Immediate versus delayed reconstruction following surgery for breast cancer

A systematic review of randomised controlled trials in breast reconstruction

BACKGROUND

For preference sensitive treatments, such as breast reconstructions, there are barriers to conducting randomised controlled trials (RCTs). The primary aims of this systematic review were to investigate what type of research questions are explored by RCTs in breast reconstruction, where have they been performed and where have they been published, and to thematise the research questions and thus create an overview of the state of the research field.

METHODS

Randomised controlled trials investigating any aspect of breast reconstructions were included. The PubMed database was searched with a pre-defined search string. Inclusion and data abstraction was performed in a pre-defined standardised fashion. For the purpose of this study, we defined key issues as comparison of categories of breast reconstruction and comparison of immediate and delayed breast reconstruction, when the thematisation was done.

RESULTS

A total of 419 abstracts were retrieved from the search. Of the 419, 310 were excluded as they were not RCTs concerning some aspect of breast reconstruction, which left us with 110 abstracts to be included in the study. The research questions of the included studies could more or less be divided into seven different themes inclusive of 2 key issues: Other issues - comparison of different categories of breast reconstruction, comparison of immediate and delayed breast reconstruction, surgical details within a category of breast reconstruction, surgical details valid for several categories of breast reconstruction, donor site management, anaesthetics, and non-surgical details. Only five studies compared key issues, and they all illustrate the challenges with RCTs in breast reconstruction.

CONCLUSIONS

A total of 110 publications based on RCTs in breast reconstruction have been published. Seven themes of research questions could be identified. Only five studies have explored the key issues. Better scientific evidence is needed for the key issues in breast reconstruction, for example by implementing a new study design in the field.

What affects women's decision-making on breast reconstruction after mastectomy for breast cancer?

PURPOSE

To establish the breast reconstruction rate in a large Dutch teaching hospital, and to gain insight into the motives of women to opt for or reject post-mastectomy breast reconstruction.

METHODS

In a retrospective, cross-sectional study, all consecutive patients who underwent mastectomy for invasive breast cancer or ductal carcinoma in situ (DCIS) were identified and categorized into two groups based on subsequent breast reconstruction or not. Patient-reported outcomes were assessed with the validated Breast-Q and a short survey about the decision-making process in breast reconstruction. These outcomes were compared between the two groups using univariable analyses, multivariable logistic regression, and multiple linear regression analyses. The Breast-Q scores were also compared to Dutch normative values.

RESULTS

A total of 319 patients were identified of whom 68% had no breast reconstruction. Of the 102 patients with breast reconstruction, the majority (93%) received immediate, instead of delayed breast reconstruction. The survey was completed by 155 (49%) patients. The non-reconstruction group, on average, reported significantly poorer psychosocial well-being, compared to the reconstruction group as well as compared to the normative data. However, the majority of the non-reconstruction group (83%) stated that they had no desire for breast reconstruction. In both groups, most patients stated that the provided information was sufficient.

CONCLUSION

Patients have personal motives to opt for or reject breast reconstruction. It seemed that patients differ in their rating of values that affect their decision since the same arguments were used to opt for or reject reconstruction. Notably, patients were well-informed in their decision making.

The effect of implant loss after immediate breast reconstruction on patient satisfaction with outcome and quality of life after five years - a case-control study

Several advantages have been suggested for immediate breast reconstruction (IBR); however, there is little scientific high-quality evidence confirming those advantages. Disadvantages of IBR, compared to delayed breast reconstruction (DBR), include an increased risk for complications, such as implant loss (prevalence 5-10% vs. 1%). Little is known on how women experience implant loss and how it affects patients' long-term satisfaction and quality of life (QoL). The primary aim of our study was to compare patient satisfaction and QoL of women with implant loss after IBR, with that of women with a successful IBR. Breast-Q, Body Esteem Scale for Adults and Adolescents (BESAA) and Hospital Anxiety and Depression Scale (HADS) were sent to women who had experienced implant loss during the last 10 years. Women of a similar age who were reconstructed, without complications, during the same period were controls. The results suggest that there might be a more permanent negative effect on satisfaction and QoL following implant loss. The proportion of possible cases of depression was higher among patients who had experienced implant loss. The findings could indicate that in patients with an elevated risk for implant loss, the possible benefits with IBR should be carefully balanced against the effects of implant loss.

Priority setting in breast reconstructive surgery: A DELPHI consensus

OBJECTIVES

Breast reconstructive surgery is often performed following breast cancer treatment to restore the natural appearance of the breast. Despite various research performed in this field, there is a discrepancy between the research question that is considered crucial jointly by patients, carers and healthcare professionals and the research performed. The Breast Reconstruction Priority Setting Partnership was formed to determine the top research priorities in all aspects of breast reconstructive surgery.

