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Sharifi N, Ahmad S. Breast cancer-related lymphedema: A critical review on recent progress. Surg Oncol 2024; 56:102124. [PMID: 39208532 DOI: 10.1016/j.suronc.2024.102124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 08/06/2024] [Accepted: 08/21/2024] [Indexed: 09/04/2024]
Abstract
Lymphedema is a chronic and debilitating condition characterized by an abnormal buildup of protein-rich fluid in the interstitial tissue, leading to the development of edema and tissue structural alterations. Breast cancer-related lymphedema (BCRL) remains a significant healthcare burden because it can develop within days and up to 11-years after the surgery. Specifically, axillary lymph node dissection leads to 30-50 % upper limb lymphedema, which involves the accumulation of protein-rich fluid. In this article, we provide a comprehensive/critical overview of post-mastectomy lymphedema, focusing on key aspects as diagnosis, prevention, and treatment methods. Beginning with clinical condition, the article explores the pathophysiology and risk factors associated with post-mastectomy lymphedema. It further delves into various diagnostic modalities available, highlighting the importance of early detection for optimal management of BCRL. We also examine preventive strategies, emphasizing the role of patient education, lifestyle modifications, and proactive measures in reducing the risk of lymphedema development. In terms of treatment, the article covers a wide array of interventions ranging from conservative approaches like manual lymphatic drainage and compression therapy to surgical techniques such as lymph node transfer and lymphaticovenular anastomosis. Thus, through a comprehensive synthesis of current evidence and clinical practices updates, the review aims to guide healthcare professionals in delivering preventive and effective care while improving outcomes for individuals affected by post-mastectomy lymphedema.
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Affiliation(s)
- Nasrin Sharifi
- AdventHealth Cancer Institute, Gynecologic Oncology Program, Orlando, FL, 32804, USA; Valencia College, Department of Health Sciences, Section of Human Anatomy & Physiology, Orlando, FL, 32802, USA
| | - Sarfraz Ahmad
- AdventHealth Cancer Institute, Gynecologic Oncology Program, Orlando, FL, 32804, USA.
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Zeng CY, Qiu YY, Li JY, Huang JH, Bai XS, Han XL, He XD. Locally advanced breast cancer patients should be cautious about the immediate breast reconstruction after mastectomy: a pooling analysis of safety and efficacy. World J Surg Oncol 2024; 22:165. [PMID: 38918808 PMCID: PMC11197261 DOI: 10.1186/s12957-024-03444-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/16/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND The purpose of this study was to compare safety and efficacy outcomes between immediate breast reconstruction (IBR) and mastectomy alone in locally advanced breast cancer patients. METHODS We conducted a comprehensive literature search of PUBMED, EMBASE, and Cochrane databases. The primary outcomes evaluated were overall survival, disease-free survival, and local recurrence. The secondary outcome was the incidence of surgical complications. All data were analyzed using Review Manager 5.3. RESULTS Sixteen studies, involving 15,364 participants were included in this meta-analysis. Pooled data demonstrated that patients underwent IBR were more likely to experience surgical complications than those underwent mastectomy alone (HR: 3.96, 95%CI [1.07,14.67], p = 0.04). No significant difference was found in overall survival (HR: 0.94, 95%CI [0.73,1.20], p = 0.62), disease-free survival (HR: 1.03, 95%CI [0.83,1.27], p = 0.81), or breast cancer specific survival (HR: 0.93, 95%CI [0.71,1.21], p = 0.57) between IBR group and Non-IBR group. CONCLUSIONS Our study demonstrates that IBR after mastectomy does not affect the overall survival and disease-free survival of locally advanced breast cancer patients. However, IBR brings with it a nonnegligible higher risk of complications and needs to be fully evaluated and carefully decided.
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Affiliation(s)
- Cheng-Yu Zeng
- Eight-Year Program of Clinical Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, China
| | - Yan-Yu Qiu
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, China Academy of Medical Science & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District,, Beijing, China
| | - Jia-Yi Li
- Eight-Year Program of Clinical Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, China
| | - Jian-Hao Huang
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, China Academy of Medical Science & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District,, Beijing, China
| | - Xue-Song Bai
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, China Academy of Medical Science & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District,, Beijing, China
| | - Xian-Lin Han
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, China Academy of Medical Science & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District,, Beijing, China.
| | - Xiao-Dong He
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, China Academy of Medical Science & Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District,, Beijing, China.
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Elmer NA, Bustos VP, Veeramani A, Hassell N, Comer CD, Manstein SM, Kinney J, Lee BT, Lin SJ. Trends of Autologous Free-Flap Breast Reconstruction and Safety during the Coronavirus Disease 2019 Pandemic. J Reconstr Microsurg 2023; 39:715-726. [PMID: 36928904 DOI: 10.1055/a-2056-0729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Autologous free-flap breast reconstruction (ABR) is a valuable surgical option for patients following mastectomy. The coronavirus disease 2019 (COVID-19) pandemic has led to a myriad of factors that have affected access to care, hospital logistics, and postoperative outcomes. This study aims to identify differences in patient selection, hospital course and severity, and postoperative outcomes for patients who underwent ABR during and prior to the COVID-19 pandemic. METHODS Patients undergoing ABR from the American College of Surgeons National Surgical Quality Improvement Program 2019 to 2020 database were analyzed to compare sociodemographics, hospital course, and outcomes over the first postoperative month. Multivariable logistic regression was used to identify factors predictive of complications based on the operative year. RESULTS In total, 3,770 breast free flaps were stratified into two groups based on the timing of reconstruction (prepandemic and pandemic groups). Patients with a diagnosis of disseminated cancer were significantly less likely to undergo ABR during the COVID-19 pandemic. On univariate analysis, there were no significant differences in postoperative complications between the two groups. When controlling for potentially confounding sociodemographic and clinical risk factors, the COVID-19 group was significantly more likely to undergo reoperation compared with the prepandemic group (p < 0.05). CONCLUSION When comparing outcomes for patients who underwent ABR prior to and during the COVID-19 pandemic, we found a significant increase in the odds of reoperation for those who had ABR during the pandemic. Debridement procedures and exploration for postoperative hemorrhage, thrombosis, or infection increased in the prepandemic group compared to the COVID-19 group. Notably, operative times decreased.
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Affiliation(s)
- Nicholas A Elmer
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Valeria P Bustos
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Anamika Veeramani
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Natalie Hassell
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Carly D Comer
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Samuel M Manstein
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jacquelyn Kinney
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T Lee
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Samuel J Lin
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Johnson MK, Cortina CS, Hsu TL, Huang S, Frebault J, Huang CC, Kong AL. National Trends in "Going Flat" After Mastectomy. Ann Surg Oncol 2023; 30:6374-6382. [PMID: 37458947 DOI: 10.1245/s10434-023-13845-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/28/2023] [Indexed: 09/20/2023]
Abstract
INTRODUCTION The "Going Flat" movement became widely publicized in 2016 and provides information and support to women who choose to forego post-mastectomy breast reconstruction (PMBR). The objectives of this study were to evaluate temporal trends in PMBR to ascertain the potential impact of this movement and assess which factors are associated with going flat. METHODS A retrospective cohort analysis was performed using the NCDB of women with non-metastatic breast cancer who underwent mastectomy between 2004 and 2019. Trends in going flat after mastectomy were examined and stratified by age (< 50, 50-69, ≥ 70). A multivariate logistic regression model was used to identify factors associated with going flat. RESULTS 650,983 patients met the inclusion criteria: 244,201 (37.5%) underwent PMBR and 406,782 (62.5%) went flat. Among women < 70, rates of going flat steadily decreased from 2004 to 2015 and then stabilized after 2015, coinciding with the rise of the "Going Flat" movement. In multivariate analysis, non-White race, older age, increasing comorbidities, government provided insurance, treatment at a community program, radiotherapy, and adjuvant chemotherapy were associated with a higher likelihood of going flat (p < 0.001). CONCLUSION In the first 2 years after the "Going Flat" movement, the number of women going flat after mastectomy has stabilized in women < 70 for the first time in over a decade. These trends suggest that the social and cultural impact of this movement may have contributed to the stabilization of PMBR rates.
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Affiliation(s)
- Morgan K Johnson
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
| | - Chandler S Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
- MCW Cancer Center, Milwaukee, WI, USA
| | - Tzu-Lun Hsu
- Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Shane Huang
- Department of Statistics, University of Wisconsin-Madison, Madison, WI, USA
| | - Julia Frebault
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN, USA
| | - Chiang-Ching Huang
- Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Amanda L Kong
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA.
- MCW Cancer Center, Milwaukee, WI, USA.
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Doherty C, McClure JA, Baxter NN, Brackstone M. Complications From Postmastectomy Radiation Therapy in Patients Undergoing Immediate Breast Reconstruction: A Population-Based Study. Adv Radiat Oncol 2023; 8:101104. [DOI: 10.1016/j.adro.2022.101104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 09/29/2022] [Indexed: 11/25/2022] Open
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Association between Immediate Breast Reconstruction and the Development of Breast Cancer-Related Lymphedema. Plast Reconstr Surg 2023; 151:214e-222e. [PMID: 36696309 DOI: 10.1097/prs.0000000000009831] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND With the increasing number of patients undergoing immediate breast reconstruction after mastectomy, the impact of immediate breast reconstruction on the risk of breast cancer-related lymphedema has become an emerging area of interest. This study aimed to identify the association between immediate breast reconstruction and postoperative lymphedema. METHODS A retrospective cohort study was conducted from 2006 to 2016 with 5900 consecutive patients who underwent mastectomy for primary breast cancer with or without immediate breast reconstruction. After excluding patients with synchronous contralateral breast cancer, lymphedema before mastectomy, history of procedures performed in the axillary region, and follow-up data of less than 1 year, the cumulative incidence of lymphedema after immediate breast reconstruction and after no reconstruction was calculated and compared using multivariate Cox regression analysis. RESULTS Overall, 5497 patients (mean age, 51.7 years) were included, and 630 developed lymphedema. The 5-year cumulative incidence rate of lymphedema was significantly reduced in patients who underwent immediate breast reconstruction versus control patients (9.6% versus 12.2%; P = 0.02). In the multivariate analysis, immediate breast reconstruction status (hazard ratio, 0.75; 95% confidence interval, 0.56 to 0.99; P = 0.042) was an independent predictor for lymphedema. Similar significant associations were observed in the subgroup analyses of patients with a body mass index less than 30 kg/m2 (P = 0.024), in those with fewer than 10 dissected lymph nodes (P = 0.042), or in those with adjuvant radiotherapy (P = 0.048). CONCLUSIONS Immediate breast reconstruction was associated with a reduced risk of lymphedema. These results may be used for predicting the development of lymphedema following breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Racial, ethnic and socioeconomic disparities in diagnosis, treatment, and survival of patients with breast cancer. Am J Surg 2023; 225:154-161. [PMID: 36030101 DOI: 10.1016/j.amjsurg.2022.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/07/2022] [Accepted: 07/14/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The objective of this study was to determine the influence of race/ethnicity and socioeconomic status (SES) on breast cancer outcomes. METHODS A retrospective analysis was performed of Non-Hispanic Black (NHB), Non-Hispanic White (NHW), and Hispanic patients with non-metastatic breast cancer in the SEER cancer registry between 2007 and 2016. RESULTS A total of 382,975 patients were identified. On multivariate analysis, NHB (OR 1.18, 95%CI: 1.15-1.20) and Hispanic (OR 1.20, 95%CI: 1.17-1.22) patients were more likely to present with higher stage disease than NHW patients. There was an increased likelihood of not undergoing breast-reconstruction for NHB (OR 1.07, 95%CI: 1.03-1.11) and Hispanic patients (OR 1.60, 95%CI 1.54-1.66). NHB patients had increased hazard for all-cause mortality (HR: 1.13, 95%CI 1.10-1.16). All-cause mortality increased across SES categories (lower SES: HR 1.33, 95%CI 1.30-1.37, middle SES: HR 1.20, 95%CI 1.17-1.23). CONCLUSIONS This population-based analysis confirms worse disease presentation, access to surgical therapy, and survival across racial, ethnic, and socioeconomic factors. These disparities were compounded across worsening SES and insurance coverage.
