Association between age and access to immediate breast reconstruction in women undergoing mastectomy for breast cancer

Immediate breast reconstruction uptake in older women with primary breast cancer: systematic review

BACKGROUND

Postmastectomy immediate breast reconstruction (PMIBR) may improve the quality of life of patients with breast cancer, of whom older women (aged 65 years or more) are a growing proportion. This study aimed to assess PMIBR in older women with regard to underlying impediments (if any).

METHODS

MEDLINE, Embase, and PubMed were searched by two independent researchers up to June 2022. Eligible studies compared PMIBR rates between younger and older women with invasive primary breast cancer.

RESULTS

A total of 10 studies (2012-2020) including 466 134 women were appraised, of whom two-thirds (313 298) were younger and one-third (152 836) older. Only 10.0 per cent of older women underwent PMIBR in contrast to 45.0 per cent of younger women. Two studies explored factors affecting uptake of PMIBR in older women; surgeon-associated (usual practice), patient-associated (socioeconomic status, ethnicity, and co-morbidities), and system-associated (insurance status and hospital location) factors were identified.

CONCLUSION

Uptake of PMIBR in older women is low with definable (and some correctable) barriers.

Surgical under-treatment of older adult patients with cancer: A systematic review and meta-analysis

BACKGROUND

Older patients with cancer often have lower surgery rates and survival than younger patients, but this may reflect surgical contraindications of advanced disease, comorbidities, and frailty - and not necessarily under-treatment.

OBJECTIVES

This review aims to describe variations in surgery rates and observed or net survival among younger (<75) and older (≥75) patients with breast, lung and colorectal cancer, while taking account of pre-existing health factors, in order to understand how under-treatment is defined and estimated in the literature.

METHOD

MEDLINE, EMBASE, Web of Science and PubMed databases were searched for studies reporting surgery rates and observed or net survival among younger and older patients with breast, lung, and colorectal cancer. Study quality was assessed using the Newcastle Ottawa Scale, and random effects meta-analyses were used to combine study results. The I-squared statistic and subgroup analyses were used to assess heterogeneity.

RESULTS

Thirty relatively high-quality studies of patients with breast (230,200; 71.9%), lung (77,573; 24.2%), and colorectal (12,407; 3.9%) cancers were identified. Compared to younger patients, older patients were less likely to receive surgical treatment for 1) breast cancer after adjusting for comorbidity, performance status (PS), functional status and patient choice, 2) lung cancer after accounting for stage, comorbidity, PS, and 3) colorectal cancer after adjusting for stage, comorbidity, and gender. The pooled unadjusted analyses showed lower surgery receipt in older patients with breast (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.13-0.78), lung (OR 0.54, 95% CI 0.39-0.75), and colorectal (OR 0.59, 95% CI 0.51-0.68) cancer. In separate analyses, older patients with breast, lung and colorectal cancer had lower observed and net survival, compared to younger patients.

CONCLUSIONS

Lower surgery rates in older patients may contribute to their poorer survival compared to younger patients. Future research quantifying under-treatment should include necessary clinical factors, patient choice, patient's quality of life and a statistically-robust approach, which will demonstrate how much of the survival deficit in older patients is due to their receiving lower surgery rates.

Immediate one-stage breast reconstruction for an 85-year-old breast cancer patient using deep inferior epigastric perforator flap surgery

The deep inferior epigastric perforator (DIEP) flap is widely recognized as safe for use as a first-choice option in autologous tissue breast reconstruction; however, DIEP is often not performed for breast reconstruction in the elderly. We report a case of an 85-year-old woman who underwent DIEP flap reconstruction. Immediate reconstruction was performed after mastectomy. The patient successfully underwent DIEP flap reconstruction with no complications. Other options for reconstruction include a latissimus dorsi flap, a transverse rectus abdominis flap and implant-based reconstruction. DIEP flap reconstruction was performed, which does not cause muscle damage and provides sufficient volume. To our knowledge, this study is the first to report DIEP breast reconstruction in a patient over 85 years of age. This case demonstrates the usefulness of DIEP flap reconstruction for elderly patients.

Patients' satisfaction with the reconstructive options provided to them measured 18 months after mastectomy surgery for breast cancer

INTRODUCTION

Mastectomy patients' satisfaction with reconstructive options has not been examined.

METHODS

A national study measured 18-month satisfaction with reconstructive options and collected case-mix and reconstructive offer and uptake data on breast cancer patients having mastectomy with or without immediate reconstruction (IR) in England between January 2008 and March 2009. Multivariable logistic regression examined the relationship between satisfaction, age, IR offer and uptake, and clinical suitability.