METHODS

The Priority Setting Partnership (PSP) was conducted in line with James Lind Alliance (JLA) principles involving patients and clinicians. An online survey was conducted to gather uncertainties related to breast reconstruction by involving patients, carers and clinicians. Following this, a modified Delphi consensus process was performed to identify the top 10 research priorities.

RESULT

A total of 239 unique research uncertainties were identified via the online survey, which involved 100 participants. A review of literature established that 58 of these uncertainties did not have a high-quality systematic review, prompting the need for more in-depth research. A further 28 research uncertainties were obtained by performing a literature search. Of the final 86 unique questions, the Delphi panel achieved consensus on the top ten research priorities. Recommendations to address these research priorities have been put forward based on current evidence.

CONCLUSION

This study involved patients, carers and healthcare professionals to establish the top 10 priority areas for research in breast reconstructive surgery. Recommendations have been put forward on the necessary future research that is required to address these uncertainties.

Breast conservation surgery & oncoplasty in India - Current scenario

Breast cancer incidence is on the rise in India as in rest of the world. While the advances in overall cancer care are at par, the surgical interventions have not been changing at the same pace in India, as in the rest of the developed world. Partly, this is due to the relatively more advanced state of cancer at detection and partly due to lack of awareness resulting in apprehension and slow acceptance of de-escalation of surgical interventions by the treating surgeons, and the beneficiaries, the patients. The article looks at the current scenario, available evidence on the practices and pitfalls with possible solutions for advancing surgical care of breast cancer in India.

Are There Disparities in Surgical Treatment for Breast Cancer Patients with Prior Physical Disability A Path Analysis

Introduction

Cancer care for patients with prior physical disability has hardly been researched in clinical research, health services research, or special education. This article aims to compare the severity of disease and the surgical treatment of diagnosed breast cancer patients with and without prior physical disability.

Methods

A total of 4,194 patients with primary breast cancer who underwent surgery in a breast cancer center in North Rhine-Westphalia, Germany, participated in an annual postoperative postal survey, which was complemented by clinical data. Latent class analysis and logit path models were applied to study (1) differences in terms of UICC staging and local cancer treatment between patients with and without prior physical disability and (2) respective differences by disability severity.

Results

Patients with physical disability (n = 780; 18.7%) had a higher chance of receiving mastectomy compared to breast-conserving therapy, even after controlling for socioeconomic status and UICC staging. Disability severity is directly and indirectly associated with receiving a mastectomy.

Conclusion

In light of the research gap on disability and cancer, this work indicates disparities in care for breast cancer patients with prior physical disability. Inequalities might be attributable to (1) unequal access to care, (2) individual preferences and difficulties, or (3) medical difficulties.

Immediate versus secondary DIEP flap breast reconstruction: a multicenter outcome study

PURPOSE

Immediate breast reconstruction (IBR) at the time of mastectomy is gaining popularity, as studies show no negative impact on recurrence or patient survival, but better aesthetic outcome, less psychological distress and lower treatment costs. Using the largest database available in Europe, the presented study compared outcomes and complications of IBR vs. delayed breast reconstruction (DBR).

METHODS

3926 female patients underwent 4577 free DIEP-flap breast reconstructions after malignancies in 22 different German breast cancer centers. The cases were divided into two groups according to the time of reconstruction: an IBR and a DBR group. Surgical complications were accounted for and the groups were then compared.

RESULTS

Overall, the rate of partial-(1.0 versus 1.2 percent of cases; p = 0.706) and total flap loss (2.3 versus 1.9 percent of cases; p = 0.516) showed no significant difference between the groups. The rate of revision surgery was slightly, but significantly lower in the IBR group (7.7 versus 9.8 percent; p = 0.039). Postoperative mobilization was commenced significantly earlier in the IBR group (mobilization on postoperative day 1: 82.1 versus 68.7 percent; p < 0.001), and concordantly the mean length of hospital stay was significantly shorter (7.3 (SD3.7) versus 8.9 (SD13.0) days; p < 0.001).

CONCLUSION

IBR is feasible and cannot be considered a risk factor for complications or flap outcome. Our results support the current trend towards an increasing number of IBR. Especially in times of economic pressure in health care, the importance of a decrease of hospitalization cannot be overemphasized.

Informational Needs in Patients With Breast Cancer With Lymphedema: Is It Important?

Introduction

Lymphedema is one of the complications of breast cancer treatment. It has no cure yet and can affect the quality of life. This study aimed to identify and investigate informational needs, preferred delivery methods, and time of receiving information about lymphedema for these patients.

