Meta-analysis for psychological impact of breast reconstruction in patients with breast cancer

The impact of physical activity on patient-reported outcomes following deep inferior epigastric perforator flap breast reconstruction

INTRODUCTION

Although higher preoperative physical activity levels have been shown to be beneficial to postoperative recovery at large, their effect on patient-reported outcomes after deep inferior epigastric perforator (DIEP) flap breast reconstruction has yet to be investigated. This study aimed to correlate patient physical activity levels with patient-reported outcome measures.

METHODS

A prospectively maintained database of patients who underwent DIEP flap breast reconstruction between July 2021 and June 2022 was analysed. Physical activity levels were assessed using the Global Physical Activity Questionnaire (GPAQ) and patient-reported outcomes were measured using the BREAST-Q questionnaire, both preoperatively and 1 year postoperatively. Patients were stratified into low (<1000 METs) and high (>1000 METs) physical activity groups.

RESULTS

Of the 136 patients who underwent surgery, 51 completed both questionnaires, with 34 responses meeting completeness criteria for statistical analysis. The low-MET group (n = 19) and high-MET group (n = 15) were comparable in age and comorbidities. Postoperatively, the low-MET group exhibited a 54% increase in physical activity levels, whereas the high-MET group showed a 17% decrease (p < 0.01). The low-MET group experienced significant declines in psychosocial well-being (9.3%, p = 0.04) and sexual well-being (14%, p = 0.02), whereas the high-MET group did not show significant changes in these domains. Satisfaction with the unclothed abdomen increased significantly in the low-MET group (2.9 from 2, p = 0.001), while the high-MET group showed a nonsignificant decrease (3.2 from 2.9, p = 0.43). However, abdominal well-being significantly decreased in both groups, with a 56% decline in the high-MET group (p = 0.006) and a 51% decline in the low-MET group (p = 0.0002). The latter reflects the perceived difference between aesthetic appearance and well-being.

CONCLUSIONS

Patients with lower preoperative physical activity levels showed improved activity postsurgery, potentially due to motivational factors from the reconstructive process. Conversely, those with higher preoperative activity levels faced greater challenges in maintaining their activity levels postsurgery, potentially arising from disruptions in daily routines and donor site symptoms, indicating a need for targeted interventions to support this group. Concurrently, patients with higher baseline exercise levels did not show a decrease in psychosocial and sexual well-being, possibly reflecting a higher resilience to the operative process. These findings underscore the importance of integrating physical activity assessments into preoperative evaluations to inform patient-centred care and optimise recovery outcomes.

Impact of immediate breast reconstruction on perioperative therapy: insights from a Japanese Nationwide Registry

BACKGROUND

Immediate breast reconstruction (IBR) is a common oncoplastic procedure used in breast cancer surgery. This study aims to investigate compliance with prosthetic breast reconstruction guidelines and its impact on perioperative treatment.

METHODS

We reviewed data from the National Clinical Database-Breast Cancer Registry between January 2019 and December 2020. We compared perioperative treatment implementation between the IBR and non-IBR groups by subtype matching for age, menopausal status, T stage, N stage, and histology.

RESULTS

A total of 8,860 patients with breast cancer who underwent IBR (6,075 breast prostheses, 2,492 autologous tissues, and 293 others) were identified. The compliance rate with the guidelines for prosthetic breast reconstruction was 97.7%. After matching, chemotherapy for luminal A-like diseases was significantly less frequent in the IBR group than in the non-IBR group (16.3% vs 20.5%, p < 0.001), and radiotherapy was less frequent in luminal A-like and HER2-positive patients (7.2% vs 9.0%, p = 0.010 and 7.1% vs 11.4%, p = 0.005, respectively). Among the 1-3 node-positive cases, fewer patients with prosthetic IBR received radiotherapy than those without IBR (15.7% vs 26.4%, p < 0.001).

