery observed in recent years. Bilateral prosthetic breast reconstruction was the ideal choice for patients with sBBC. Chinese surgeons should take responsibility for patient education and inform their patients about their surgical options.

Early Surgical Site Infection Following Tissue Expander Breast Reconstruction with or without Acellular Dermal Matrix: National Benchmarking Using National Surgical Quality Improvement Program

Background

Surgical site infections (SSIs) result in significant patient morbidity following immediate tissue expander breast reconstruction (ITEBR). This study determined a single institution's 30-day SSI rate and benchmarked it against that among national institutions participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

Methods

Women who underwent ITEBR with/without acellular dermal matrix (ADM) were identified using the ACS-NSQIP database between 2005 and 2011. Patient characteristics associated with the 30-day SSI rate were determined, and differences in rates between our institution and the national database were assessed.

Results

12,163 patients underwent ITEBR, including 263 at our institution. SSIs occurred in 416 (3.4%) patients nationwide excluding our institution, with lower rates observed at our institution (1.9%). Nationwide, SSIs were significantly more common in ITEBR patients with ADM (4.5%) compared to non-ADM patients (3.2%, P=0.005), and this trend was observed at our institution (2.1% vs. 1.6%, P=1.00). A multivariable analysis of all institutions identified age ≥50 years (odds ratio [OR], 1.4; confidence interval [CI], 1.1-1.7), body mass index ≥30 kg/m² vs. <25 kg/m² (OR, 3.4; CI, 2.6-4.5), and operative time >4.25 hours (OR, 1.9; CI, 1.5-2.4) as risk factors for SSIs. Our institutional SSI rate was lower than the nationwide rate (OR, 0.4; CI, 0.2-1.1), although this difference was not statistically significant (P=0.07).

Conclusions

The 30-day SSI rate at our institution in patients who underwent ITEBR was lower than the nation. SSIs occurred more frequently in procedures involving ADM both nationally and at our institution.

Assessing Outcomes and Safety of Inpatient Versus Outpatient Tissue Expander Immediate Breast Reconstruction

BACKGROUND

With the rising cost of healthcare delivery and bundled payments for episodes of care, there has been impetus to minimize hospitalization and increase utilization of outpatient surgery mechanisms. Given the increase in outpatient mastectomy and immediate tissue expander (TE)-based reconstruction and the paucity of data on its comparative safety to inpatient procedures, we sought to understand the risk for early postoperative complications in an outpatient model compared with more traditional inpatient status using the National Surgical Quality Improvement Program database.

METHODS

NSQIP data files from 2005 to 2012 were queried to identify patients undergoing immediate TE-based breast reconstruction after mastectomy. Patients were stratified by whether they received outpatient or inpatient care and then propensity score matched based on preoperative baseline characteristics to produce matched cohorts. Multivariate regression analysis was used to determine whether outpatient versus inpatient status conferred differing risk for 30-days complications.

RESULTS

Of the 2014 patients who met criteria, 1:1 propensity matching yielded 634 patients in each of the matched cohorts. Overall complications (5.2 vs. 5.4 %), overall surgical complications (4.3 vs. 3.9 %), overall medical complications (1.3 vs. 2.1 %), and return to the operating room (6.6 vs. 7.3 %) were similar between outpatient and inpatients cohorts (p > .2), respectively. There was a small, but significant increased risk of organ/space SSI in outpatients (1.9 vs. 0.5 %, p = .02) and trend for increased risk for pulmonary embolus (PE) and urinary tract infection (UTI) in inpatients (0.3 vs. 0 %, p = .16; 0.3 vs. 0 %, p = .16).

CONCLUSIONS

Our studies suggest that outpatient TE confers similar safety profiles to inpatient TE with regards to 30-day postoperative overall complications, medical and surgical morbidity, and return to the operating room. A slightly increased risk for surgical site infection must be balanced against potential risk for known inpatient-related complications such as UTI and PE.

Immediate Reconstruction of the Radiated Breast: Recent Trends Contrary to Traditional Standards

BACKGROUND

Immediate, implant-only breast reconstruction is traditionally discouraged in patients who receive radiation. It is not clear whether this widely recognized mantra of breast reconstruction is observed in practice. The purpose of this study was to evaluate immediate reconstruction trends and practices in patients who have undergone mastectomy and radiation therapy.