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Racial Disparities in Breast Reconstruction at a Comprehensive Cancer Center. J Racial Ethn Health Disparities 2022; 9:2323-2333. [PMID: 34647274 DOI: 10.1007/s40615-021-01169-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Breast reconstruction after a mastectomy is an important component of breast cancer care that improves the quality of life in breast cancer survivors. African American women are less likely to receive breast reconstruction than Caucasian women. The purpose of this study was to further investigate the reconstruction disparities we previously reported at a comprehensive cancer center by assessing breast reconstruction rates, patterns, and predictors by race. METHODS Data were obtained from women treated with definitive mastectomy between 2000 and 2012. Sociodemographic, tumor, and treatment characteristics were compared between African American and Caucasian women, and logistic regression was used to identify significant predictors of reconstruction by race. RESULTS African American women had significantly larger proportions of public insurance, aggressive tumors, unilateral mastectomies, and modified radical mastectomies. African American women had a significantly lower reconstruction rate (35% vs. 49%, p < 0.01) and received a larger proportion of autologous reconstruction (13% vs. 7%, p < 0.01) compared to Caucasian women. The receipt of adjuvant radiation therapy was a significant predictor of breast reconstruction in Caucasian but not African American women. CONCLUSIONS We identified breast reconstruction disparities in rate and type of reconstruction. These disparities may be due to racial differences in sociodemographic, tumor, and treatment characteristics. The predictors of breast reconstruction varied by race, suggesting that the mechanisms underlying breast reconstruction may vary in African American women. Future research should take a target approach to examine the relative contributions of sociodemographic, tumor, and treatment determinants of the breast reconstruction disparities in African American women.
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Adesoye T, Sun SX, Schaverien MV, Woodward WA, Lucci A. Immediate Breast Reconstruction in Inflammatory Breast Cancer: Are We There Yet? Ann Surg Oncol 2022; 29:10.1245/s10434-022-11788-7. [PMID: 35471749 DOI: 10.1245/s10434-022-11788-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Taiwo Adesoye
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susie X Sun
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark V Schaverien
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wendy A Woodward
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony Lucci
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Gao P, Wang X, Bai P, Kong X, Wang Z, Fang Y, Wang J. Clinical outcomes and patient satisfaction with the use of biological and synthetic meshes in one-stage implant-based breast reconstruction. Breast Cancer 2022; 29:450-457. [PMID: 34978672 DOI: 10.1007/s12282-021-01324-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 12/12/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Biological and synthetic meshes were used to cover the damaged muscle and augment the subpectoral pocket in breast reconstruction. However, few studies have directly compared the effects of biological and synthetic meshes. This study analyzed postoperative complications and assessed the patient-reported outcomes with the use of BioDesign® Surgisis and TiLOOP Bra/TiMesh® in one-stage implant-based breast reconstruction. METHODS Patients undergoing one-stage implant-based breast reconstruction were enrolled in this study. Post-mastectomy breast reconstructions were facilitated with either Surgisis mesh or TiLOOP mesh. Complications were examined and patient-reported quality-of-life outcomes were evaluated using the BREAST-Q questionnaire (ver 2.0). The multivariate linear regression models were used for data analysis. RESULTS Overall, 79 of 116 patients (68%) received breast reconstruction with Surgisis mesh and 37 (32%) with TiLOOP mesh. There was no difference in complication rates between the two groups postoperatively. But patient-reported satisfaction was higher with the use of Surgisis mesh than with TiLOOP mesh (P = 0.05). CONCLUSIONS This study reported no difference between the Surgisis group and the TiLOOP group in either complication rates or most patient-reported outcomes postoperatively. Yet the assessment of patient-reported satisfaction showed preference toward Surgisis mesh, a finding with a potential implication for mesh selection.
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Affiliation(s)
- Peng Gao
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Xiangyu Wang
- Department of The Operating Room, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Ping Bai
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Xiangyi Kong
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Zhongzhao Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
| | - Yi Fang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
| | - Jing Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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Oskar S, Nelson JA, Hicks ME, Seier KP, Tan KS, Chu JJ, West S, Allen RJ, Barrio AV, Matros E, Afonso AM. The Impact of Race on Perioperative and Patient-Reported Outcomes following Autologous Breast Reconstruction. Plast Reconstr Surg 2022; 149:15-27. [PMID: 34936598 PMCID: PMC9099419 DOI: 10.1097/prs.0000000000008633] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Racial disparities are evident in multiple aspects of the perioperative care of breast cancer patients, but data examining whether such differences translate to clinical and patient-reported outcomes are limited. This study examined the impact of race on perioperative outcomes in autologous breast reconstruction. METHODS A retrospective cohort study including all breast cancer patients who underwent immediate autologous breast reconstruction at a single institution from 2010 to 2017 was conducted. Self-reported race was used to classify patients into three groups: white, African American, and other. The primary and secondary endpoints were occurrence of any major complications within 30 days of surgery and patient-reported outcomes (measured with the BREAST-Q), respectively. Regression models were constructed to identify factors associated with the outcomes. RESULTS Overall, 404 patients, including 259 white (64 percent), 63 African American (16 percent), and 82 patients from other minority groups (20 percent), were included. African American patients had a significantly higher proportion of preoperative comorbidities. Postoperatively, African American patients had a higher incidence of 30-day major complications (p = 0.004) and were more likely to return to the operating room (p = 0.006). Univariable analyses examining complications demonstrated that race was the only factor associated with 30-day major complications (p = 0.001). Patient-reported outcomes were not statistically different at each time point through 3 years postoperatively. CONCLUSIONS African American patients continue to present with increased comorbidities and may be more likely to experience major complications following immediate autologous breast reconstruction. However, patient-reported satisfaction or physical well-being outcomes may not differ between groups. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
- Sabine Oskar
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonas A. Nelson
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Madeleine E.V. Hicks
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kenneth P. Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jacqueline J. Chu
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Scott West
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert J. Allen
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrea V. Barrio
- Breast Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Evan Matros
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anoushka M. Afonso
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
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Parmeshwar N, Sultan SM, Kim EA, Piper ML. A Systematic Review of the Utility of Indocyanine Angiography in Autologous Breast Reconstruction. Ann Plast Surg 2021; 86:601-606. [PMID: 33346549 DOI: 10.1097/sap.0000000000002576] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In the last decade, a number of studies have demonstrated the utility of indocyanine green (ICG) angiography in predicting mastectomy skin flap necrosis for immediate breast reconstruction. However, data are limited to investigate this technique for autologous breast reconstruction. Although it may have the potential to improve free flap outcomes, there has not been a large multicenter study to date that specifically addresses this application. METHODS A thorough literature review based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was conducted. All studies that examined the use of intraoperative ICG angiography or SPY to assess perfusion of abdominally based free flaps for breast reconstruction from January 1, 2000, to January 1, 2020, were included. Free flap postoperative complications including total flap loss, partial flap loss, and fat necrosis were extracted from selected studies. RESULTS Nine relevant articles were identified, which included 355 patients and 824 free flaps. A total of 472 free flaps underwent clinical assessment of perfusion intraoperatively, whereas 352 free flaps were assessed with ICG angiography. Follow-up was from 3 months to 1 year. The use of ICG angiography was associated with a statistically significant decrease in flap fat necrosis in the follow-up period (odds ratio = 0.31, P = 0.02). There was no statistically significant difference for total or partial flap loss. CONCLUSIONS From this systematic review, it can be concluded that ICG angiography may be an effective and efficient way to reduce fat necrosis in free flap breast reconstruction and may be a more sensitive predictor of flap perfusion than clinical assessment alone. Future prospective studies are required to further determine whether ICG angiography may be superior to clinical assessment in predicting free flap outcomes.
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Affiliation(s)
- Nisha Parmeshwar
- From the Division of Plastic Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Steven M Sultan
- Division of Plastic Surgery, Department of Surgery, Ucahn School of Medicine at Mount Sinai
| | - Esther A Kim
- From the Division of Plastic Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Merisa L Piper
- From the Division of Plastic Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
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13
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Saheb-Al-Zamani M, Cordeiro E, O'Neill AC, Hofer SO, Cil TD, Zhong T. Early Postoperative Complications From National Surgical Quality Improvement Program: A Closer Examination of Timing and Technique of Breast Reconstruction. Ann Plast Surg 2021; 86:S159-S164. [PMID: 33208650 PMCID: PMC7969155 DOI: 10.1097/sap.0000000000002590] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/13/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality. STUDY DESIGN The NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications. RESULTS Of 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01). CONCLUSIONS Immediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.
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Affiliation(s)
| | | | - Anne C. O'Neill
- From the Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto
| | - Stefan O.P. Hofer
- From the Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto
| | - Tulin D. Cil
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Toni Zhong
- From the Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto
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14
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Mandelbaum A, Nakhla M, Seo YJ, Dobaria V, Attai DJ, Baker JL, Thompson CK, DiNome ML, Benharash P, Lee MK. National trends and predictors of mastectomy with immediate breast reconstruction. Am J Surg 2021; 222:773-779. [PMID: 33627231 DOI: 10.1016/j.amjsurg.2021.02.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/14/2021] [Accepted: 02/07/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE This study aimed to evaluate national trends in utilization, resource use, and predictors of immediate breast reconstruction (IR) after mastectomy. METHODS The 2005-2014 National Inpatient Sample database was used to identify adult women undergoing mastectomy. IR was defined as any reconstruction during the same inpatient stay. Multivariable regression models were utilized to identify factors associated with IR. RESULTS Of 729,340 patients undergoing mastectomy, 41.3% received IR. Rates of IR increased from 28.2% in 2005 to 58.2% in 2014 (NP-trend<0.001). Compared to mastectomy alone, IR was associated with increased length of stay (2.5 vs. 2.1 days, P < 0.001) and hospitalization costs ($17,628 vs. $8,643, P < 0.001), which increased over time (P < 0.001). Predictors of IR included younger age, fewer comorbidities, White race, private insurance, top income quartile, teaching hospital designation, high mastectomy volume, and performance of bilateral mastectomy. CONCLUSION Mastectomy with IR is increasingly performed with resource utilization rising at a steady pace. Our study points to persistent sociodemographic and hospital level disparities associated with the under-utilization of IR. Efforts are needed to alleviate disparities in IR.