Methods

One hundred participants were recruited through Lymphedema Clinic in Motamed Cancer Institute in Tehran, Iran, through convenience sampling and were asked to complete a self-administered survey. Data collection took place on all opening days between October 2018 and mid-March 2019.

Results

Most of the participants were above 40 years, have a diploma, homemaker, and the average income of most of the participants (57.2%) was low. The importance of having lymphedema information was very high for them. Most of them wanted detailed information at diagnosis of breast cancer. The preferred information of delivery methods were private sessions and social networks.

Conclusions

Patients with breast cancer who have lymphedema have high needs as regards concise lymphedema information. Private sessions with physicians and social networks can provide detailed information for them.

Surgery for BRCA, TP53 and PALB2: a literature review

Introduction

The presence of a deleterious mutation, most commonly a BRCA mutation, has a tremendous impact on the management of breast cancer. We review the surgical management of BRCA mutation carriers, and two other potentially high-risk mutations, TP53 and PALB2.

Methodology

A search was done on PubMed, limited to reviews and the English language only. The search terms used were ‘BRCA’ or ‘PALB2’ or ‘TP53’ and ‘surgery’. Fifteen articles were identified by searching and one article was obtained from other sources.

Results

Breast-conserving surgery has equivalent survival, but may have an increased risk of local recurrence, compared to mastectomy among BRCA mutation carriers. Contralateral prophylactic mastectomy may not improve overall survival, despite reducing the risk of developing contralateral breast cancer. The use of preoperative genetic testing allows patients to have combined curative and prophylactic surgery. However, preoperative genetic testing may influence patients to make rash decisions. In healthy BRCA mutation carriers, bilateral prophylactic mastectomy is done to prevent breast cancer from occurring. Bilateral prophylactic mastectomy is highly effective in reducing the risk of breast cancer in healthy BRCA mutation-positive women and may have a survival benefit. Prophylactic oophorectomy reduces the risk of ovarian cancer, but may not have an effect on the risk of breast cancer. There is a lack of studies on surgery for non-BRCA mutations. TP53 and PALB2 are potentially high-risk mutations for breast cancer, which may justify the use of prophylactic surgery. Advice should be given on a case-by-case basis.

Conclusion

A comprehensive approach is needed to provide optimum treatment for breast cancer patients with deleterious mutations.

Risk of recurrence and death in patients with breast cancer after delayed deep inferior epigastric perforator flap reconstruction

Background

Postmastectomy reconstruction using a deep inferior epigastric perforator (DIEP) flap is increasingly being performed in patients with breast cancer. The procedure induces extensive tissue trauma, and it has been hypothesized that the release of growth factors, angiogenic agonists and immunomodulating factors may reactivate dormant micrometastasis. The aim of the present study was to estimate the risk of breast cancer recurrence in patients undergoing DIEP flap reconstruction compared with that in patients treated with mastectomy alone.

Methods

Each patient who underwent delayed DIEP flap reconstruction at Karolinska University Hospital, Sweden, between 1999 and 2013, was compared with up to four controls with breast cancer who did not receive a DIEP flap. The control patients were selected using incidence density matching with respect to age, tumour and nodal status, neoadjuvant therapy and year of mastectomy. The primary endpoint was breast cancer‐specific survival. Survival analysis was carried out using Kaplan–Meier survival estimates and Cox proportional hazard regression analysis.

Results

The analysis included 250 patients who had 254 DIEP flap reconstructions and 729 control patients. Median follow‐up was 89 and 75 months respectively (P = 0·053). Breast cancer recurrence developed in 50 patients (19·7 per cent) in the DIEP group and 174 (23·9 per cent) in the control group (P = 0·171). The 5‐year breast cancer‐specific survival rate was 92·0 per cent for patients with a DIEP flap and 87·9 per cent in controls (P = 0·032). Corresponding values for 5‐year overall survival were 91·6 and 84·7 per cent (P < 0·001). After adjustment for tumour and patient characteristics and treatment, patients without DIEP flap reconstruction had significantly lower overall but not breast cancer‐specific survival.

Conclusion

The present findings do not support the hypothesis that patients with breast cancer undergoing DIEP flap reconstruction have a higher rate of breast cancer recurrence than those who have mastectomy alone.

Deep inferior epigastric perforator is safe

Patient-reported Outcomes after ADM-assisted Implant-based Breast Reconstruction: A Cross-sectional Study

Background

Although the use of acellular dermal matrices (ADMs) in implant-based reconstruction increases, there is a lack of studies evaluating patient-reported outcome measures after this reconstruction method. We aim to evaluate the patient satisfaction after ADM-assisted implant-based breast reconstruction (IBBR) in 1 of the largest series of patients undergoing ADM-assisted IBBR.