METHODS

Female patients with unilateral breast cancer who required radiation in addition to mastectomy were extracted from the Surveillance, Epidemiology, and End Results (SEER) database from 2000 through 2010. Patients who underwent immediate reconstruction were identified and analyzed. Univariate and logistic regression analyses were performed to study the relationship between reconstructive method and patient demographic and oncologic characteristics.

RESULTS

A total of 5,481 female patients who underwent radiation and breast reconstruction were included for analysis. Postmastectomy radiation therapy was performed in 98.3 % of the patients. The immediate breast reconstruction rate among patients requiring radiation increased from 13.6 to 25.1 %. The percentage of reconstructed patients who had implant-only reconstruction increased from 27 to 52 % (p < 0.001) with a decrease in tissue-only reconstruction from 56 to 32 % (p < 0.001). In regression analysis, the odds of implant reconstruction over autologous reconstruction increased each year by an odds ratio of 1.13 (95 % CI 1.10-1.15).

CONCLUSIONS

The frequency of immediate reconstruction continues to increase in the setting of postmastectomy radiation therapy, with immediate implant-based reconstruction representing the most commonly utilized method, contrary to traditional recommendations. These findings likely reflect changing attitudes towards implant reconstruction in the setting of planned postmastectomy radiation.

Predictors of contralateral prophylactic mastectomy and the impact on breast reconstruction

BACKGROUND

Contralateral prophylactic mastectomy (CPM) is being performed with increased frequency. Predictors of CPM and their impact on breast reconstruction are examined.

METHODS

A retrospective review of a dually trained oncologic and plastic surgeon's experience with patients undergoing total mastectomy from 2002 to 2012 was performed. Patients who underwent bilateral therapeutic mastectomies or who had previous contralateral mastectomy were excluded from this series.

RESULTS

Four hundred forty-six patients were treated with total mastectomy and 174 (39%) underwent CPM. The incidence of CPM nearly tripled over the period studied. Compared to women treated with unilateral mastectomy, women who elected for CPM were younger (mean age, 50.4 vs 56.8 years, P < 0.001), leaner (mean body mass index, 26.1 vs 27.4 kg/m2, P = 0.036), more often white (86.8% vs 73.8%, P = 0.004), and more often had a family history of breast cancer (52% vs 33.3%, P < 0.001). The CPM group was also more likely to have undergone a preoperative magnetic resonance imaging (56.3% vs 39%, P < 0.001) and to have stage I disease (31% vs 22.8%, P = 0.053). They were less likely to have undergone prior attempts at breast conservation (6.9% vs 15.8%, P = 0.004) and considerably more likely to pursue breast reconstruction (83.9% vs 63.6%, P < 0.001). Multivariate analysis confirmed age, white race, family history, prior attempt at breast conservation, and receipt of breast reconstruction to be independently associated with prophylactic mastectomy. Incidental contralateral cancers were discovered in 4% of women who underwent CPM (n = 7), lobular carcinoma in situ in 2.3% (n = 4), and atypical lesions in an additional 11.6% (n = 20). Women who underwent CPM favored reconstruction with breast implants (60.9% vs 17.3%), whereas the transverse rectus abdominis musculocutaneous flap predominated among their unilateral counterparts (38.6% vs 15.5%). Among women who underwent immediate breast reconstruction, the addition of a contralateral procedure expectedly increased breast complication rates (50.3% vs 35.0%, P = 0.007), especially the more severe complications that required hospitalization or reoperation (18.6% vs 5.0%, P < 0.001).

CONCLUSIONS

The incidence of CPM is increasing and is associated with younger age, white race, family history, and the use of breast reconstruction. Implant-based reconstructions predominate in this cohort. The added morbidity of a contralateral procedure is significant.