CONCLUSION

Prosthetic breast reconstruction was performed with strict adherence to the Japanese guidelines. The implementation rates of chemotherapy and radiotherapy were lower in the specific IBR group than those in the non-IBR group. Therefore, large-scale, long-term follow-up data are required.

A New Start with HAART: Evaluating Breast Reconstruction in the Era of Highly Active Antiretroviral Therapy

Background

As HIV-positive individuals utilizing highly active antiretroviral therapy live longer, the burden of breast cancer increases in the population. Breast reconstruction is an integral aspect of surgical treatment for many patients after a breast cancer diagnosis, prompting this examination of the characteristics and outcomes of breast reconstruction in this growing patient population.

Methods

Using Merative MarketScan Research Databases, a large multipayer database, HIV-positive adult patients who underwent autologous or implant-based breast reconstruction between 2007 and 2021 were identified using International Classification of Disease codes and Common Procedural Terminology codes. In both HIV-positive and -negative cohorts, patient demographics, procedure-related complications, and postoperative revisions were recorded. Shapiro-Wilk, chi-square, Wilcoxon-Mann-Whitney, and multivariable logistic regression tests were used for statistical analysis.

Results

Of 173,421 patients who underwent breast reconstruction, 1816 had an HIV diagnosis. HIV-positive patients were younger (P < 0.001), underwent surgery more recently (P < 0.001), more often underwent immediate breast reconstruction (P < 0.001), and had higher comorbidity levels (P < 0.001). There was a regional variation in which the patient cohorts underwent breast reconstruction. There was no significant difference in overall complication rates between patient groups, but HIV-negative patients more often underwent revision procedures (P = 0.009).

Conclusions

When compared to their HIV-negative counterparts, breast reconstruction can be considered safe and efficacious in patients living with HIV. HIV-positive patients are a growing demographic who seek breast reconstruction, and surgeons must continue to further understand the unique implications of breast reconstruction in this population.

Assessing quality of life and depression in non-metastatic breast cancer patients following surgical treatment: A cross-sectional study in Lebanon

Breast cancer is a global health concern that significantly impacts the quality of life (QOL) of individuals. This study aims to comprehensively examine the interplay between QOL and depression among nonmetastatic breast cancer patients in Lebanon, a region with limited research in this context. A cross-sectional study was conducted at Hammoud Hospital-University Medical Center from January 2018 to January 2023. Data was collected through a self-administered questionnaire distributed as Google Forms via WhatsApp. A total of 193 patients had non-metastatic breast cancer. Out of these, 81 valid responses were obtained. The Patient Health Questionnaire and Quality of Life Scale were used to assess depression and QOL, respectively. A total of 81 patients were included with mean age 54.4 years. Results revealed that 77.8% of patients experienced provisional depression, with 35.8% meeting criteria for major depressive disorder. Financial status and chronic diseases were associated with the likelihood of developing major depressive disorder. The mean QOL score was 81.14, lower than the average for healthy individuals. Educational level and presence of chronic diseases were significant factors influencing QOL. Postsurgical depression prevalence is substantial, underscoring the importance of integrating mental health care. Economic status and comorbidities are influential factors, necessitating targeted interventions. Breast cancer's impact on QOL is profound, falling below that of other chronic conditions. Education empowers coping, while comorbidities impact QOL. Our findings emphasize the multidimensional nature of breast cancer care, advocating for holistic support and addressing emotional well-being.

Efficacy of Exclusive Fat Grafting for Breast Reconstruction: An Updated Systematic Review and Meta-analysis

BACKGROUND

Exclusive fat grafting is an alternative method to implant- or flap- based reconstruction techniques following mastectomies or breast conservation therapies. Its efficacy has been explored before but new data has come to light, resulting in previous results becoming outdated. Concerns have also been raised about the oncological safety of this procedure which must be evaluated alongside the efficacy to gain a comprehensive understanding of the merits of this alternative technique.