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Affiliation(s)
- Ava Mandelbaum
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Morcos Nakhla
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Young Ji Seo
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Deanna J Attai
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States
| | - Jennifer L Baker
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States
| | - Carlie K Thompson
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States
| | - Maggie L DiNome
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Minna K Lee
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States.
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15
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Wang J, Xiu B, Guo R, Zhang Q, Su Y, Li L, Chi W, Shao Z, Wu J. Autologous tissue reconstruction after mastectomy-A cross-sectional survey of 110 hospitals in China. Eur J Surg Oncol 2020; 46:2202-2207. [PMID: 32807619 DOI: 10.1016/j.ejso.2020.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 06/11/2020] [Accepted: 07/06/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Autologous reconstruction after mastectomy became more and more popular, so this study aimed to obtain up-to-date and comprehensive data on autologous reconstruction in China. METHODS An electronic questionnaire was sent to 110 hospitals, which were chosen depending on geographical distribution and hospital types. The questionnaire investigated the demographics, characteristics, breast cancer treatment and reconstruction situation of these hospitals through different modules. We only focused on the autologous breast reconstruction module data. RESULTS 96 hospitals have performed breast reconstruction surgery. The proportion of the hospital performing latissimus dorsi flap (LDF, N = 91), pedicle transverse rectus abdominis myocutaneous flap (pTRAM, N = 62), free abdominal flap (N = 43) and other kinds of flap decreased in sequence. Of the overall reconstruction cases, only 34.3% were autologous reconstruction and LDF was still the most popular option for autologous reconstruction. Related factors of hospital performing different procedures included years of performing breast reconstruction, breast surgical volume, and establishment of an independent plastic surgery department. Compared with LDF, abdominal breast reconstruction was associated with a higher flap necrosis rate. CONCLUSIONS This cross-sectional survey offers real-life autologous reconstruction information on a large population and covers the national surgical landscape in China. Autologous reconstruction is still an important part of breast reconstruction. Nevertheless, its low proportion and lower proportion of abdominal flap reconstruction in each institution, demonstrates that special training should be developed for breast surgeons and multidisciplinary cooperation would be promoted in the future.
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Affiliation(s)
- Jia Wang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center and Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Bingqiu Xiu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center and Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Rong Guo
- Department of Breast Surgery, Fudan University Shanghai Cancer Center and Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Qi Zhang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center and Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Yonghui Su
- Department of Breast Surgery, Fudan University Shanghai Cancer Center and Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Lun Li
- Department of Breast Surgery, Fudan University Shanghai Cancer Center and Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Weiru Chi
- Department of Breast Surgery, Fudan University Shanghai Cancer Center and Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Zhimin Shao
- Department of Breast Surgery, Fudan University Shanghai Cancer Center and Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Jiong Wu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center and Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
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16
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Hart SE, Momoh AO. Breast Reconstruction Disparities in the United States and Internationally. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00366-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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17
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Reid CM, Parmeshwar N, Brandel MG, Crisera CA, Herrera FA, Suliman AS. Detailed analysis of the impact of surgeon and hospital volume in microsurgical breast reconstruction. Microsurgery 2020; 40:670-678. [PMID: 32304337 DOI: 10.1002/micr.30591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/13/2020] [Accepted: 04/02/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Prior investigations of microsurgical breast reconstruction have not distinguished the effects of surgeon versus hospital volume and failed to address the effect of patient clustering. Our data-driven analysis aims to determine the impacts of surgeon and hospital volume on outcomes of microsurgical breast reconstruction. METHODS Nationwide Inpatient Sample (NIS) data from 2008 to 2011 was analyzed for patients who underwent microsurgical breast reconstruction. Volume-outcome relationships were analyzed with restricted cubic spline analysis. A multivariable mixed-effects logistic regression was used to account for patient clustering effect. RESULTS A total of 5,404 NIS patients met inclusion criteria. High-volume (HV) surgeons had a 59% decrease in the risk of inpatient complications, which became non-significant after clustering correction. For HV hospitals, there was a 47% decrease in the risk of inpatient complications (odds ratio = 0.53; 95% confidence intervals 0.30, 0.91; p = 0.021) that was statistically significant with the clustering adjustment. Neither the volume-cost relationship for surgeons nor hospitals remained statistically significant after accounting for clustering. CONCLUSIONS Hospital volume plays a significant impact on outcomes in microsurgical breast reconstruction, while surgeon volume has comparatively not shown to be similarly impactful. The complexity of care related to microsurgical breast reconstruction warrants equally complex and engineered health systems.
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Affiliation(s)
- Chris M Reid
- Division of Plastic Surgery, Department of Surgery, University of California, San Diego, California, USA.,Section of Plastic & Reconstructive Surgery, VA San Diego Healthcare System, San Diego, California, USA
| | - Nisha Parmeshwar
- Division of Plastic Surgery, Department of Surgery, University of California, San Francisco, California, USA
| | - Michael G Brandel
- Division of Plastic Surgery, Department of Surgery, University of California, San Diego, California, USA
| | - Christopher A Crisera
- Division of Plastic Surgery, Department of Surgery, University of California, Los Angeles, California, USA
| | - Fernando A Herrera
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ahmed S Suliman
- Division of Plastic Surgery, Department of Surgery, University of California, San Diego, California, USA.,Section of Plastic & Reconstructive Surgery, VA San Diego Healthcare System, San Diego, California, USA
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18
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Doherty C, Pearce S, Baxter N, Knowles S, Ross D, McClure JA, Brackstone M. Trends in immediate breast reconstruction and radiation after mastectomy: A population study. Breast J 2020; 26:446-453. [DOI: 10.1111/tbj.13500] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Christopher Doherty
- Division of Plastic & Reconstructive Surgery Western University London Ontario Canada
| | - Sabrina Pearce
- Division of Plastic & Reconstructive Surgery Western University London Ontario Canada
| | - Nancy Baxter
- Division of General Surgery University of Toronto Toronto Ontario Canada
| | - Sarah Knowles
- Division of General Surgery Western University London Ontario Canada
| | - Douglas Ross
- Division of Plastic & Reconstructive Surgery Western University London Ontario Canada
| | - J. Andrew McClure
- Institute for Clinical and Evaluative Sciences Western University London Ontario Canada
| | - Muriel Brackstone
- Division of General Surgery Western University London Ontario Canada
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19
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Qi X, Wang K, Sun D, Zhang L. Does Choice of Reconstruction Type Affect Survival in Patients With Metastatic Breast Cancer? J Surg Res 2019; 247:479-489. [PMID: 31668432 DOI: 10.1016/j.jss.2019.09.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/02/2019] [Accepted: 09/25/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND To compare the breast cancer-specific survival (BCSS) and overall survival (OS) between patients who underwent implant or tissue reconstruction after mastectomy with distant metastatic breast cancer (MBC). MATERIALS AND METHODS Using the Surveillance, Epidemiology, and End Results database, we enrolled 371 female MBC cases diagnosed during the years 2004-2014. Patients were subdivided into implant (176) and tissue groups (195) for survival comparison between the two groups. The end points were BCSS and OS. Comparisons of the distribution of clinicopathologic characteristics were evaluated by chi-square test and Fisher exact test. Survival outcomes were compared by Kaplan-Meier model and multivariate Cox regression model for known clinicopathologic variables in both the entire population and in the reconstruction cohorts. RESULTS In the entire cohort, patients with implant exhibited distinctly better BCSS (log rank, P = 0.002) and OS (log rank, P = 0.001) than patients with tissue reconstruction. Multivariate Cox regression model revealed that patients, who received prosthetic implants, were married, and progesterone receptor-positive group showed better survival rates in BCSS and OS. In addition, after stratification of the implant group and tissue groups according to clinicopathologic variables, the survival rate of patients in the implant group was higher than that in the tissue reconstruction group under the influence of factors, such as married, estrogen receptor-negative, nonradiotherapy, and chemotherapy. CONCLUSIONS Our study provides further survival evidence supporting the practice of mastectomy with prosthetic implant reconstruction in patients with MBC under certain conditions.
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Affiliation(s)
- Xin Qi
- Department of Breast Surgery, China-Japan Union Hospital, Jilin University, Changchun, Jilin, China
| | - Keren Wang
- Department of Breast Surgery, China-Japan Union Hospital, Jilin University, Changchun, Jilin, China
| | - Denghua Sun
- Department of Breast Surgery, China-Japan Union Hospital, Jilin University, Changchun, Jilin, China
| | - Le Zhang
- Department of Breast Surgery, China-Japan Union Hospital, Jilin University, Changchun, Jilin, China.
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20
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Samiei S, van Kaathoven BN, Boersma L, Granzier RWY, Siesling S, Engelen SME, de Munck L, van Kuijk SMJ, van der Hulst RRJW, Lobbes MBI, Smidt ML, van Nijnatten TJA. Risk of Positive Sentinel Lymph Node After Neoadjuvant Systemic Therapy in Clinically Node-Negative Breast Cancer: Implications for Postmastectomy Radiation Therapy and Immediate Breast Reconstruction. Ann Surg Oncol 2019; 26:3902-3909. [PMID: 31359276 PMCID: PMC6787110 DOI: 10.1245/s10434-019-07643-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Residual axillary lymph node involvement after neoadjuvant systemic therapy (NST) is the determining factor for postmastectomy radiation therapy (PMRT). Preoperative identification of patients needing PMRT is essential to enable shared decision-making when choosing the optimal timing of breast reconstruction. We determined the risk of positive sentinel lymph node (SLN) after NST in clinically node-negative (cN0) breast cancer. METHODS All cT1-3N0 patients treated with NST followed by mastectomy and SLNB between 2010 and 2016 were identified from the Netherlands Cancer Registry. Rate of positive SLN for different breast cancer subtypes was determined. Logistic regression analysis was performed to determine correlated clinicopathological variables with positive SLN. RESULTS In total 788 patients were included, of whom 25.0% (197/788) had positive SLN. cT1-3N0 ER+HER2+, cT1-3N0 ER-HER2+ , and cT1-2N0 triple-negative patients had the lowest rate of positive SLN: 7.2-11.5%, 0-6.3%, and 2.9-6.2%, respectively. cT1-3N0 ER+HER2- and cT3N0 triple-negative patients had the highest rate of positive SLN: 23.8-41.7% and 30.4%, respectively. Multivariable regression analysis showed that cT2 (odds ratio [OR] 1.93; 95% confidence interval [CI] 1.01-3.96), cT3 (OR 2.56; 95% CI 1.30-5.38), grade 3 (OR 0.44; 95% CI 0.21-0.91), and ER+HER2- subtype (OR 3.94; 95% CI 1.77-8.74) were correlated with positive SLN. CONCLUSIONS In cT1-3N0 ER+HER2+, cT1-3N0 ER-HER2+, and cT1-2N0 triple-negative patients treated with NST, immediate reconstruction can be considered an acceptable option due to low risk of positive SLN. In cT1-3N0 ER+HER2- and cT3N0 triple-negative patients treated with NST, risks and benefits of immediate reconstruction should be discussed with patients due to the relatively high risk of positive SLN.