Methods

Patients with ADM-assisted IBBR were invited to fill out the BREAST-Q, a validated and standardized questionnaire to measure patient satisfaction after a breast reconstruction. A retrospective chart review was performed to identify patient and surgical characteristics.

Results

In total, 208 patients (38.4%) responded and reported a mean satisfaction of 70.6 ± 20.2 with their breasts and 78.0 ± 20.5 with the outcome. An overall complication rate of 7.7% was noted, with 1.5% severe complications leading to hospital readmission (0.5%) and implant removal (0.5%). Patients with complications and unilateral reconstruction for oncological reasons reported overall less satisfaction rates compared with patients with bilateral, preventive surgery, and an uncomplicated postoperative course. Strongly related domains indicate the importance of patient satisfaction with their breasts and outcome on psychosocial and sexual functioning and satisfaction with information on satisfaction with breasts, outcome, and surgeon.

Conclusion

There is an increased demand for patient-reported outcome measures in a changing practice to which the opinion of the patient assumes a larger role. With high satisfaction rates, ADM-assisted IBBR is a valuable reconstruction method, provided that complication rates remain low. Hence, it should only be performed in a selected group of women.

Outcomes of immediate versus delayed breast reconstruction: Results of a multicenter prospective study

BACKGROUND

Previous studies suggest that immediate reconstruction following mastectomy produces superior results over delayed procedures. However, for medical or oncological reasons, some patients may be poor candidates for immediate reconstruction. We compared complications and patient-reported outcomes between immediate and delayed breast reconstructions in a prospective, multicenter study.

METHODS

1957 patients (1806 immediate, 151 delayed) met eligibility criteria. Demographic data, major complications, infections, and reconstructive failure rates were evaluated. Patient-reported outcomes were assessed with BREAST-Q, PROMIS, and EORTC QLQ-BR23 surveys, pre- and two years post-operatively. Subscale scores were compared across cohorts using mixed-effects regression models, controlling for patient characteristics and hospitals.

FINDINGS

Complete data were available in 1639 immediate and 147 delayed reconstruction patients. There were significant baseline differences between immediate and delayed cohorts in age, BMI, prevalence of diabetes, lymph node management, use of radiation, and chemotherapy. Controlling for clinical covariates, the delayed group had lower odds of any (OR 0.38, p < 0.001) and major (OR 0.52, p = 0.016) complications, compared with immediate patients. Furthermore, delayed reconstruction was associated with a significantly lower failure rates (6% vs. 1.3%, p = 0.032). However, multivariate analyses found no significant differences in patient satisfaction or in psychosocial, sexual, or physical well-being at two years.

CONCLUSIONS

Compared with immediate techniques, delayed reconstruction following mastectomy was associated with lower rates of overall and major complication, while providing equivalent patient satisfaction and quality of life benefits. Although immediate reconstruction is still the preferred choice of most patients and surgeons, delaying reconstruction does not appear to compromise clinical or patient-reported outcomes.

Helical Tomotherapy for Postmastectomy Radiotherapy after Immediate Left Breast Reconstruction: A Case Study

A 43-year-old premenopausal female presented with a multicentric infiltrating lobular carcinoma of the left breast with axillary nodes metastasis. She underwent modified radical mastectomy with axillary lymph node dissection (level I and II) followed by a mixed autologous latissimus dorsi flap reconstruction with the addition of prosthesis. The final pathological analysis revealed a 6 cm invasive lobular carcinoma pT3N2aM0, grade III/III, estrogen and progesterone positive, human epidermal growth factor receptor 2 (HER2) negative, with 5/16 positive lymph nodes. She received neoadjuvant chemotherapy with doxorubicin and cyclophosphamide followed by paclitaxel. Post-mastectomy radiotherapy with axillary, supraclavicular and internal mammary lymph nodes (IMLN) irradiation was delivered to a dose of 50 Gy/25 fx. In this case with multiple risk factors for radiation-induced cardiac toxicity (left-sided lesion, internal mammary lymph nodes (IMLN) irradiation), we discuss the role of helical tomotherapy as a treatment alternative to conventional tangential radiotherapy.

Breast Reconstruction Following Cancer Treatment

BACKGROUND

About 8000 breast reconstructions after mastectomy are per - formed in Germany each year. It has become more difficult to advise patients because of the wide variety of heterologous and autologous techniques that are now available and because of changes in the recommendations about radiotherapy.

METHODS

This article is based on a review of pertinent articles (2005-2014) that were retrieved by a selective search employing the search terms "mastectomy" and "breast reconstruction."