Doing More: Trends in Breast Cancer Surgery, 2005 to 2011

An increasing number of women may be choosing mastectomy over breast-conserving surgery for breast cancer as well as undergoing more bilateral resection, immediate reconstruction, and prophylactic operations. Women who had breast cancer operations between 2005 and 2011 were selected from the National Surgical Quality Improvement Program database. Annual trends were explored using robust Poisson multivariable regression as were predictors for mastectomy versus breast-conserving surgery. A total of 85,401 women were identified. Mastectomy increased from 2005 to 2011, starting at 40 per cent in 2005 and peaking at 51 per cent in 2008 ( P < 0.001). Bilateral resection, immediate reconstruction, and prophylactic mastectomy also increased (all P < 0.001). Independent predictors of mastectomy included young age, Asian race, invasive cancer (vs carcinoma in situ), bilateral resection, axillary dissection, higher American Society of Anesthesiologists class, and lower body mass index (all P < 0.001). There was an increase in mastectomy, bilateral resection, immediate reconstruction, and prophylactic mastectomy from 2005 to 2011.

Diminishing relative contraindications for immediate breast reconstruction

BACKGROUND

The rise in U.S. immediate breast reconstruction over the past decade may reflect greater patient awareness or expanding use in women not previously offered reconstruction. The purpose of the current study was to determine whether reconstruction in high-risk surgical and oncologic patients was a factor contributing to increased reconstruction rates, specifically using prosthetic techniques.

METHODS

Information from a cohort of mastectomy patients from 2001 to 2012 was extracted from an institutional database, including the presence of high-risk surgical or oncologic features (age over 60 years old, body mass index greater than 30, comorbidities, smoking, advanced disease, and prior or postmastectomy radiotherapy). Trends in reconstruction rates and method were analyzed with Poisson regression. Reconstructive success was defined as tissue expander exchange to a permanent implant or autologous techniques without vascular complications.

RESULTS

A total of 10,299 patients were included. Immediate reconstruction in high-risk patients increased from 45.0 to 70.7 of 100 mastectomies (p < 0.01). Although autologous use increased only for obese patients (p < 0.01), prosthetic techniques were greater for all high-risk features (p < 0.01). Reconstructive success was 88 percent in high-risk patients; however, the number of failures was greater, including tissue expander loss, implant explantation, and flap vascular complications.

CONCLUSIONS

The proportion of high-risk patients undergoing immediate breast reconstruction-specifically using prosthetic-based techniques-increased over the study period. Increased complications may be a tradeoff for the benefits of reconstruction. These findings support diminishing relative contraindications for immediate breast reconstruction at a tertiary cancer center.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, IV.

Wound healing complications after autologous breast reconstruction: a model to predict risk

INTRODUCTION

Delayed wound healing is costly to the breast reconstruction patient and the health care infrastructure. The purpose of this study is to identify potentially modifiable risk factors and to create a model to assess patient risk of these complications.

METHODS

We performed a retrospective study of all free autologous reconstructions at a single institution (2005-2011). Patients with delayed wound healing (operative wounds requiring dressing changes for longer than 3 weeks) were compared to patients with normal healing with respect to history and case characteristics. A risk model was developed to stratify patients based on the multivariate logistic regression results.

RESULTS

Delayed wound healing impacted 297 (44%) of 682 patients. These patients were older (p = 0.02), with higher BMI(p < 0.0001), and higher rates of medical comorbidities (p < 0.001), active smoking (p = 0.02) and bilateral reconstruction (p = 0.02). They received a lower rate/kg of fluid resuscitation intraoperatively (p = 0.001) and more commonly received vasopressors (p = 0.004), with a greater total reconstructive cost (p = 0.003). A regression demonstrated that progressive obesity, smoking, bilateral reconstruction, and utilization of vasopressors were associated with delayed healing (p < 0.05). The final model, with three risk groups (low, intermediate and high) demonstrated that high risk patients have an 86% risk of wound healing complications, compared to a 33% risk in patients with few risk factors.

CONCLUSIONS

While patient disease remains a major predictor of wound complications, potentially modifiable variables including smoking and vasopressor administration impacted this complication. Utilizing the simple model to preoperatively assess patient risk, targeted measures can be undertaken with the goal of ultimately reducing wound healing complications and cost.