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MESH Headings
- Adolescent
- Adult
- Aged
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Breast Neoplasms/drug therapy
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/therapy
- Carcinoma, Lobular/drug therapy
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/therapy
- Combined Modality Therapy
- Female
- Follow-Up Studies
- Humans
- Mammaplasty/methods
- Mastectomy/methods
- Middle Aged
- Neoadjuvant Therapy/methods
- Prognosis
- Radiotherapy, Adjuvant/methods
- Receptor, ErbB-2/metabolism
- Receptors, Estrogen/metabolism
- Receptors, Progesterone/metabolism
- Retrospective Studies
- Sentinel Lymph Node Biopsy
- Young Adult
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Affiliation(s)
- S Samiei
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands.
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | - B N van Kaathoven
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - L Boersma
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Radiation Oncology, Maastricht University Medical Center+ (MAASTRO Clinic), Maastricht, The Netherlands
| | - R W Y Granzier
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - S Siesling
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
- Department of Health Technology and Services Research, Technical Medical Center, University of Twente, Enschede, The Netherlands
| | - S M E Engelen
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - L de Munck
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - R R J W van der Hulst
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - M B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - M L Smidt
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - T J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
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21
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Breast Reconstruction with Free Abdominal Flaps Is Associated with Persistent Lower Extremity Venous Stasis. Plast Reconstr Surg 2019; 143:1144e-1150e. [PMID: 30907811 DOI: 10.1097/prs.0000000000005613] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous work has demonstrated the occurrence of lower extremity venous stasis in the early postoperative period after breast reconstruction with free abdominal flaps. The authors investigated whether venous stasis persisted through the day of discharge, thus potentially exposing patients to an elevated risk of venous thromboembolism following discharge. METHODS Patients who underwent breast reconstruction with free abdominal flaps were enrolled prospectively and underwent duplex ultrasound of the common femoral vein at the following time points: preoperatively, postoperative day 1, and day of discharge. Parameters of interest included common femoral vein diameter, area, and maximum flow velocity. RESULTS Thirty patients with a mean age of 50.3 years (range, 29 to 70 years) underwent breast reconstruction with 52 free abdominal flaps. A significant increase in common femoral vein diameter (19.1 percent; p < 0.01) and area (46.8 percent; p < 0.01) correlated with a significant reduction in maximum flow velocity (-10.9 percent; p = 0.03) between baseline and postoperative day 1. These changes persisted through the day of discharge [common femoral vein diameter, 17.8 percent (p < 0.01); area, 46 percent (p < 0.01); and maximum flow velocity, -11.3 percent (p = 0.01)]. Venous parameters were not influenced by unilateral versus bilateral flap harvest (p = 0.48). CONCLUSIONS Postoperative lower extremity venous stasis following autologous breast reconstruction with free abdominal flaps seems to persist through the day of discharge. This finding may explain why patients remain at risk for venous thromboembolism after discharge. Although the authors' findings are at odds with current venous thromboembolism prophylaxis recommendations, additional studies are indicated to examine whether these findings translate into venous thromboembolism events. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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22
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Immediate Breast Reconstruction in The Netherlands and the United States: A Proof-of-Concept to Internationally Compare Quality of Care Using Cancer Registry Data. Plast Reconstr Surg 2019; 144:565e-574e. [PMID: 31568284 DOI: 10.1097/prs.0000000000006011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Studies based on large-volume databases have made significant contributions to research on breast cancer surgery. To date, no comparison between large-volume databases has been made internationally. This is the first proof-of-concept study exploring the feasibility of combining two existing operational databases of The Netherlands and the United States, focusing on breast cancer care and immediate breast reconstruction specifically.313/291 METHODS:: The National Breast Cancer Organization The Netherlands Breast Cancer Audit (NBCA) (2011 to 2015) and the U.S. Surveillance, Epidemiology, and End Results (SEER) database (2010 to 2013) were compared on structure and content. Data variables were grouped into general, treatment-specific, cancer-specific, and follow-up variables and were matched. As proof-of-concept, mastectomy and immediate breast reconstruction rates in patients diagnosed with invasive breast cancer or ductal carcinoma in situ were analyzed. RESULTS The NBCA included 115 variables and SEER included 112. The NBCA included significantly more treatment-specific variables (n = 46 versus 6), whereas the SEER database included more cancer-specific variables (n = 74 versus 26). In patients diagnosed with breast cancer or ductal carcinoma in situ, immediate breast reconstruction was performed in 19.3 percent and 24.0 percent of the breast cancer cohort and 44.0 percent and 35.3 percent of the ductal carcinoma in situ cohort in the NBCA and SEER, respectively. Immediate breast reconstruction rates increased significantly over time in both data sets. CONCLUSIONS This study provides a first overview of available registry data on breast cancer care in The Netherlands and the United States, and revealed limited data on treatment in the United States. Comparison of treatment patterns of immediate breast reconstruction showed interesting differences. The authors advocate the urgency for an international database with alignment of (treatment) variables to improve quality of breast cancer care for patients across the globe.
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23
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DeCoster RC, Bautista RMF, Burns JC, Dugan AJ, Edmunds RW, Rinker BD, Webster JM, Vasconez HC. Rural-Urban Differences in Breast Reconstruction Utilization Following Oncologic Resection. J Rural Health 2019; 36:347-354. [PMID: 31508853 DOI: 10.1111/jrh.12396] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 07/19/2019] [Accepted: 08/19/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Breast reconstruction (BR) is the reconstructive surgical technique that focuses on restoring normal form and function to the breast following oncologic resection. The goal of this study was to determine if BR disparities exist among rural female patients in Kentucky. METHODS A retrospective (2006-2015), population-based cohort study was conducted on breast cancer patients (stages I-III) treated with mastectomy with or without BR. We used 2013 Beale codes to stratify patients according to geographic status. Chi-square tests were used to examine the association of BR along the rural-urban continuum. A multivariate logistic regression model controlling for patient, disease, and treatment factors was used to predict BR. The likelihood of BR was reported in odds ratios (OR) using a 95% confidence interval (CI). RESULTS Overall, 10,032 patients met study criteria. Of those, 2,159 (21.5%) underwent BR. The rate of BR among urban, near-metro, and rural patients was 31.1%, 20.4%, and 13.4%, respectively (P < .001). Multivariate analysis revealed that women from near metro (OR 0.54, CI: 0.47-0.61; P < .001) and rural areas (OR 0.36, CI: 0.31-0.41; P < .001) were less likely to undergo BR than women from urban areas. CONCLUSION Although BR benefits are well documented, women from rural Kentucky undergo BR at lower rates and are less likely to receive BR than their urban counterparts. Efforts should seek to promote equitable access to BR for all patients, including those from rural areas.
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Affiliation(s)
- Ryan C DeCoster
- Lucille P. Markey Cancer Center, University of Kentucky, Lexington, Kentucky.,Division of Plastic and Reconstructive Surgery, University of Kentucky, Lexington, Kentucky
| | - Robert-Marlo F Bautista
- Lucille P. Markey Cancer Center, University of Kentucky, Lexington, Kentucky.,Department of Surgery, Division of General Surgery, University of Kentucky, Lexington, Kentucky
| | - Jack C Burns
- Division of Plastic and Reconstructive Surgery, University of Kentucky, Lexington, Kentucky
| | - Adam J Dugan
- Department of Biostatistics, University of Kentucky, Lexington, Kentucky
| | - R Wesley Edmunds
- Division of Plastic and Reconstructive Surgery, University of Kentucky, Lexington, Kentucky
| | - Brian D Rinker
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Jacksonville, Florida
| | - J Matthew Webster
- Department of Behavioral Science, University of Kentucky, Lexington, Kentucky
| | - Henry C Vasconez
- Department of Surgery, Division of General Surgery, University of Kentucky, Lexington, Kentucky
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24
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Abstract
BACKGROUND The purpose of this systematic review was to comprehensively summarize barriers of access to breast reconstruction and evaluate access using the Penchansky and Thomas conceptual framework based on the six dimensions of access to care. METHODS The authors performed a systematic review that focused on (1) breast reconstruction, (2) barriers, and (3) breast cancer. Eight databases (i.e., EMBASE, MEDLINE, PsycINFO, CINHAL, ePub MEDLINE, ProQuest, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials) were searched. English peer-reviewed articles published between 1996 and 2016 were included. RESULTS The authors' search retrieved 4282 unique articles. Two independent reviewers screened texts, selecting 99 articles for inclusion. All studies were observational and qualitative in nature. The availability of breast reconstruction was highest in teaching hospitals, private hospitals, and national cancer institutions. Accessibility affected access, with lower likelihood of breast reconstruction in rural geographic locations. Affordability also impacted access; high costs of the procedure or poor reimbursement by insurance companies negatively influenced access to breast reconstruction. Acceptability of the procedure was not universal, with unfavorable physician attitudes toward breast reconstruction and specific patient and tumor characteristics correlating with lower rates of breast reconstruction. Lastly, lack of patient awareness of breast reconstruction reduced the receipt of breast reconstruction. CONCLUSIONS Using the access-to-care framework by Penchansky and Thomas, the authors found that barriers to breast reconstruction existed in all six domains and interplayed at many levels. The authors' systematic review analyzed this complex relationship and suggested multiprong interventions aimed at targeting breast reconstruction barriers, with the goal of promoting equitable access to breast reconstruction for all breast cancer patients.