RESULTS

The goal of reconstruction is to achieve an oncologically safe and aestically satisfactory result for the patient over the long term. Heterologous, i.e., implant-based, breast reconstruction (IBR) and autologous breast reconstruction (ABR) are complementary techniques. Immediate reconstruction preserves the skin of the breast and its natural form and prevents the psychological trauma associated with mastectomy. If post-mastectomy radiotherapy (PMRT) is not indicated, implant-based reconstruction with or without a net/acellular dermal matrix (ADM) is a common option. Complications such as seroma formation, infection, and explantation are significantly more common when an ADM is used (15.3% vs. 5.4% ). If PMRT is performed, then the complication rate of implant-based breast reconstruction is 1 to 48% ; in particular, Baker grade III/IV capsular fibrosis occurs in 7 to 22% of patients, and the prosthesis must be explanted in 9 to 41% . Primary or, preferably, secondary autologous reconstruction is an alternative. The results of ABR are more stable over the long term, but the operation is markedly more complex. Autologous breast reconstruction after PMRT does not increase the risk of serious complications (20.5% vs. 17.9% without radiotherapy).

CONCLUSION

No randomized controlled trials have yet been conducted to compare the reconstructive techniques with each other. If radiotherapy will not be performed, immediate reconstruction with an implant is recommended. On the other hand, if post-mastectomy radiotherapy is indicated, then secondary autologous breast reconstruction is the procedure of choice. Future studies should address patients' quality of life and the long-term aesthetic results after breast reconstruction.

National study of the impact of patient information and involvement in decision-making on immediate breast reconstruction rates

Background

Reconstructive alternatives should be discussed with women facing mastectomy for breast cancer. These include immediate and delayed reconstruction, which both have inherent advantages and disadvantages. Immediate reconstruction rates vary considerably in Swedish healthcare regions, and the aim of the study was to analyse reasons for this disparity.

Methods

All women who underwent mastectomy for primary breast cancer in Sweden in 2013 were included. Tumour data were retrieved from the Swedish National Breast Cancer Registry and from questionnaires regarding patient information and involvement in preoperative decision‐making sent to women who were still alive in 2015.

Results

Of 2929 women who had undergone 2996 mastectomies, 2906 were still alive. The questionnaire response rate was 76·3 per cent. Immediate reconstruction rates varied regionally, between 3·0 and 26·4 per cent. Tumour characteristics impacted on reconstruction rates but did not explain regional differences. Patient participation in decision‐making, availability of plastic surgery services and patient information, however, were independent predictors of immediate breast reconstruction, and varied significantly between regions. Even in younger patients with low‐risk tumours, rates of patient information ranged between 34·3 and 83·3 per cent.

Conclusion

Significant regional differences in immediate reconstruction rates were not explained by differences in tumour characteristics, but by disparities in patient information, availability of plastic surgery services and involvement in decision‐making.

Information is key

A Complication Analysis of 2 Acellular Dermal Matrices in Prosthetic-based Breast Reconstruction

BACKGROUND

Acellular dermal matrices (ADM) are now routine in postmastectomy prosthetic-based breast reconstruction. The goal of the current study was to compare the complications of 2 ADM products-AlloDerm and Cortiva.

METHODS

A retrospective analysis of prosthetic-based breast reconstruction in Atlanta, Ga., over 5 years. Inclusion criteria were the use of the ADM types (AlloDerm or Cortiva) and use of a tissue expander or implant. Statistical analysis compared group demographics, risk factors, and early complications.

RESULTS

Of the 298 breast reconstructions, 174 (58.4%) used AlloDerm and 124 (41.6%) used Cortiva. There was no difference in overall complication frequency (16 AlloDerm and 18 Cortiva; P = 0.195). Within specific categories, there was a difference in mastectomy skin flap necrosis, but, based on further regression analysis, this was attributable to differences in body mass index (P = 0.036). Furthermore, there were no differences in the rates of infection (6 AlloDerm and 5 Cortiva; P = 1.0), seroma/hematoma (9 AlloDerm and 7 Cortiva; P = 1.0), or drain duration (13.2 day AlloDerm and 14.2 day Cortiva, P = 0.2). By using a general estimating equation for binomial logistical regression, it was found that only current tobacco use (P = 0.033) was a significant predictor for a complication. Trending predictors were body mass index (P = 0.074) and age (P = 0.093). The type of matrix was not a significant predictor for any of the recorded complication (P = 0.160).

CONCLUSIONS

Although AlloDerm is well established, we have shown that Cortiva has an equivalent complication frequency. Future work will focus on long-term outcome measures and histological evaluation of vascularization and integration.

Different types of implants for reconstructive breast surgery

BACKGROUND

Breast cancer is the most common cancer in women worldwide, and is a leading cause of cancer death among women. Prophylactic or curative mastectomy is often followed by breast reconstruction for which there are several surgical approaches that use breast implants with which surgeons can restore the natural feel, size and shape of the breast.