Mastectomy with or without immediate implant reconstruction has similar 30-day perioperative outcomes

BACKGROUND

Immediate breast reconstruction (IBR) using implants remains a favorable reconstructive option in breast cancer. Understanding the added risk associated with IBR continues to enhance the risk counseling process and management of these patients.

METHODS

Women undergoing mastectomy alone and mastectomy with tissue expander (TE) were identified in the ACS-NSQIP datasets. Specific complications examined included any, wound, medical complications, and deep infections. Bivariate and multivariate analyses were performed to identify predictors of outcomes, and propensity-matching was used to compare cohorts.

RESULTS

A total of 42,823 patients who underwent either mastectomy alone (N = 30,440) or mastectomy with immediate TE placement (N = 12,383) were identified. Notable independently associated perioperative differences between mastectomy and TE patients included: race (P < 0.001), comorbidity burden (P < 0.001), year of surgery (P < 0.001), ASA physical status (P < 0.001), functional status (P < 0.001), inpatient procedures (P < 0.001), bilateral procedures (P < 0.001), BMI (P < 0.001), age (P < 0.001), and lymphadenectomy (P < 0.001). IBR using TE was not found to be associated with greater risk of wound (3.3% vs. 3.2%, P = 0.855), medical (1.7% vs. 1.6%, P = 0.751), or overall (9.6% vs. 10.0%, P = 0.430) complications. TE placement was associated with higher rates of deep wound infections (2.0% vs. 1.0%, P < 0.001) and unplanned reoperations (6.9% vs. 6.1%, P = 0.025). Additionally, the rate of 30-day device loss was 0.8% in patients receiving reconstruction. Multivariate conditional (fixed-effects) logistic regression analysis failed to demonstrate significantly associated independent risk of wound, medical, or overall complications with the addition of TE.

CONCLUSIONS

Undergoing IBR with TE placement does not confer added risk of wound, medical, or overall morbidity relative to mastectomy alone based upon propensity-matched 30-day complication rates in 15,238 patients from the 2005-2011 ACS-NSQIP datasets. These findings further confirm the safety profile of prosthetic-based IBR.

LEVEL OF EVIDENCE

Prognostic/risk category, level II.

Breast reconstruction after mastectomy among Department of Defense beneficiaries by race

BACKGROUND

Postmastectomy breast reconstruction increased approximately 20% between 1998 and 2008 in the United States and has been found to improve body image, self-esteem, and quality of life. These procedures, however, tend to be less common among minority women, which may be due to variations in health care access. The Department of Defense provides equal health care access, thereby affording an exceptional environment in which to assess whether racial variations persist when access to care is equal.

METHODS

Linked Department of Defense cancer registry and medical claims data were used. The receipt of reconstruction was compared between white women (n = 2974) and black women (n = 708) who underwent mastectomies to treat incident histologically confirmed breast cancer diagnosed from 1998 through 2007.

RESULTS

During the study period, postmastectomy reconstruction increased among both black (27.3% to 40.0%) and white (21.8% to 40.6%) female patients with breast cancer. Receipt of reconstruction did not vary significantly by race (odds ratio, 0.93; 95% confidence interval, 0.76-1.15). Reconstruction decreased significantly with increasing age, tumor stage, and receipt of radiotherapy and was significantly more common in more recent years and among active service women, TRICARE Prime (health maintenance organization) beneficiaries, and women whose sponsor was an officer.

CONCLUSIONS

The receipt of breast reconstruction did not vary by race within this equal-access health system, indicating that the racial disparities reported in previous studies may have been due in part to variations in access to health care. Additional research to determine why a large percentage of patients with breast cancer do not undergo reconstruction might be beneficial, particularly because these procedures have been associated with noncosmetic benefits.

Diminishing relative contraindications for immediate breast reconstruction: a multicenter study

BACKGROUND

During the past decade, there has been a rise in US breast reconstruction rates, with a greater expansion in prosthetic-based techniques relative to autologous transfer. Immediate reconstruction in high-risk oncologic and surgical patients might be a contributing factor to these trends.