METHODS

We queried the PubMed electronic database from its inception until August 2023 for studies evaluating the efficacy and oncological safety of exclusive fat grafting breast reconstruction following cancer-related mastectomy or breast conservation therapy. Results of the analysis were pooled and presented as means or valid proportions. Results of the analysis were pooled using a random-effects model and presented with 95% confidence intervals (95% CIs) where appropriate.

RESULTS

41 studies were included in our analysis. Pooled results show that on average, 1.7 sessions of exclusive fat grafting were required to complete reconstruction in Breast Conservation Therapy (BCT) patients, with an average volume of 114.2 ml being injected. For mastectomy patients with irradiated breasts, 4.7 sessions were needed on average with 556.8 ml being required to complete reconstruction, compared to their non-irradiated Counterparts requiring only 2.6 sessions and 207.2 ml to complete reconstruction. Oncological recurrence events were found in 29/583 non-irradiated mastectomy patients (p = 0.014) and in 41/517 BCT patients (p = 0.301) CONCLUSION: Exclusive fat grafting is an oncologically safe and reasonably efficacious alternative to more common methods of breast reconstruction. More data is needed to fully characterize the oncological safety of this procedure in irradiated and non-irradiated mastectomy patients.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outcomes of Deep Inferior Epigastric Artery Perforator (DIEP) Flap in Indian Population-A Prospective Single-Institute Study

Introduction  Breast reconstruction has become integral part of breast cancer treatment. Deep inferior epigastric perforator (DIEP)-based flap is considered the gold standard in autologous breast reconstruction. Aims and Objectives  The aim of this study was to evaluate the patient satisfaction and the incidence of complications in DIEP flaps in an Indian setup for breast reconstruction. Materials and Methods  This is a prospective, nonrandomized study at a single institute-Manipal Hospitals, Old Airport Road, Bangalore. Eligible patients were women aged between 28 and 60 years with primary breast cancer requiring mastectomy and radiotherapy, who consented for DIEP flap reconstruction. Results  The study includes subjects who had autologous breast reconstruction after mastectomy with DIEP flap between January 2019 and August 2021 that included 31 patients with a minimum follow-up of 2 years. Four flaps were turbocharged and 17 flaps were superdrained primarily. The average operative time for the whole procedure by adopting a two-team approach is 353.8 ± 43.793 minutes. About 94.1% patients had excellent aesthetic score results. Six patients developed mastectomy flap necrosis, one had fat necrosis that was managed conservatively, whereas one patient had donor site re-exploration for hematoma. We had no DIEP flap necrosis, seroma, flap site hematoma, or flap failure. Physical well-being module of Breast-Q indicated an average of 83 points, psychosocial well-being module indicated 80 points, whereas sexual scores reverted an average of 77 points. Among satisfaction module, aesthetic outcomes for breast showed an average of 94 points, whereas the donor site had 96 points. Satisfaction with information, surgeon, medical staff each gained more than 87 points. Conclusion  Breast reconstruction with DIEP flap yields good aesthetic outcomes and quality of life in Indian population. The incidence of fat necrosis, flap and donor site complications is less over time and will enhance the patient satisfaction score further.

Patterns of breast reconstruction and the influence of a surgical multidisciplinary clinic

BACKGROUND

Of the 40% of breast cancer patients who have a mastectomy as part of their surgical treatment, only approximately 29% have a breast reconstruction. In 2016, Alfred Health established a multidisciplinary surgical clinic with breast and plastic surgeons, aiming to improve interdisciplinary collaboration. This study aimed to assess the provision of breast reconstruction at an Australian tertiary public hospital and examine whether the multidisciplinary surgical clinic have improved our reconstructive service provision.

METHODS

A retrospective cohort study of patients who underwent mastectomy at Alfred Health between October 2011 and September 2021 was conducted. Patients were divided into before and after groups, treated during the 5-year period before and after establishing the multidisciplinary clinic respectively. Demographic data, operative details, histopathology, and treatments were compared.