OBJECTIVES

To assess the effects of different types of breast implants on capsular contracture, surgical short- and long-term complications, postoperative satisfaction level and quality of life in women who have undergone reconstructive breast surgery after mastectomy.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register on 20 July 2015, MEDLINE (1985 to 20 July 2015), EMBASE (1985 to 20 July 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 8, 2015). We also searched the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 16 July 2015.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared different types of breast implants for reconstructive surgery. We considered the following types of intervention: implant envelope surfaces - texturised versus smooth; implant filler material - silicone versus saline, PVP-Hydrogel versus saline; implant shape - anatomical versus round; implant volume - variable versus fixed; brands - different implant manufacturing companies and implant generation (fifth versus previous generations).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed methodological quality and extracted data. We used standard Cochrane methodological procedures. The quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

MAIN RESULTS

Five RCTs with 202 participants met the inclusion criteria. The women participants were typically in their 50s, and the majority of them (about 82%) received reconstructive surgery following breast cancer, while the others had reconstructive surgery after prophylactic mastectomy. The studies were heterogenous in terms of implant comparisons, which prevented us from pooling the data.The studies were judged as being at an unclear risk of bias for most risk of bias items owing to poor quality of reporting in the trial publications. Three of the five RCTs were judged to be at high risk of attrition bias, and one at high risk of detection bias.Textured silicone versus smooth silicone implants: textured implants were associated with worse outcomes when compared to smooth implants (capsular contracture: risk ratio (RR) 0.82, 95% CI 0.14 to 4.71; 1 study, 20 participants; very low quality evidence; reintervention: RR 0.82, 95% CI 0.14 to 4.71; 1 study, 20 participants; very low quality evidence). No results in this comparison were statistically significant.Silicone versus saline implants: saline-filled implants performed better than silicone-filled implants for some outcomes; specifically, they produced less severe capsular contracture (RR 3.25, 95% CI 1.24 to 8.51; 1 study, 60 participants; very low quality evidence) and increased patient satisfaction (RR 0.60, 95% CI 0.41 to 0.88; 1 study, 58 participants; very low quality evidence). However reintervention was significantly more frequent in the saline-filled implant group than in the silicone-filled group (OR 0.08, 95% CI 0.01 to 0.43; 1 study, 60 participants; very low quality evidence).Poly(N-vinyl-2-pyrrolidone) hydrogel-filled (PVP-hydrogel) versus saline-filled implants: PVP-hydrogel-filled implants were associated with worse outcomes when compared to saline-filled implants (capsular contracture: RR 3.50, 95% CI 0.83 to 14.83; 1 study, 40 participants; very low quality evidence; short-term complications: RR 2.10, 95% CI 0.21 to 21.39; 1 study, 41 participants; very low quality evidence).Anatomical versus round implants: anatomical implants were associated with worse outcomes than round implants (capsular contracture: RR 2.00, 95% CI 0.20 to 20.15; 1 study, 36 participants; very low quality evidence; short-term complications: RR 2.00, 95% CI 0.42 to 9.58; 1 study, 36 participants; very low quality evidence; reintervention: RR 1.50, 95% CI 0.51 to 4.43; 1 study, 36 participants; very low quality evidence). No results in this comparison were statistically significant.Variable-volume versus fixed-volume implants: data about one-stage reconstruction using variable-volume implants were compared with data about fixed-volume implants positioned during the second surgical procedure of two-stage reconstructions. Fixed-volume implant reconstructions were possibly associated with a greater number of women reporting that their reconstruction corresponded with expected results (RR 0.25, 95% CI 0.10 to 0.62; 1 study, 40 participants; very low quality evidence) and fewer reinterventions (RR 7.00, 95% CI 1.82 to 26.89; 1 study, 40 participants; very low quality evidence) when compared to variable-volume implants. A higher patient satisfaction level (rated from 1 to 6, with 1 being very bad and 6 being very good) was found with the fixed-volume implants for overall aesthetic result (mean difference (MD) -1.10, 95% CI -1.59 to -0.61; 1 study, 40 participants; very low quality evidence).There were no studies that examined the effects of recent (fifth) generation silicone implants versus previous generations or different implant manufacturing companies.

AUTHORS' CONCLUSIONS

Despite the central role of breast reconstruction in women with breast cancer, the best implants to use in reconstructive surgery have been studied rarely in the context of RCTs. Furthermore the quality of these studies and the overall evidence they provide is largely unsatisfactory. Some of our results can be interpreted as early evidence of potentially large differences between different surgical approaches, which should be confirmed in new high-quality RCTs that include a larger number of women. These days - even after a few million women have had breasts reconstructed - surgeons cannot inform women about the risks and complications of different implant-based breast reconstructive options on the basis of results derived from RCTs.