STUDY DESIGN

The National Cancer Data Base from the American College of Surgeons and the American Cancer Society was used to identify a breast cancer cohort (1998 to 2011) treated with mastectomy. The patients were divided into high risk and low risk based on presence or absence of historic surgical or oncologic relative contraindications. Reconstructions were categorized as either autologous or implants. To understand trends for each high-risk characteristic, rates were adjusted by 1,000 total mastectomies performed for patients within each specific group and analyzed with Poisson regression.

RESULTS

Information from 1,040,088 patients with mastectomy was included. Rates of high-risk features did not change from 1998 to 2011. The increase in immediate reconstruction rates was greater for high-risk than low-risk patients (incidence rate ratio = 1.09 vs 1.06; p < 0.05 for both). There was a greater rate increase in implant than autologous reconstructions for both high-risk and low-risk groups. For high-risk patients, implant use increased for all features, but with the greatest change for elderly, comorbidities, and post-mastectomy radiotherapy (p < 0.01). For high-risk patients, autologous tissue use increased significantly for all features except pre-mastectomy radiotherapy.

CONCLUSIONS

Breast reconstruction increased in high-risk surgical and oncologic patients, suggestive of a diminishing set of relative contraindications. Increased implant use in high-risk patients might be a contributing factor toward the preferential national expansion of prosthetic techniques.

Impact of breast reconstruction on the decision to undergo contralateral prophylactic mastectomy

BACKGROUND

In the last decade, there has been increasing use of contralateral prophylactic mastectomy (CPM) in patients with unilateral breast cancer and ductal carcinoma-in-situ (DCIS) undergoing mastectomy. Although many factors have been proposed to explain this trend, the impact of breast reconstruction on CPM has not been studied.

METHODS

A retrospective review of patients with unilateral invasive breast cancer or DCIS from Surveillance, Epidemiology, and End Results registry data (2004-2008) was conducted. Characteristics of patients undergoing CPM and reconstruction were evaluated.

RESULTS

A total of 102,674 patients diagnosed with DCIS or stage I to III infiltrating breast cancer underwent mastectomy for their primary lesion. Of these, 16,197 patients (16 %) underwent a CPM. A significantly higher proportion of women undergoing CPM had reconstruction performed (46 %) than those patients not undergoing CPM (15 %) (p < 0.001). Of the 20,760 patients (20 %) who underwent reconstruction, 7410 (36 %) had implant reconstruction, 7705 (37 %) tissue reconstruction, and 1941 (9 %) combined tissue/implant reconstruction; there were no data for 3,702 (18 %). There was an increasing trend of patients undergoing reconstruction from 2004 (n = 3390, 16.3 %) to 2008 (n = 5406, 26 %) (p < 0.001). On multivariable analysis, significant variables predicting CPM included age <45 years, stage I disease (odds ratio [OR] 1.44, 95 % confidence interval [CI] 1.35-1.54), lobular histology (OR 1.15, 95 % CI 1.11-1.20), and undergoing breast reconstruction (OR 3.58, 95 % CI 3.41-3.75).

CONCLUSIONS

Besides age, undergoing reconstructive surgery is the factor most strongly associated with CPM. This suggests that apart from risk reduction, the availability of and/or patient willingness to undergo breast reconstruction may influence the decision to undergo CPM.

Long-term follow-up of changing practice patterns in breast reconstruction due to increased use of tissue expanders and perforator flaps

BACKGROUND

As the science of breast reconstruction evolves, significant changes in reconstruction strategies and outcomes are expected. The purpose of this study is to determine the changes in breast reconstruction trends and outcomes that occurred at a multidisciplinary academic institution during the last decade.

METHODS

We compared 265 patients over two distinct 6-month intervals separated by 5 years (2002 vs. 2007) and performed long-term follow-up (4.75 ± 3.38 years 2002, 2.99 ± 2.25 years 2007). We studied patients seeking prophylactic mastectomy, patients with early breast cancer, and patients with locally advanced disease. We analyzed demographic data, breast cancer history and treatment, type and timing of reconstruction, and complications.