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Sergesketter AR, Thomas SM, Lane WO, Orr JP, Shammas RL, Fayanju OM, Greenup RA, Hollenbeck ST. Decline in Racial Disparities in Postmastectomy Breast Reconstruction: A Surveillance, Epidemiology, and End Results Analysis from 1998 to 2014. Plast Reconstr Surg 2019; 143:1560-1570. [PMID: 31136468 PMCID: PMC6708552 DOI: 10.1097/prs.0000000000005611] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite increasing emphasis on reducing racial disparities in breast cancer care in the United States, it remains unknown whether access to breast reconstruction has improved over time. The authors characterized contemporary patterns of breast reconstruction by race and ethnicity. METHODS The Surveillance, Epidemiology, and End Results database was used to identify women undergoing mastectomy for stage 0 to III breast cancer from 1998 to 2014. Multivariable logistic regression was used to estimate the association of demographic factors with likelihood of postmastectomy reconstruction. Multivariable logistic regression was used to predict reconstruction subtype. Patients undergoing reconstruction were grouped by diagnosis year to assess change in the population over time by race and ethnicity. RESULTS Of 346,418 patients, 21.8 percent underwent immediate reconstruction. Non-Hispanic black race (OR, 0.71) and Hispanic ethnicity (OR, 0.63) were associated with a decreased likelihood of reconstruction (all p < 0.001). Race was predictive of reconstruction type, with non-Hispanic black (OR, 1.52) and Hispanic women (OR, 1.22) more likely to undergo autologous versus implant-based reconstruction (p < 0.001). Although rates of reconstruction increased over time across all races, non-Hispanic black and Hispanic patients had a higher adjusted per-year increase in rate of reconstruction compared with non-Hispanic white patients (interaction p < 0.001). CONCLUSIONS Rates of postmastectomy reconstruction have increased more quickly over time for minority women compared with white women, suggesting that racial disparities in breast reconstruction may be improving. However, race continues to be associated with differences in types and rates of reconstruction. Further research is necessary to continue to improve access to breast reconstruction in the United States. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Amanda R Sergesketter
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
| | - Samantha M Thomas
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
| | - Whitney O Lane
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
| | - Jonah P Orr
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
| | - Ronnie L Shammas
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
| | - Oluwadamilola M Fayanju
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
| | - Rachel A Greenup
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
| | - Scott T Hollenbeck
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
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The influence of neoadjuvant chemotherapy on complications of immediate DIEP flap breast reconstructions. Breast Cancer Res Treat 2019; 176:367-375. [PMID: 31030303 PMCID: PMC6555777 DOI: 10.1007/s10549-019-05241-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 04/15/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The impact of neoadjuvant chemotherapy on the surgical outcomes of immediate breast reconstruction remains controversial. The aim of this study was to analyze the incidence of complications of immediate deep inferior epigastric artery perforator (DIEP) flap breast reconstructions in patients who received neoadjuvant chemotherapy compared to patients without neoadjuvant chemotherapy prior to surgery. METHODS A multicenter, retrospective cohort study was conducted of all patients who underwent immediate DIEP flap breast reconstruction between January 2010 and June 2017. Patients were divided in two groups as breast reconstructions with or without neoadjuvant chemotherapy, respectively. The primary outcome was the incidence of postoperative flap re-explorations, recipient-site complications and donor-site complications. RESULTS In total 432 immediate DIEP flap breast reconstructions in 326 patients were included. Forty-eight patients (n = 67 flaps) received neoadjuvant chemotherapy prior to immediate breast reconstruction and 278 patients (n = 365 flaps) did not. No statistically significant differences for any major (4.5% vs. 10.4%; p = 0.175) or minor (16.4% vs. 24.7%; p = 0.191) recipient-site complication were observed. Donor-site complications were recorded in 9 (18.8%) and 62 (22.2%) patients, respectively (p = 0.587). There was no difference in need for flap re-exploration between groups (3.0% vs. 8.5%; p = 0.139). Correction for potential confounding variables did not result in significant differences. CONCLUSIONS This study demonstrated similar complication rates for patients with and without neoadjuvant chemotherapy prior to immediate breast reconstruction, indicating that it is safe to perform an immediate DIEP flap breast reconstruction after neoadjuvant chemotherapy.
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Wang M, Chen H, Wu K, Ding A, Zhang P, Zhang M. Post-mastectomy immediate breast reconstruction is oncologically safe in well-selected T4 locally advanced breast cancer: a large population-based study and matched case–control analysis. Breast Cancer Res Treat 2019; 176:337-347. [DOI: 10.1007/s10549-019-05240-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 04/15/2019] [Indexed: 02/07/2023]
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Factors Leading to Decreased Rates of Immediate Postmastectomy Reconstruction. J Surg Res 2019; 238:207-217. [PMID: 30772679 DOI: 10.1016/j.jss.2019.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 12/19/2018] [Accepted: 01/04/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study was performed to determine if there was a difference in immediate breast reconstruction (IBR) rates between our public hospital and private cancer center, which share a common faculty with a consistent management philosophy in multidisciplinary care. We investigated the factors affecting postmastectomy reconstruction and IBR rates. MATERIALS AND METHODS We retrospectively identified women with clinical stage I-II breast cancer who underwent mastectomy at our public hospital, Los Angeles County Medical Center, and our private cancer center, Keck Hospital of USC/Norris Comprehensive Cancer Center. Univariate and multivariate analyses were performed to study predictors of IBR and any breast reconstruction. RESULTS Of 293 mastectomy patients, the rate of any breast reconstruction at the private cancer (56.6%) center was higher than that at the public hospital (36.2%). IBR rates for the private cancer center (93.6%) and for patients with private insurance were higher than for the public hospital (40.8%) and likewise for those without insurance (86.7% versus 45.5%). In a multivariate analysis, the odds of IBR at our private cancer center were 22.96 times higher than that at our public hospital. Age >50 y and radiotherapy were independent predictive factors associated with less likelihood of any breast reconstruction. CONCLUSIONS Patients at the public hospital had a much lower rate of breast reconstruction than the private cancer center patients, even after controlling for stage and the team of treating physicians. Our results showed that older age and radiotherapy affect rates of breast reconstruction, as do hospital system and insurance status.
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Hypofractionated versus conventional fractionated postmastectomy radiotherapy for patients with high-risk breast cancer: a randomised, non-inferiority, open-label, phase 3 trial. Lancet Oncol 2019; 20:352-360. [PMID: 30711522 DOI: 10.1016/s1470-2045(18)30813-1] [Citation(s) in RCA: 225] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/16/2018] [Accepted: 10/18/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND To our knowledge, no randomised study has compared postmastectomy hypofractionated radiotherapy with conventional fractionated radiotherapy in patients with breast cancer. This study aimed to determine whether a 3-week schedule of postmastectomy hypofractionated radiotherapy is as efficacious and safe as a 5-week schedule of conventional fractionated radiotherapy. METHODS This randomised, non-inferiority, open-label, phase 3 study was done in a single academic hospital in China. Patients aged 18-75 years who had undergone mastectomy and had at least four positive axillary lymph nodes or primary tumour stage T3-4 disease were eligible to participate. Patients were randomly assigned (1:1) according to a computer-generated central randomisation schedule, without stratification, to receive chest wall and nodal irradiation at a dose of 50 Gy in 25 fractions over 5 weeks (conventional fractionated radiotherapy) or 43·5 Gy in 15 fractions over 3 weeks (hypofractionated radiotherapy). The modified intention-to-treat population (including all eligible patients who underwent randomisation but excluding those who were considered ineligible or withdrew consent after randomisation) was used in primary and safety analyses. The primary endpoint was 5-year locoregional recurrence, and a 5% margin was used to establish non-inferiority (equivalent to a hazard ratio <1·883). This trial is registered at ClinicalTrials.gov, number NCT00793962. FINDINGS Between June 12, 2008, and June 16, 2016, 820 patients were enrolled and randomly assigned to the conventional fractionated radiotherapy group (n=414) or hypofractionated radiotherapy group (n=406). 409 participants in the conventional fractionated radiotherapy group and 401 participants in the hypofractionated radiotherapy group were included in the modified intention-to-treat analyses. At a median follow-up of 58·5 months (IQR 39·2-81·8), 60 (7%) patients had developed locoregional recurrence (31 patients in the hypofractionated radiotherapy group and 29 in the conventional fractionated radiotherapy group); the 5-year cumulative incidence of locoregional recurrence was 8·3% (90% CI 5·8-10·7) in the hypofractionated radiotherapy group and 8·1% (90% CI 5·4-10·6) in the conventional fractionated radiotherapy group (absolute difference 0·2%, 90% CI -3·0 to 2·6; hazard ratio 1·10, 90% CI 0·72 to 1·69; p<0·0001 for non-inferiority). There were no significant differences between the groups in acute and late toxicities, except that fewer patients in the hypofractionated radiotherapy group had grade 3 acute skin toxicity than in the conventional fractionated radiotherapy group (14 [3%] of 401 patients vs 32 [8%] of 409 patients; p<0·0001). INTERPRETATION Postmastectomy hypofractionated radiotherapy was non-inferior to and had similar toxicities to conventional fractionated radiotherapy in patients with high-risk breast cancer. Hypofractionated radiotherapy could provide more convenient treatment and allow providers to treat more patients. FUNDING National Key Projects of Research and Development of China; the Chinese Academy of Medical Science Innovation Fund for Medical Sciences; and Beijing Marathon of Hope, Cancer Foundation of China.
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Wirth LS, Hinyard L, Keller J, Bucholz E, Schwartz T. Geographic variations in racial disparities in postmastectomy breast reconstruction: A SEER database analysis. Breast J 2018; 25:112-116. [PMID: 30536478 DOI: 10.1111/tbj.13166] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 11/21/2017] [Accepted: 11/22/2017] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to determine whether racial disparities in reconstruction in the United States vary by geographic region. The SEER database years 2000-2013 was queried for all mastectomies in women ages 20-85+. Logistic regression was used to examine the main effects and interaction of race and geographic region on reconstruction. Hot spot Analysis was used to examine clustering of reconstruction across counties by race. We found large regional variation in racial differences in the rate of immediate postmastectomy reconstruction. Understanding how racial disparities vary by region can identify important factors for intervention to reduce disparities in practice.
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Affiliation(s)
| | - Leslie Hinyard
- Saint Louis University Center for Health Outcomes Research, Saint Louis, Missouri
| | - Jennifer Keller
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Eleanor Bucholz
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Theresa Schwartz
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri
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Siotos C, Sebai ME, Wan EL, Bello RJ, Habibi M, Cooney DS, Manahan MA, Cooney CM, Seal SM, Rosson GD. Breast reconstruction and risk of arm lymphedema development: A meta-analysis. J Plast Reconstr Aesthet Surg 2018; 71:807-818. [DOI: 10.1016/j.bjps.2018.01.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 12/13/2017] [Accepted: 01/21/2018] [Indexed: 11/15/2022]
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Trends in breast reconstruction: Implications for the National Health Insurance Service. Arch Plast Surg 2018; 45:239-245. [PMID: 29788687 PMCID: PMC5968321 DOI: 10.5999/aps.2017.01417] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 03/02/2017] [Accepted: 03/15/2017] [Indexed: 01/02/2023] Open
Abstract
Background Breast reconstruction has become more common as mastectomy has become more frequent. In Korea, the National Health Insurance Service (NHIS) began covering breast reconstruction in April 2015. This study aimed to investigate trends in mastectomy and breast reconstruction over the past 10 years and to evaluate the impact of NHIS coverage on breast reconstruction. Methods Nationwide data regarding mastectomy and breast reconstruction were collected from the Korean Breast Cancer Society registry database. Multiple variables were analyzed in the records of patients who underwent breast reconstruction from January 2005 to March 2017 at a single institution. Results At Seoul National University Hospital, the total number of reconstruction cases increased 13-fold from 2005 to 2016. The proportion of immediate breast reconstruction (IBR) cases out of all cases of total mastectomy increased from 4% in 2005 to 52.0% in 2016. The proportion of delayed breast reconstruction (DBR) cases out of all cases of breast reconstruction and the overall number of DBR cases increased from 8.8% (20 cases) in 2012 to 18.3% (76 cases) in 2016. After NHIS coverage was initiated, the proportions of IBR and DBR showed statistically significant increases (P<0.05). Among the IBR cases, the percentage of prosthesis-based reconstructions increased significantly (P<0.05), but this trend was not found with DBR. Total mastectomy became significantly more common after the expansion of NHIS coverage (P<0.05). Conclusions Over the last decade, there has been an increase in mastectomy and breast reconstruction, and the pace of increase accelerated after the expansion of NHIS coverage. It is expected that breast reconstruction will be a routine option for patients with breast cancer under the NHIS.