RESULTS

Of 4796 patients, 1889 were not offered IR, 1489 declined an offer and 1418 underwent it. Women not offered IR were more likely older, obese or smokers and had higher ASA grades, ECOG scores, tumour burdens and adjuvant chemotherapy and radiotherapy likelihoods (9% of lowest suitability group offered IR; 81% in highest suitability group). 83.7% were satisfied with their reconstructive options, varying significantly by IR offer and uptake (76.1% for those not offered IR; 85.8% for those who declined IR; 91.7% following IR). Older women and women deemed more suitable for IR were more often satisfied (p-values <0.001).

CONCLUSIONS

Satisfaction varied by offer and uptake status, age and suitability score. Clinicians should target equity for women deemed unsuitable by exploring their needs and desired outcomes, standardising operative fitness assessments and utilising shared decision-making aids.

Higher Distress in Patients with Breast Cancer Is Associated with Declining Breast Reconstruction

Background:

Distress among newly diagnosed patients with breast cancer is common and may have an impact on their surgical decision-making. The revised Edmonton Symptom Assessment System (ESAS-r) is a validated instrument that provides an estimate of patients’ total distress, and no previous study has related preoperative scores to the choice to have breast reconstruction.

Methods:

Women with breast cancer treated at the Princess Margaret Cancer Centre in 2014 were reviewed, and patient and tumor characteristics were collected from local databases. Breast reconstruction status was obtained from patients’ electronic medical records until April 2017. A multivariable logistic regression model assessed for an independent association between preoperative ESAS-r total distress scores and patients’ decision to have breast reconstruction.

Results:

A total of 312 patients were analyzed. ESAS-r values had an overall median score of 10.0 and ranged from 0 to 69 (interquartile range, 17). Of these patients, 82 chose to undergo breast reconstruction surgery (26.8%). Multivariable logistic regression analysis showed that higher ESAS-r scores were associated with patients forgoing breast reconstruction surgery (lumpectomy-alone group: odds ratio estimate, 1.034 [1.004–1.064], P = 0.025; mastectomy-alone group: odds ratio estimate, 1.031 [1.004–1.059], P = 0.023).

Conclusions:

This study of patients with breast cancer found that higher distress scores as measured by the ESAS-r were associated with reduced breast reconstruction. Distress in patients with breast cancer is important to address, as it is often treatable, and its resolution may unmask a desire for breast reconstruction, which has known benefits psychosocially.

Reconstructive utilisation and outcomes following mastectomy surgery in women with breast cancer treated in England

INTRODUCTION

Breast cancer usually necessitates breast-conserving surgery or mastectomy, which adversely affect appearance and wellbeing. Immediate reconstruction restores the breast mound but its availability and efficacy are uncertain.

MATERIALS AND METHODS

Two discrete datasets were used to evaluate mastectomies in England: Hospital Episode Statistics to measure overall activity and variation over time and by region and a national prospective audit to evaluate immediate reconstruction decision making, complication rates and patient-reported satisfaction with information, choice and outcomes.

RESULTS

The 2005-08 Hospital Episode Statistics analyses identified 20% breast-conserving surgery reoperation rates nationally, frequently involving mastectomy. Rates were higher with in-situ disease present (30% vs 18%) and varied across NHS trusts (10th-90th centiles 12-30%). The 2008-09 national audit examined 18,216 women. The 19% immediate reconstruction rate varied regionally (9-43%), as did 2006-09 Hospital Episode Statistics data (8-32%). A total of 48% of women were offered immediate reconstruction, again varying regionally (24-75%). Offer likelihood fell with increasing age. National immediate reconstruction rates increased from 10% to 23% from 2000 to 2014, but regional variation persisted. Despite high care satisfaction, just 65% of mastectomy patients received the right amount of reconstructive information (90% for immediate reconstruction). Women from deprived areas experienced higher complication rates. Flap-based immediate reconstruction led to greater satisfaction with breast area appearance, emotional and sexual wellbeing and overall outcome than mastectomy; implant-only immediate reconstruction scored no better.

CONCLUSION

Reconstruction is central to improving breast cancer outcomes. The differential outcomes and persistent regional inequalities identified should facilitate decision making, support improved access to all reconstructive options and inform the development of an optimal patient pathway.

Surgery in the Older Patient with Breast Cancer

PURPOSE OF REVIEW

Breast cancer incidence and mortality increase with age. Older patients (≥ 70) are often excluded from studies. Due to multiple factors, it is unclear whether this population is best-treated using standard guidelines. Here, we review surgical management in older women with breast cancer.