RESULTS

Implant to flap reconstruction ratio was 48:49 in 2002 and 76:102 in 2007. Use of transverse rectus abdominis myocutaneous flap declined from 57 to 4%; conversely, deep inferior epigastric perforator flap increased from 27 to 91% (P < 0.001). Correspondingly, donor site chronic pain (4 vs. 0, P = 0.012) and postoperative abdominal wall bulge (9 vs. 3, P = 0.004) rates decreased. Timing of reconstruction showed increased staged cases in 2007 compared to 2002 (P = 0.045). Post-final reconstruction radiation therapy was reduced in 2007 (P = 0.016), with subsequent lower rates of implant rupture (P < 0.001).

CONCLUSIONS

At our institution and over the last decade, increasing staged reconstructions have successfully reduced the rates of post-final reconstruction radiotherapy with optimized outcomes. Contrary to national trends, the rates of autologous flap reconstructions have increased with reduced donor site morbidity. This suggests that academic breast reconstruction trends are independent from national trends.

Cost-effectiveness of contralateral prophylactic mastectomy for prevention of contralateral breast cancer

BACKGROUND

A growing number of women with sporadic unilateral, early-stage breast cancers are undergoing ipsilateral therapeutic mastectomy with contralateral prophylactic mastectomy (CPM) to prevent the development of new cancers in the contralateral breast.

METHODS

A decision-tree using TreeAge Pro 2012 software was used to model the costs and effects of CPM versus unilateral mastectomy (UM) in women younger than 50 years of age with sporadic unilateral, early stage breast cancers. Cost estimates were obtained from the Medicare Fee Schedule and the Healthcare Utilization Project. Probability estimates were obtained from the literature. Outcome effects were measured by incremental cost per quality-adjusted life year (QALY) gained. A 10-year risk period for contralateral breast cancer (CBC), a lifetime time horizon, and a societal perspective were used.

RESULTS

Treatment with CPM results in 0.2 QALYs less than UM and $279 less in costs during a 10-year risk period and lifetime follow-up. The resulting incremental cost effectiveness ratio (ICER) is a savings of $1397 per QALY lost. The ICER is sensitive to the rate and method of postmastectomy reconstruction and the cost of radiologic surveillance after UM.

CONCLUSIONS

CPM is cost-saving for the prevention of CBC in women younger than 50 years of age with sporadic, unilateral, early-stage breast cancers, but also reduces resulting health. The savings for health lost are insufficient to be considered cost-effective at this time.

Patient-centred decision making in breast reconstruction utilising the delayed-immediate algorithm

Delayed-immediate reconstruction is an increasingly valuable algorithm for patients anticipating post-mastectomy radiation therapy. Despite the cosmetic and long-term advantages of autologous tissue repair, a subset of patients choose implant-based reconstruction after their initial preference for autologous reconstruction. A critical evaluation of patients who initially planned to undergo delayed-immediate reconstruction but later chose to continue with implant-based reconstruction has not been previously reported. A retrospective analysis of the senior author's (M.Y.N.) patients who initially intended to undergo delayed-immediate autologous breast reconstruction following mastectomy and chose to abandon autologous reconstruction in favour of prosthetic reconstruction was completed from 2005 to 2011. Seven patients (10 breasts) met inclusion criteria. The mean patient age and body mass index were 50.2 years and 32.1 kg m(-2), respectively. Expansion required an average of 4.4 office visits to achieve adequate expansion volume, mean 483 ml (240-600 ml). The mean time from expander placement to definitive reconstruction was 14.6 months. Mean follow-up time was 20.4 months. Complications included infection (1/7), incisional dehiscence (1/7) and capsular contracture (2/7), and late revision surgery was performed in two patients. Successful reconstruction was achieved in 100% of patients (7/7) with a patient-reported satisfaction of 100%. Patient motivations for changing the reconstructive algorithm included a faster post-operative recovery in four patients (4/7) and potential donor-site morbidity in three patients (3/7). Depression or cancer-related fatigue symptoms were self-reported in 4/7. Avoiding donor-site morbidity and a simpler recovery are the main factors that influence patients to change their desire for autologous reconstruction to an implant-based reconstruction. Cancer-related fatigue and depression are prevalent in this population and may be implicated in a patient's desire to undergo less extensive reconstructive surgery. Allowing for the choice of definitive implant-based reconstruction in select patients is safe and is likely to result in high patient satisfaction with satisfactory aesthetic outcomes.