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The National Surgical Quality Improvement Program 30-Day Challenge: Microsurgical Breast Reconstruction Outcomes Reporting Reliability. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1643. [PMID: 29707443 PMCID: PMC5908495 DOI: 10.1097/gox.0000000000001643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 11/29/2017] [Indexed: 12/04/2022]
Abstract
Supplemental Digital Content is available in the text. Background: The aim was to assess reliability of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) 30-day perioperative outcomes and complications for immediate, free-tissue transfer breast reconstruction by direct comparisons with our 30-day and overall institutional data, and assessing those that occur after 30 days. Methods: Data were retrieved for consecutive immediate, free-tissue transfer breast reconstruction patients from a single-institution database (2010–2015) and the ACS-NSQIP (2011–2014). Multiple logistic regressions were performed to compare adjusted outcomes between the 2 datasets. Results: For institutional versus ACS-NSQIP outcomes, there were no significant differences in surgical-site infection (SSI; 30-day, 3.6% versus 4.1%, P = 0.818; overall, 5.3% versus 4.1%, P = 0.198), wound disruption (WD; 30-day, 1.3% versus 1.5%, P = 0.526; overall, 2.3% versus 1.5%, P = 0.560), or unplanned readmission (URA; 30-day, 2.3% versus 3.3%, P = 0.714; overall, 4.6% versus 3.3%, P = 0.061). However, the ACS-NSQIP reported a significantly higher unplanned reoperation (URO) rate (30-day, 3.6% versus 9.5%, P < 0.001; overall, 5.3% versus 9.5%, P = 0.025). Institutional complications consisted of 5.3% SSI, 2.3% WD, 5.3% URO, and 4.6% URA, of which 25.0% SSI, 28.6% WD, 12.5% URO, and 7.1% URA occurred at 30–60 days, and 6.3% SSI, 14.3% WD, 18.8% URO, and 42.9% URA occurred after 60 days. Conclusion: For immediate, free-tissue breast reconstruction, the ACS-NSQIP may be reliable for monitoring and comparing SSI, WD, URO, and URA rates. However, clinicians may find it useful to understand limitations of the ACS-NSQIP for complications and risk factors, as it may underreport complications occurring beyond 30 days.
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Role of Age, Tumor Grade, and Radiation Therapy on Immediate Postmastectomy Breast Reconstruction. Clin Breast Cancer 2017; 18:313-319. [PMID: 29305307 DOI: 10.1016/j.clbc.2017.11.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 10/23/2017] [Accepted: 11/29/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Despite the psychological benefits and oncologic safety of postmastectomy breast reconstruction, most breast cancer patients do not undergo reconstruction. To better understand the patterns of breast reconstruction usage, it is important to identify the clinicopathologic factors associated with immediate breast reconstruction (IBR), and whether modification of the reconstruction incidence when stratified by patient- or cancer-related factors exists in the breast cancer population. The primary objectives were to determine whether the incidence of immediate postmastectomy breast reconstruction varies across age, and whether the tumor grade or radiation therapy modify the effect of age on the incidence of immediate breast reconstruction. MATERIALS AND METHODS Using the Surveillance, Epidemiology, and End Results database, we identified women who had undergone mastectomy for breast cancer from 2000 to 2014. Inverse probability of treatment-weighted log-binomial regression was used to estimate the effect of age on IBR after accounting for potential confounding by patient demographic data and cancer characteristics. Potential effect measure modification by tumor grade and radiation therapy on the age-IBR relationship was also assessed. RESULTS Of 321,206 women, 77,798 (24.2%) had undergone IBR. Age was significantly associated with IBR prevalence (P < .0001), with younger women more likely to undergo IBR. Both tumor grade (P < .0001) and radiation therapy (P < .0001) modified the effect of age on IBR. CONCLUSION Compared with their older counterparts, younger breast cancer patients were more likely to undergo IBR, and both tumor grade and radiation therapy were differentially associated with the likelihood of IBR across patient age.
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Onega T, Weiss JE, Goodrich ME, Zhu W, DeMartini WB, Kerlikowske K, Ozanne E, Tosteson ANA, Henderson LM, Buist DSM, Wernli KJ, Herschorn SD, Hotaling E, O'Donoghue C, Hubbard R. Relationship between preoperative breast MRI and surgical treatment of non-metastatic breast cancer. J Surg Oncol 2017; 116:1008-1015. [PMID: 29127715 PMCID: PMC5760434 DOI: 10.1002/jso.24796] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 06/11/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND OBJECTIVES More extensive surgical treatments for early stage breast cancer are increasing. The patterns of preoperative MRI overall and by stage for this trend has not been well established. METHODS Using Breast Cancer Surveillance Consortium registry data from 2010 through 2014, we identified women with an incident non-metastatic breast cancer and determined use of preoperative MRI and initial surgical treatment (mastectomy, with or without contralateral prophylactic mastectomy (CPM), reconstruction, and breast conserving surgery ± radiation). Clinical and sociodemographic covariates were included in multivariable logistic regression models to estimate adjusted odds ratios and 95% confidence intervals. RESULTS Of the 13 097 women, 2217 (16.9%) had a preoperative MRI. Among the women with MRI, results indicated 32% higher odds of unilateral mastectomy compared to breast conserving surgery and of mastectomy with CPM compared to unilateral mastectomy. Women with preoperative MRI also had 56% higher odds of reconstruction. CONCLUSION Preoperative MRI in women with DCIS and early stage invasive breast cancer is associated with more frequent mastectomy, CPM, and reconstruction surgical treatment. Use of more extensive surgical treatment and reconstruction among women with DCIS and early stage invasive cancer whom undergo MRI warrants further investigation.
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Affiliation(s)
- Tracy Onega
- The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Julie E Weiss
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Martha E Goodrich
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Weiwei Zhu
- Group Health Research Institute, Seattle, Washington
| | - Wendy B DeMartini
- Department of Radiology, Stanford University Medical Center, Stanford, California
| | - Karla Kerlikowske
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Elissa Ozanne
- The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Louise M Henderson
- Department of Radiology, The University of North Carolina, Chapel Hill, North Carolina
| | | | | | - Sally D Herschorn
- University of Vermont and Vermont Cancer Center, Burlington, Vermont
- Department of Radiology, University of Vermont, Burlington, Vermont
| | - Elise Hotaling
- Department of Radiology, University of Vermont, Burlington, Vermont
| | | | - Rebecca Hubbard
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
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See MSF, Farhadi J. Radiation Therapy and Immediate Breast Reconstruction: Novel Approaches and Evidence Base for Radiation Effects on the Reconstructed Breast. Clin Plast Surg 2017; 45:13-24. [PMID: 29080655 DOI: 10.1016/j.cps.2017.08.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Patients who undergo breast reconstruction experience higher complication rates if they have had a history of radiotherapy. However, implant-based reconstruction confers significantly higher complication and reconstruction failure rates compared with autologous reconstruction. This article analyses the factors that contribute to the complications of the different breast reconstruction modalities and the strategies described to mitigate these problems.
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Affiliation(s)
- Marlene Sue-Fen See
- Department of Plastic Surgery, St. Thomas' Hospital, Guy's and St. Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK.
| | - Jian Farhadi
- Department of Plastic Surgery, St. Thomas' Hospital, Guy's and St. Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK; Reconstructive and Aesthetic Surgery, University of Basel, Petersplatz 1, 4001 Basel, Switzerland; Centre for Plastic Surgery, Klinik Pyramide am See, Bellerivestrasse 34, 8034 Zürich, Switzerland
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O'Halloran N, Lowery A, Kalinina O, Sweeney K, Malone C, McLoughlin R, Kelly J, Hussey A, Kerin M. Trends in breast reconstruction practices in a specialized breast tertiary referral centre. BJS Open 2017; 1:148-157. [PMID: 29951617 PMCID: PMC5989961 DOI: 10.1002/bjs5.23] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 08/29/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Breast reconstruction is an important component of multidisciplinary breast cancer management. The practice of breast reconstruction after mastectomy has evolved significantly in the past decade as a result of both increasing mastectomy rates and advances in reconstructive strategy. These changes have significantly influenced the contemporary surgical management of breast cancer. The aim of this study was to examine trends in breast reconstruction after mastectomy in an Irish population. METHODS Data were reviewed from a database of all patients who had mastectomy with or without breast reconstruction at Galway University Hospital, a tertiary breast cancer referral centre, between 2004 and 2014. Trends in breast reconstruction after mastectomy were explored with respect to patient demographics, clinicopathological features, and neoadjuvant and adjuvant therapy. RESULTS Of 1303 patients who underwent mastectomy during interval studied, 706 (54.2 per cent) had breast reconstruction after mastectomy. In 629 patients (89·1 per cent), breast reconstruction was performed in the immediate setting. Reconstruction rates increased over time from 20·5 per cent in 2004 to 44·7 per cent in 2014. Reconstruction was more commonly performed in younger patients and those with benign, in situ and early-stage disease. A negative relationship between radiotherapy and reconstruction was observed. A pedicled flap with or without an implant was the most commonly used reconstructive approach in patients receiving radiotherapy. CONCLUSION Breast reconstruction after mastectomy has become the standard of care in the surgical treatment of breast cancer. Recent trends show a transition favouring implant-based approaches.
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Affiliation(s)
- N. O'Halloran
- Department of SurgeryNational University of Ireland GalwayGalwayIreland
| | - A. Lowery
- Department of SurgeryNational University of Ireland GalwayGalwayIreland
| | - O. Kalinina
- Department of MathematicsNational University of Ireland GalwayGalwayIreland
| | - K. Sweeney
- Department of SurgeryNational University of Ireland GalwayGalwayIreland
| | - C. Malone
- Department of SurgeryNational University of Ireland GalwayGalwayIreland
| | - R. McLoughlin
- Department of SurgeryNational University of Ireland GalwayGalwayIreland
| | - J. Kelly
- Department of SurgeryNational University of Ireland GalwayGalwayIreland
| | - A. Hussey
- Department of SurgeryNational University of Ireland GalwayGalwayIreland
| | - M. Kerin
- Department of SurgeryNational University of Ireland GalwayGalwayIreland
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Mahmoudi E, Lu Y, Metz AK, Momoh AO, Chung KC. Association of a Policy Mandating Physician-Patient Communication With Racial/Ethnic Disparities in Postmastectomy Breast Reconstruction. JAMA Surg 2017; 152:775-783. [PMID: 28564674 DOI: 10.1001/jamasurg.2017.0921] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance With the stabilization of breast cancer incidence and substantial improvement in survival, more attention has focused on postmastectomy breast reconstruction (PBR). Despite its demonstrated benefits, wide disparities in the use of PBR remain. Physician-patient communication has an important role in disparities in health care, especially for elective surgical procedures. Recognizing this, the State of New York enacted Public Health Law (NY PBH Law) 2803-o in 2011 mandating that physicians communicate about reconstructive surgery with patients undergoing mastectomy. Objective To evaluate whether mandated physician-patient communication is associated with reduced racial/ethnic disparities in immediate PBR (IPBR). Design, Setting, and Participants This retrospective study used state inpatient data from January 1, 2008, through December 31, 2011, in New York and California to evaluate a final sample of 42 346 women aged 20 to 70 years, including 19 364 from New York (treatment group) and 22 982 from California (comparison group). The primary hypothesis tested the effect of the New York law on racial/ethnic disparities, using California as a comparator. The National Academy of Medicine's (formerly Institute of Medicine) definition of a disparity was applied, and a difference-in-differences method (before-and-after comparison design) was used to evaluate the association of NY PBH Law 2803-o mandating physician-patient communication with disparities in IPBR. Data were analyzed from July 1, 2016, to February 24, 2017. Exposures New York PBH Law 2803-o was implemented on January 1, 2011. The preexposure period included January 1, 2008, through December 31, 2010 (3 years); the postexposure period, January 1 through December 31, 2011 (1 year). Main Outcomes and Measures The primary outcome was use of IPBR among white, African American, Hispanic, and other minority groups before and after the implementation of NY PBH Law 2803-o. Results Among the 42 346 women (mean [SD] age, 53 [10] years), 65.3% (27 654) were white, 12.7% (5365) were Hispanic, 9.4% (3976) were African American, and 12.6% (5351) were other minorities. The new legislation was not associated with the overall IPBR rate or disparity in IPBR between whites and African Americans (reduction of 1 percentage point; 95% CI, -0.02 to 0.04), but it was associated with a reduction in disparities in IPBR between Hispanic and white patients by 9 (95% CI, 0.06-0.11) percentage points and between other minorities and white patients by 13 (95% CI, 0.11-0.16) percentage points. Conclusions and Relevance Physician-patient communication may help to address inequity in the use of elective surgical procedures, such as IPBR. However, lack of patient trust and/or effective physician-patient communication may reduce the potential effect of mandatory communication for some subpopulations, including African American individuals.