Body image and quality of life of breast cancer patients: influence of timing and stage of breast reconstruction

OBJECTIVE

The process of cancer-related breast reconstruction is typically multi-staged and can take months to years to complete, yet few studies have examined patient psychosocial well-being during the reconstruction process. We investigated the effects of reconstruction timing and reconstruction stage on body image and quality of life at specific time points during the breast reconstruction process.

METHODS

In this cross-sectional study, 216 patients were grouped into four reconstructive stages: pre-reconstruction, completed stage 1, completed stage 2, and final stages. Multiple regression analyses examined the roles of reconstruction timing (immediate vs delayed reconstruction) and reconstruction stage as well as their interaction in predicting body image and quality of life, controlling for patient age, BMI, type of reconstruction, chemotherapy, radiation therapy, and major complication(s).

RESULTS

A difference in pattern of body image was observed across the reconstructive stages, with those receiving delayed reconstruction showing significant decrease in body image dissatisfaction compared with those with immediate reconstruction. At pre-reconstruction, patients awaiting delayed reconstruction reported significantly lower social well-being compared with those awaiting immediate reconstruction. Reconstruction stage predicted emotional well-being, with higher emotional well-being observed in those who had commenced reconstruction.

CONCLUSIONS

Timing and stage of reconstruction are important to consider when examining psychosocial outcomes of breast cancer patients undergoing reconstruction. Those waiting to initiate delayed reconstruction appear at particular risk for body image, emotional, and social distress. Our findings have implications for delivery of psychosocial treatment to maximize body image and quality of life of patients undergoing cancer-related breast reconstruction.Copyright © 2015 John Wiley & Sons, Ltd.

DEGRO practical guidelines for radiotherapy of breast cancer V: Therapy for locally advanced and inflammatory breast cancer, as well as local therapy in cases with synchronous distant metastases

AIM

The purpose of this work is to give practical guidelines for radiotherapy of locally advanced, inflammatory and metastatic breast cancer at first presentation.

METHODS

A comprehensive survey of the literature using the search phrases "locally advanced breast cancer", "inflammatory breast cancer", "breast cancer and synchronous metastases", "de novo stage IV and breast cancer", and "metastatic breast cancer" and "at first presentation" restricted to "clinical trials", "randomized trials", "meta-analysis", "systematic review", and "guideline" was performed and supplemented by using references of the respective publications. Based on the German interdisciplinary S3 guidelines, updated in 2012, this publication addresses indications, sequence to other therapies, target volumes, dose, and fractionation of radiotherapy.

RESULTS

International and national guidelines are in agreement that locally advanced, at least if regarded primarily unresectable and inflammatory breast cancer should receive neoadjuvant systemic therapy first, followed by surgery and radiotherapy. If surgery is not amenable after systemic therapy, radiotherapy is the treatment of choice followed by surgery, if possible. Surgery and radiotherapy should be administered independent of response to neoadjuvant systemic treatment. In patients with a de novo diagnosis of breast cancer with synchronous distant metastases, surgery and radiotherapy result in considerably better locoregional tumor control. An improvement in survival has not been consistently proven, but may exist in subgroups of patients.

CONCLUSION

Radiotherapy is an important part in the treatment of locally advanced and inflammatory breast cancer that should be given to all patients regardless to the intensity and effect of neoadjuvant systemic treatment and the extent of surgery. Locoregional radiotherapy in patients with primarily distant metastatic disease should be prescribed on an individual basis.

Influence of Patient and Hospital Characteristics on the Performance of Direct Reconstruction after Mastectomy

Aim: International studies have shown that the performance of a direct (or immediate) reconstruction (DR) after mastectomy is associated with patient (e.g., socio-economic status, insurance status, age) and hospital (number of cases, teaching status) characteristics. The present article addresses the question if such relationships also exist in Germany. Material and Methods: The results of a nationwide questionnaire to the patients of certified breast cancer centres were coupled with the clinical features of the patients and the characteristics of the hospital. Predictors for receiving a DR (vs. delayed or no reconstruction) were estimated by means of a logistic multilevel model for a sample of 1165 patients from 105 certified locations. Results: Substantial differences between the treating hospitals were found (intraclass correlation coefficient null model: 0.195) which can in part be explained by the total model (total model: 0.169). Patients with the following features are more likely to receive a DR: younger age, private health insurance, secondary school leaving certificate (vs. primary school leaving certificate), lower stage and acquisition of more information about reconstruction. ASA and partnership status are not statistically significantly related with DR. DR is more likely to be performed in hospitals with higher caseload of patients with primary breast cancer. Teaching status, operations per surgeon and urbanity of the location are not related to receiving a DR. Conclusions: Non-clinical features of the patients and the primary case number are associated with the performance of a DR, this poses questions concerning reasons and the equality of health care.