RECENT FINDINGS

Geriatric assessments can guide treatment recommendations and aid in predicting survival and quality of life. Surgery remains a principal component of breast cancer treatment in older patients, though differences exist compared with younger women, including higher mastectomy rates and evidence-based support of omission of post-lumpectomy radiation or axillary dissection in subsets of patients. In those forgoing surgical management, there is increased use of endocrine therapy. Hospice is also a valuable element of end-of-life care. Physicians should utilize geriatric assessment to make treatment recommendations for older breast cancer patients, including omission of radiation therapy, alterations to standard surgeries, or enrollment in hospice care.

Outcomes of breast reconstruction in older women: patterns of uptake and clinical outcomes in a large metropolitan practice

BACKGROUND

Older age is associated with lower rates of breast reconstruction (BR) following mastectomy. This study compared a range of factors in women aged 60 years and older who had received mastectomy and BR with those who received no BR (NBR).

METHODS

An audit of 338 women aged 60 or over treated with mastectomy with (n = 86) or without (n = 252) BR for primary breast cancer from 2009 to 2016 was conducted. Demographic, tumour, treatment, comorbidity and surgical complication data were obtained from patient medical records.

RESULTS

NBR patients were associated with older age (P ≤ 0.001), more comorbidities (P = 0.038) and more extensive disease (P = 0.001) than BR patients. Total number of complications was not significantly different between BR and NBR patients (P = 0.286), or the different types of BR (P = 0.697). BR patients had higher rates of unplanned returns to the operating theatre, particularly in the late post-operative period (P = 0.025). Implant-based reconstruction was associated with more unplanned operating theatre returns than autologous reconstruction in the late post-operative period (P = 0.013).

CONCLUSION

Post-mastectomy BR in elderly patients has a clinical complication profile similar to NBR patients. This audit found no clinical-based reasons to not offer oncologically suitable and clinically fit elderly women the option of BR.

Association of sociodemographic and oncological features with decision on implant-based versus autologous immediate postmastectomy breast reconstruction in Chinese patients

Background and objectives

Immediate postmastectomy breast reconstruction (IPBR) has gained wide popularity in China. We sought to clarify the prevalence and predictors of implant‐based vs autologous IPBR among Chinese patients.

Methods

A retrospective cohort study was performed using a prospectively maintained database. Women who underwent IPBR during 2001‐2017 were included. The modality‐specific trends were deciphered by curve fitting analysis. The association of sociodemographic and oncological features with the decision for implant‐based vs autologous IPBR was investigated using multivariate logistic regression and structural equation modeling.

Results

Among 905 patients included in the study, 479 underwent implant‐based IPBR and 426 underwent autologous procedures. The implant/autologous ratio has increased exponentially over time. Multivariate analysis demonstrated that unmarried patients with BMI ≤ 24 kg/m², earlier clinical tumor stage, and preoperative pathological diagnosis of noninvasive lesion are more likely to choose implant‐based IPBR compared to autologous procedures. The indirect effects of age, mastectomy type, and neoadjuvant chemotherapy were further demonstrated by the structural equations.

Conclusions

The sociodemographic and oncological features are directly or indirectly associated with the decision on type of IPBR. The findings may facilitate both patients and physicians to make a high‐quality decision by holistic evaluation of the sociodemographic and oncological features.

Patient-Reported Satisfaction after Prophylactic Operations of the Breast

Background

Prophylactic mastectomies in carriers of mutations in BRCA1 or BRCA2 are becoming increasingly more accepted. We investigated the outcome after prophylactic mastectomy, especially regarding satisfaction with the procedure, in a monocenter study.

Methods

BRCA1/2 mutation carriers and non-carriers with elevated pedigree-based cancer risk were followed prospectively in a structured surveillance program between 2000 and 2017. A retrospective telephone survey was conducted among all patients with documented prophylactic mastectomy. Complications and satisfaction with the decision for prophylactic mastectomy were recorded.

Results

39 patients who opted for a prophylactic mastectomy (38 BRCA1/2 mutation carriers and 1 non-carrier) were interviewed. Mostly nipple-sparing mastectomy with reconstruction was performed (87%). Half of the patients (22/39; 56.4%) had a history of unilateral breast cancer. The median time since prophylactic mastectomy was 5.6 years. While 61.5% did not report any complications, flap loss was seen in 15% (3/20) and moderate limitations in everyday life were present in 20% (7/35). An improvement in quality of life was noticed by 82% after prophylactic mastectomy and no patient expressed regret with regard to the decision.