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Affiliation(s)
- Elham Mahmoudi
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor
| | - Yiwen Lu
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor
| | - Allan K Metz
- Office of Health Equity and Inclusion, Michigan Health Science Undergraduate Research Academy, University of Michigan, Ann Arbor.,currently an undergraduate student at Youngstown State University, Youngstown, Ohio
| | - Adeyiza O Momoh
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor
| | - Kevin C Chung
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor
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Berthet G, Faure C, Dammacco MA, Vermesch C, Delay E, Ho Quoc C, Carrabin N. Tolerance of latissimus dorsi in immediate breast reconstruction without implant to radiotherapy. J Plast Reconstr Aesthet Surg 2017; 71:15-20. [PMID: 28918997 DOI: 10.1016/j.bjps.2017.08.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 07/02/2017] [Accepted: 08/06/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Immediate breast reconstruction (IBR) improves the quality of life of patients who undergo mastectomy. The latissimus dorsi flap (LDF) method provides particularly good aesthetic results, but its tolerance to subsequent radiotherapy remains unclear. We thus sought to assess tolerance and esthetic results and satisfaction, as reported by patients who underwent IBR by LDF with or without subsequent radiotherapy. MATERIALS AND METHODS We performed a retrospective case-control study in a population of women who were diagnosed with breast cancer between January 1999 and January 2014 and who had mastectomies with IBR by LDF without prostheses. We paired 29 patients who needed postoperative radiotherapy to 58 control patients who did not. These patients responded to a questionnaire to evaluate tolerance and their satisfaction with the aesthetic results of the reconstruction. RESULTS In total, 86.2% of all patients reported "very good" or "good" overall aesthetic satisfaction. Consistency was judged as "very good" or "good" by 82.7% of control patients and by 93.1% of case patients. No statistically significant differences were identified between the two groups with regard to reconstruction results. The number of surgical procedures needed did not differ significantly between the two groups. CONCLUSION In our study, IBR by LDF appeared to have excellent tolerance to subsequent radiotherapy, the latter having no impact on patient aesthetic satisfaction. Our results suggest that the possibility of postoperative radiotherapy should not prevent physicians from proposing this method to women who are candidates for it.
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Affiliation(s)
- G Berthet
- Breast Surgery Department, Centre Léon Bérard, 28, rue Laennec, 69373 Lyon Cedex 08, France; Faculté de médecine Lyon EST, Université Lyon 1, 8 Avenue Rockefeller, 69003 Lyon, France
| | - C Faure
- Breast Surgery Department, Centre Léon Bérard, 28, rue Laennec, 69373 Lyon Cedex 08, France
| | - M A Dammacco
- Breast Surgery Department, Centre Léon Bérard, 28, rue Laennec, 69373 Lyon Cedex 08, France
| | - C Vermesch
- Breast Surgery Department, Centre Léon Bérard, 28, rue Laennec, 69373 Lyon Cedex 08, France
| | - E Delay
- Plastic, Aesthetic and Reconstructive Surgery Department, Centre Léon Bérard, 28, rue Laennec, 69373 Lyon Cedex 08, France
| | - C Ho Quoc
- Plastic, Aesthetic and Reconstructive Surgery Department, Centre Léon Bérard, 28, rue Laennec, 69373 Lyon Cedex 08, France
| | - N Carrabin
- Breast Surgery Department, Centre Léon Bérard, 28, rue Laennec, 69373 Lyon Cedex 08, France; Clinique CHARCOT, Gynecologic and Breast Surgery, 51-53, rue du Commandant Charcot, 69110 Sainte-Foy-lès-Lyon, France.
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Holliday TL, Suggs PD, Thompson SN, Richmond BK. Disparities in Rural Breast Cancer Care: Factors Affecting Choice of Breast Reconstruction in a West Virginia Tertiary Care Hospital. Am Surg 2017. [DOI: 10.1177/000313481708300727] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The decision to pursue immediate postmastectomy breast reconstruction (IBR) is not uniform across all groups of women in the United States. We sought to investigate if the challenges of caring for a socioeconomically and geographically challenged rural population affected the incidence of IBR and to identify predictive factors of IBR in this population. Using our institution's cancer registry, we conducted a 10-year review of women with early-stage, unilateral breast cancer who received mastectomy. Demographics, insurance status, comorbidities, and surgeon graduation year were compared for patients receiving IBR versus no reconstruction. Variables with P < 0.05 on univariate analysis were included into a multivariate logistic regression model to determine independent predictors of IBR. From 2006 to 2015, 53/423 (12.5%) patients underwent IBR. On multivariate analysis, three factors independently predicted the decision to undergo IBR: age (P = 0.004), insurance type (P = 0.034), and use of contralateral prophylactic mastectomy (CPM, P < 0.001). Our data indicate that age, insurance type, and utilization of CPM influence the decision to pursue reconstruction. Additionally, the rate of IBR was found to be much lower in our West Virginia population than reported nationally, suggesting disparities in the care of women with early-stage, unilateral breast cancer in a rural population, even in a tertiary care environment.
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Affiliation(s)
- Tyler L. Holliday
- West Virginia University School of Medicine–Charleston Division, Charleston, West Virginia
| | - Patrick D. Suggs
- West Virginia University School of Medicine–Charleston Division, Charleston, West Virginia
| | - Stephanie N. Thompson
- Charleston Area Medical Center Health Education and Research Institute, Charleston, West Virginia
| | - Bryan K. Richmond
- Department of Surgery, West Virginia University Charleston Division, Charleston, West Virginia
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Henderson J, Kandola S, Hignett S, Teasdale R, Topps A, Pennick M, Hwang M, Barnes N, Kirwan C. Infection Prophylaxis for Breast Implant Surgery: Could We Do Better? EPLASTY 2017; 17:e19. [PMID: 28663774 PMCID: PMC5475307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: Infective complications following breast implant surgery may result in implant removal. This causes patient distress and is costly to treat. A range of precautions is undertaken at the time of surgery to reduce infection, with varying levels of supporting evidence. This study aimed to determine how frequently and consistently infection prevention precautions are used during breast implant surgery. Methods: Multicenter observational study of surgical practice with real-time data collection during breast implant surgery. Results: From 7 NHS breast units, 121 implant procedures were assessed in 94 patients under the care of 22 consultant surgeons. The commonest procedure was immediate reconstruction (58%; 70/121). All patients were methicillin-resistant Staphylococcus aureus (but not methicillin-sensitive Staphylococcus aureus) screened. Antibiotics were given at surgery in all cases; 92% (85/94) received postoperative antibiotics. Other precautions included closed glove technique (67%; 63/94), door signs to reduce theater traffic (72%; 68/94), glove changing prior to implant handling (98%; 119/121), laminar air flow theaters (55%; 52/94), disposable drapes (94%; 88/94) and gowns (74%; 70/94), and cavity washing (89%; 108/121). Among the 14 consultants evaluated on more than 1 procedure (range, 2-22; median = 5), only 1 consistently used exactly the same precautions when siting an implant. Conclusion: Despite national guidance, infection prevention measures are not applied consistently during breast implant surgery, with variability between surgeons and within individual surgeon's practice. The introduction of an infection prevention checklist for all breast implant procedures could improve the reliability with which these precautions are undertaken.
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Affiliation(s)
- Julia R. Henderson
- Royal Liverpool and Broadgreen University Hospital NHS Trust, Liverpool, United Kingdom
- North West Breast Research Collaborative, United Kingdom
| | | | - Susan P. Hignett
- North West Breast Research Collaborative, United Kingdom
- Mid Cheshire NHS Foundation Trust, Crewe, United Kingdom
| | | | | | - Mandana Pennick
- Royal Liverpool and Broadgreen University Hospital NHS Trust, Liverpool, United Kingdom
- North West Breast Research Collaborative, United Kingdom
| | - Meiju Hwang
- North West Breast Research Collaborative, United Kingdom
- University Hospital of South Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Nicola Barnes
- North West Breast Research Collaborative, United Kingdom
- University Hospital of South Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Cliona C. Kirwan
- North West Breast Research Collaborative, United Kingdom
- University Hospital of South Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Division of Molecular and Clinical Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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Kamali P, Curiel D, van Veldhuisen CL, Bucknor AEM, Lee BT, Rakhorst HA, Lin SJ. Trends in immediate breast reconstruction and early complication rates among older women: A big data analysis. J Surg Oncol 2017; 115:870-877. [PMID: 28409847 DOI: 10.1002/jso.24595] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 02/08/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Although approximately 57% of breast cancer (BC) diagnoses are in older patients (>60 years), only 4.1-14% receives breast reconstruction (BR). This has been attributed to physician concerns about operative complications. This paper aims to: 1) analyze the 30-day complication rates in the older patient population undergoing immediate breast reconstruction (IBR); and 2) analyze links between complication type and category of reconstruction. METHODS Using the ACS-NSQIP database (2005-2014), all women older than 60 years of age diagnosed with BC and DCIS were identified. IBR and complication rates were plotted for all ages. Patients were divided into those with and those without complications. Patient demographics and co-morbidities were compared. Complications within each type of reconstruction were analyzed. RESULTS Of the 4450 BC and 1104 DCIS patients, 22.3% (BC) and 20.9% (DCIS) had complications. IBR decreased significantly with increased age (P < 0.00 in both cohorts), while complication rates remained stable across all ages (P = 0.32 in BC, P = 0.69 in DCIS patients). Patients were well matched in terms of demographics. CONCLUSIONS The rates of breast reconstruction decrease with increasing age. Despite increasing age, associated complication rates in IBR patients remained stable.