Postmastectomy radiotherapy: indications and implications

BACKGROUND

Although breast conservation surgery, when combined with radiotherapy, has been shown to provide excellent locoregional control for breast cancer, approximately one third of women with breast cancer require mastectomy. Many of these women are offered immediate reconstruction. Postmastectomy radiotherapy (PMRT) is indicated in some cases, but is associated with side-effects, including its impact on the reconstructed breast.

OBJECTIVE

To review the pertinent issues surrounding PMRT, including patient selection for radiotherapy and the effect of radiotherapy on reconstructive decisions.

METHODS

A literature review was performed using the Medline database.

CONCLUSIONS

PMRT is indicated in patients who are deemed to have a high risk of loco-regional recurrence. Although PMRT is strongly recommended for patients with four or more positive lymphnodes, other indications for PMRT remain controversial. Immediate reconstruction post mastectomy has been shown to have favorable outcomes. However, PMRT may increase the need for revision surgery post immediate reconstruction. There are few randomized trials looking at these key issues, and the evidence is largely derived from observational retrospective studies. Patients should be carefully counseled before a decision is made to proceed with immediate reconstruction, where there is a high chance that PMRT may be indicated.

Body image in recently diagnosed young women with early breast cancer

OBJECTIVE

To assess body image concerns among young women following a breast cancer diagnosis.

METHODS

A total of 419 women with recently diagnosed stage 0-III breast cancer were surveyed following enrollment as part of a prospective cohort study of women age 40 or younger at diagnosis. Body image was assessed using three items from the psycho-social scale of the Cancer Rehabilitation Evaluation System (CARES). CARES scores range from 0 to 4, with higher scores indicative of greater image concerns. Mean CARES scores were calculated and compared between treatment groups using t-tests and analysis of variance. Multiple linear regression models were fit to evaluate the relationship between physical and psychological factors and body image.

RESULTS

Mean time from diagnosis to completion of the baseline survey was 5.2 months. The mean CARES score for all women was 1.28. Mean CARES scores in the mastectomy-only group (1.87) and in the mastectomy with reconstruction group (1.52) were significantly higher (p < 0.0001) compared with the scores in the lumpectomy group (0.85), indicating that radical surgery was associated with more body image concerns. Radiation (p = 0.01), anxiety (p = 0.0001), depression (p < 0.0001), fatigue (p = 0.04), musculoskeletal pain symptoms (p < 0.0001), weight gain (p = 0.01), and weight loss (p = 0.02), in addition to surgery type (p < 0.0001), were all associated with more body image concerns in the multi-variable analysis.

CONCLUSION

This analysis highlights the impact of treatment, along with physical and psychological factors, on body image early in the survivorship period. Our findings provide targets for potential future intervention and may aid young women in the surgical decision-making process.

Influence of health insurance, hospital factors and physician volume on receipt of immediate post-mastectomy reconstruction in women with invasive and non-invasive breast cancer

For women with breast cancer who undergo mastectomy, immediate breast reconstruction (IR) offers a cosmetic and psychological advantage. We evaluated the association between demographic, hospital, surgeon and insurance factors and receipt of IR. We conducted a retrospective hospital-based analysis with the Perspective database. Women who underwent a mastectomy for invasive breast cancer (IBC) and ductal carcinoma in situ (DCIS) from 2000 to 2010 were included. Logistic regression analysis was used to determine factors predictive of IR. Analyses were stratified by age (<50 vs. ≥ 50) and IBC versus DCIS. Of the 108,992 women with IBC who underwent mastectomy, 30,859 (28.3 %) underwent IR, as compared to 6,501 (44.2 %) of the 14,710 women with DCIS who underwent mastectomy underwent IR. In a multivariable model for IBC, increasing age, black race, being married, rural location, and increased comorbidities were associated with decreased IR. Odds ratios (OR) of IR increased with commercial insurance (OR 3.38) and Medicare (OR 1.66) insurance (vs. self-pay), high surgeon-volume (OR 1.19), high hospital-volume (OR 2.24), and large hospital size (OR 1.20). The results were identical for DCIS, and by age category. The absolute difference between the proportion of patients who received IR with commercial insurance compared to other insurance, increased over time. Immediate in-hospital complication rates were higher for flap reconstruction compared to implant or no reconstruction (15.2, 4.0, and 6.1 %, respectively, P < .0001). IR has increased significantly over time; however, modifiable factors such as insurance status, hospital size, hospital location, and physician volume strongly predict IR. Public policy should ensure that access to reconstructive surgery is universally available.