Conclusions

Prophylactic mastectomy is a procedure with risk for long-term complications in some cases. Our results confirm high satisfaction with the decision and improved quality of life.

Patient-reported outcomes of breast reconstruction in older women: Audit of a large metropolitan public/private practice in Sydney, Australia

OBJECTIVE

Older age is associated with lower rates of breast reconstruction (BR) for women requiring mastectomy. This study compared patient-reported outcomes between women aged 60 years and older who had received mastectomy and BR with those who received no BR (NBR).

METHODS

About 135 women aged 60 or over treated between 2009 and 2016 with mastectomy only (N = 87) or mastectomy with BR (N = 48) for primary breast cancer completed patient-reported outcome measures using a set of validated questionnaires. Reasons for choosing or declining BR were also explored using a set of nonvalidated questionnaires.

RESULTS

Patients who received BR were generally younger (P = <0.001) and reported greater satisfaction with their bodies (P = 0.048) than NBR patients. Patients with autologous reconstruction reported greater satisfaction with their breasts than implant-based reconstruction patients. Both BR and NBR patients reported good quality of life, low pain scores, good body image, and low levels of decisional regret.

CONCLUSIONS

These data do not identify any quality of life-related reasons to not offer clinically fit, well-informed older women the option of BR.

Surgeons’ Recommendation is the Factor in Determining the Breast Cancer Surgery Procedures: an Experience from Rural Hospital in Thailand

Introduction:

The majority of breast cancer patients in rural hospital in developing countries still warrant for total mastectomy. Surgeon advice regard surgical procedure is one of the most important factors in decision making. Our study aims to compare the rate of breast-conserving surgery (BCS), mastectomy (MT) and mastectomy with immediate breast reconstruction (MTIBR) between the surgeons who offer only MT (group A) and who offer BCS MT and MTIBR (group B).

Method:

A retrospective cohort study was conducted at Ratchaburi hospital, Thailand from January 2010 to April 2014. We categorized patients into 2 groups (group A and B). Univariated analysis was selected to determine the factors that associated with the breast surgery procedures.

Results:

From January 2010 to April 2014, we recruited 310 breast cancer patients, 221 patients (71.2%) were treated by surgeons in group A, 89 patients (28.7%) by surgeons in group B. The choice of breast surgery is significantly different between 2 groups (P<0.001). In group A, 213 (96.3%) patient had MT and only 3 (1.3%) BCS and 5 (2.2%) MTIBR. Whilst in group B, 58 (65.1%) patient had MT and 11 (12.3%) BCS and 20(22.4%) MTIBR. Choice of breast surgery in patients with stage 1,2,3 are significantly different between 2 groups (P=0.004, <0.001, 0.025 respectively). Age is the only factor that significantly affects the choice of surgery in the group B but not in group A.

Conclusion:

Surgeon’s competency and comprehensive preoperative consultation by offering BCS, MT and MTIBR can affect the choice of surgical procedure for breast cancer patient.

Regional variation in immediate breast reconstruction in Australia

Background

Breast reconstruction following mastectomy has proven benefits and is the standard of care in many high‐income countries. This audit documented regional variation in immediate breast reconstruction rates across Australia.

Methods

The Breast Surgeons of Australia and New Zealand (BreastSurgANZ) Quality Audit database and geospatial software were used to model the distribution of breast reconstructions performed on women having mastectomy in Australia in 2013. Geospatial mapping identified the distribution of these procedures in relation to the Greater Capital City Statistical Areas (GCCSAs) of the five largest states. Data were analysed using χ² tests of independence and an independent‐samples t test.

Results

Of 3786 patients having a mastectomy, 692 underwent breast reconstruction of which 679 (98·1 per cent) were immediate reconstructions. Rates of reconstruction differed significantly between jurisdictions (χ² = 164·90), and were significantly higher in GCCSAs (χ² = 144·60) and private hospitals (χ² = 50·72) (all P < 0·001). Immediate breast reconstruction was not reported for 43·8 per cent of hospitals where mastectomy was conducted by members of BreastSurgANZ, including 29·8 per cent of hospitals within GCCSAs. A wider age range of women appeared to have had immediate reconstructions at hospitals within GCCSAs, although the difference in mean age between regions was not significant. Immediate breast reconstruction was considerably less likely to be performed in women who lived in areas of lower to mid socioeconomic status.

Conclusion

Variations in the rate of immediate breast reconstruction may not be purely resource‐driven.