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Affiliation(s)
- Parisa Kamali
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Daniel Curiel
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Charlotte L van Veldhuisen
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alexandra E M Bucknor
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Hinne A Rakhorst
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Division of Plastic- Reconstructive and Hand Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Differences in the Reporting of Racial and Socioeconomic Disparities among Three Large National Databases for Breast Reconstruction. Plast Reconstr Surg 2017; 139:795-807. [DOI: 10.1097/prs.0000000000003207] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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45
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Freitas-Júnior R, Gagliato DM, Moura Filho JWC, Gouveia PA, Rahal RMS, Paulinelli RR, Oliveira LFP, Freitas PF, Martins E, Urban C, Lucena CÊM. Trends in breast cancer surgery at Brazil's public health system. J Surg Oncol 2017; 115:544-549. [PMID: 28168857 DOI: 10.1002/jso.24572] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 01/07/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES To analyze time trend patterns in Breast Cancer (BC) surgeries performed at Brazil's Public Health System, known as SUS from 2008 to 2014. METHODS Ecological study of time series, based on the database system from SUS. Information on surgical procedures performed for BC treatment was collected. Analysis of the absolute number of surgeries was performed using Poisson Regression through Jointpoint Regression, and the trends were calculated through the annual percentage change (APC), with a confidence interval (CI) of 95%, and statistical significance when P < 0.05. RESULTS Data analysis from 193.596 breast surgeries revealed a reduced number of simple mastectomies (APC -4.4%; CI -7.4 to -1.4; P < 0.05); stable trends in radical mastectomy with lymphadenectomy (APC -1.0%; CI -2.4 to 0.5; P = 0.1) and breast conserving surgery (APC 0.4%; CI -1.6 to 2.4; P = 0.6). Also, we observed a reduced number of axillary lymphadenectomy dissection (APC -16.8%; CI -26.8 to -5.4; P < 0.05); increased trends in breast reconstruction with implants after 2011 (APC 9.1%; CI 0.1-18.8; P < 0.05) and with flaps after 2012 (APC 61.3%; CI 41.3-84.0; P < 0.05). The overall rate of patients with breast reconstruction increased from 15% in 2008 to 29.2% in 2014. CONCLUSIONS We found a significant increase in breast reconstruction in public health system in Brazil, and also a reduction in simple mastectomy and axillary lymphadenectomy.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Edesio Martins
- Clinical Hospital of the Federal University of Goias, Goiania, Brazil
| | - Cicero Urban
- Centro de Oncologia do Paraná, Curitiba, Brazil.,Positive University, Curitiba, Brazil
| | - Clécio Ênio Murta Lucena
- Santa Casa of Belo Horizonte, Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, Brazil
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Rodby KA, Danielson KK, Shay E, Robinson E, Benjamin M, Antony AK. Trends in Breast Reconstruction by Ethnicity: An Institutional Review Centered on the Treatment of an Urban Population. Am Surg 2017; 82:497-504. [PMID: 27305880 DOI: 10.1177/000313481608200609] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Previous studies have investigated reconstructive decisions after mastectomy and such studies document a preference among African American women for autologous tissue-based procedures and among Latin American women for implant-based reconstructions, however, there is a paucity of studies evaluating the current relationship between ethnicity and reconstructive preferences. This institutional review provides a unique, up-to-date evaluation of an understudied urban population composed of majority ethnic minority patients and explores reconstructive trends. Consecutive breast reconstruction patients were entered into a prospectively maintained database at the University of Illinois at Chicago and affiliate hospitals between July 2010 and October 2013. Demographics and oncologic characteristics including tumor stage, pathology, BRCA status, and adjuvant treatment were reviewed, and reconstructive trends were assessed by racial group with a focus on reconstructive procedure, mastectomy volume, and implant characteristics. Statistical analysis was performed using SAS (version 9.2). One-hundred and sixty breast reconstructions were performed in 105 women; of which 50 per cent were African American, 26 per cent Hispanic, 22 per cent Caucasian, and 2 per cent Asian. Age, tumor stage, prevalence of triple negative disease, chemotherapy, and radiation treatment was comparable between groups. Rates of obesity, hypertension, and diabetes mellitus were slightly higher in African American and Hispanic cohorts, with more African American patients having one or more of these comorbidities as compared with the Caucasian and Hispanic cohorts (P = 0.047). Despite comparable positive BRCA testing rates, significant differences were seen in the percentage of bilateral mastectomy; 68 per cent African American, 48 per cent Caucasian, and 30 per cent Hispanic (P = 0.004). Hispanics predominantly underwent flap-based reconstruction (56%), while African American (74%) and Caucasian (60%) patients had a preference toward tissue expander reconstruction (P = 0.04 across all groups). African American and Hispanic presented with increased mastectomy weights and thus required higher implant volumes as compared with Caucasians that approached significance (P = 0.06 and P = 0.06). Implant size utilization followed a unimodal distribution for Caucasians, peaking at 500 cc; while African American and Hispanic demonstrated a bimodal distribution, peaking once at 550 cc and again at the max implant volume of 800 cc. This study of a large proportion of minority patients in an urban geographic setting offers an evolving understanding of breast reconstruction patterns. The data demonstrated unique findings of increased rates of bilateral implant-based reconstruction in African American women and unilateral flap-based reconstructions in Hispanic patients. Reconstructive decision-making seems to be greatly influenced by cultural and geographically driven preferences.
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Affiliation(s)
- Katherine A Rodby
- Division of Plastic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Connors SK, Goodman MS, Myckatyn T, Margenthaler J, Gehlert S. Breast reconstruction after mastectomy at a comprehensive cancer center. SPRINGERPLUS 2016; 5:955. [PMID: 27429869 PMCID: PMC4930439 DOI: 10.1186/s40064-016-2375-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 05/20/2016] [Indexed: 11/23/2022]
Abstract
Background Breast reconstruction after mastectomy is an integral part of breast cancer treatment that positively impacts quality of life in breast cancer survivors. Although breast reconstruction rates have increased over time, African American women remain less likely to receive breast reconstruction compared to Caucasian women. National Cancer Institute-designated Comprehensive Cancer Centers, specialized institutions with more standardized models of cancer treatment, report higher breast reconstruction rates than primary healthcare facilities. Whether breast reconstruction disparities are reduced for women treated at comprehensive cancer centers is unclear. The purpose of this study was to further investigate breast reconstruction rates and determinants at a comprehensive cancer center in St. Louis, Missouri. Methods Sociodemographic and clinical data were obtained for women who received mastectomy for definitive surgical treatment for breast cancer between 2000 and 2012. Logistic regression was used to identify factors associated with the receipt of breast reconstruction. Results We found a breast reconstruction rate of 54 % for the study sample. Women who were aged 55 and older, had public insurance, received unilateral mastectomy, and received adjuvant radiation therapy were significantly less likely to receive breast reconstruction. African American women were 30 % less likely to receive breast reconstruction than Caucasian women. Conclusion These findings suggest that racial disparities in breast reconstruction persist in comprehensive cancer centers. Future research should further delineate the determinants of breast reconstruction disparities across various types of healthcare institutions. Only then can we develop interventions to ensure all eligible women have access to breast reconstruction and the improved quality of life it affords breast cancer survivors.
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Affiliation(s)
- Shahnjayla K Connors
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA
| | - Melody S Goodman
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA
| | - Terence Myckatyn
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA
| | - Julie Margenthaler
- Division of Endocrine Oncologic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA
| | - Sarah Gehlert
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA ; George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, MO USA
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Immediate Implant Reconstruction Is Associated With a Reduced Risk of Lymphedema Compared to Mastectomy Alone: A Prospective Cohort Study. Ann Surg 2016; 263:399-405. [PMID: 25607768 DOI: 10.1097/sla.0000000000001128] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE We sought to determine the risk of lymphedema associated with immediate breast reconstruction compared to mastectomy alone. BACKGROUND Immediate breast reconstruction is increasingly performed at the time of mastectomy. Few studies have examined whether breast reconstruction impacts development of lymphedema. METHODS A total of 616 patients with breast cancer who underwent 891 mastectomies between 2005 and 2013 were prospectively screened for lymphedema at our institution, with 22.2 months' median follow-up. Mastectomies were categorized as immediate implant, immediate autologous, or no reconstruction. Arm measurements were performed preoperatively and during postoperative follow-up using a Perometer. Lymphedema was defined as 10% or more arm volume increase compared to preoperative. Kaplan-Meier and Cox regression analyses were performed to determine lymphedema rates and risk factors. RESULTS Of 891 mastectomies, 65% (580/891) had immediate implant, 11% (101/891) immediate autologous, and 24% (210/891) no reconstruction. The two-year cumulative incidence of lymphedema was as follows: 4.08% [95% confidence interval (CI): 2.59-6.41%] implant, 9.89% (95% CI: 4.98-19.1%) autologous, and 26.7% (95% CI: 20.4-34.4%) no reconstruction. By multivariate analysis, immediate implant [hazards ratio (HR): 0.352, P < 0.0001] but not autologous (HR: 0.706, P = 0.2151) reconstruction was associated with a significantly reduced risk of lymphedema compared to no reconstruction. Axillary lymph node dissection (P < 0.0001), higher body mass index (P < 0.0001), and greater number of nodes dissected (P = 0.0324) were associated with increased lymphedema risk. CONCLUSIONS This prospective study suggests that in patients for whom implant-based reconstruction is available, immediate implant reconstruction does not increase the risk of lymphedema compared to mastectomy alone.
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Oh D, Flitcroft K, Brennan M, Spillane A. Patterns and outcomes of breast reconstruction in older women – A systematic review of the literature. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2016; 42:604-15. [DOI: 10.1016/j.ejso.2016.02.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 01/30/2016] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
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Zhang Y, Xu H, Wang T, He J, Qiao Y, Wei J, Dong J. Psychosocial Predictors and Outcomes of Delayed Breast Reconstruction in Mastectomized Women in Mainland China: An Observational Study. PLoS One 2015; 10:e0144410. [PMID: 26641252 PMCID: PMC4671805 DOI: 10.1371/journal.pone.0144410] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 11/18/2015] [Indexed: 11/19/2022] Open
Abstract
Background The aim of the present study was to evaluate potential psychosocial factors that impact Chinese female breast cancer patients to select breast reconstruction (BR), and potential connection of psychosocial outcomes with their satisfaction with BR. Methods A total of 264 female breast cancer patients with mastectomy were recruited from 2012 to 2014. All patients were informed with BR options at their first visit. Personal and medical profiles were collected. Body image, self-esteem, depression and anxiety were assessed using validated scales. Patients who were selected to undergo BR after the first visit were followed up for six months. The same assessment was performed at 6 months post BR, and their satisfaction with BR was evaluated using the Alderman scale. Multivariate linear and logistic regressions were performed. Results Forty-seven percent of the patients (126/264) opted to undergo BR within six months after the initial visit. Multivariate logistic regression analysis revealed that self-esteem (P < 0.05), body image (P < 0.01), education level (P < 0.05), and their husband’s recommendation (P < 0.05) were highly related to the patients’ decision to undergo BR. In addition, multivariate linear regression analysis showed that patient satisfaction with BR was significantly associated with preoperative body image (P < 0.01), postoperative improvement in self-esteem (P < 0.01), improvement in body image (P < 0.01), reduction in depression (P < 0.05), pain (P < 0.05), and scarring (P < 0.01). Conclusions The psychosocial factors including self-esteem and body image are highly related to selecting the BR option and post-BR satisfaction in Chinese female breast cancer patients.
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Affiliation(s)
- Yi Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hua Xu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tao Wang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinguang He
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yufei Qiao
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiao Wei
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiasheng Dong
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- * E-mail:
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