RESULTS

Over the 10-year period, 423 mastectomies were performed for 351 patients. Of those, 153 patients underwent breast reconstruction, providing an overall reconstruction rate of 43.6%. There was a statistically significant increase in the breast reconstruction rate from 36.5% before to 53.4% after the creation of the multidisciplinary surgical clinic. Patient factors such as age and tumour receptor status did not differ significantly between the groups.

CONCLUSION

The establishment of a surgical multidisciplinary clinic has led to a statistically significant increase in the rate of breast reconstruction from 36.5% to 53.4%, leading to improved healthcare provision for our patients. Factors identified to be associated with increased uptake in the reconstruction service include younger age and node negative disease.

Novel single-centre experience - evaluation of outcomes post-implementation of a coordinated combined breast reconstruction service

BACKGROUND

Autologous breast reconstruction services are logistically complex and challenging to implement but have better outcomes than implants. This study aimed to evaluate the effect of implementing a coordinated, low-cost combined breast reconstruction service (0.8 FTE nurse liaison, 0.25 FTE plastic surgeon, two dedicated breast surgeons 0.05 FTE each and protected weekly all-day oncoplastic theatre) on unit productivity and efficiency in reducing wait times for immediate autologous breast reconstruction.

METHODS

A retrospective cohort study was conducted on all patients who underwent immediate autologous breast reconstruction at Fiona Stanley Hospital between two study periods, pre-intervention - February 2016 to June 2019 and post-intervention - November 2022. Data were analysed using SPSS v.27.

RESULTS

One hundred twenty-seven participants were included, with 49% (n = 62) in the post-intervention group. Most procedures performed were therapeutic (n = 108, 85%). DIEP was the most common flap (84%), and the mean BMI was 26.9 (SD ± 4.2). There was a statistically significant increase in the number of high-risk gene carriers' prophylactic cases and bilateral cases performed post-intervention (5% to 26%, P = 0.001) and (29% to 55%, P = 0.003), respectively. Time to surgery on the waitlist did not significantly change after the intervention (therapeutic group: 3.1 to 3.5 weeks, P = 0.821; prophylactic group: 55.0 to 61.1 weeks, P = 1.000). Overall, there was a marked increase in the overall productivity of the breast service unit in terms of mastectomies, total reconstructions, and autologous reconstructions performed.

CONCLUSIONS

This single-centre experience showed that implementing a coordinated service significantly increased the unit's productivity. This low-cost intervention can be applied to other healthcare settings.

Prevalence and associated factors of depression among breast cancer patients in Sub-Saharan Africa: A systematic review and meta-analysis

Introduction

Even though breast cancer incidence is lower in Sub-Saharan Africa, its mortality is higher in these countries. However, the impact does not end with diagnosis and treatment; rather many patients struggle with depression which is very common among these patients. This systematic review and meta-analysis helps to provide valuable insights into the overall prevalence of depression and associated factors among breast cancer patients in Sub-Saharan Africa.

Method

We searched several databases, including MEDLINE, Embase, Scopus, Hinary, CINHAL and Google Scholar to retrieve relevant literatures from inception up to 15 June 2023. All observational studies, published in English at any time were included, while, letters to editor, review articles, commentaries, interventional and qualitative studies, and, abstracts presented in conferences or seminars were excluded. The results of this systematic review and meta-analysis have been written based on the PRISMA 2020 checklist and the protocol have been registered in PROSPERO database (CRD42023428910).

Result

We have included nine articles with 2226 study participants. The result showed that, the pooled prevalence of depression among breast cancer patients in Sub-Saharan Africa was 45.6% (95% CI: 30%-61%) with significant heterogeneity I2 = 98.9%, (Cochrane) Q < 0.0001. There was no single study effect and publication bias but substantial heterogeneity was observed. In addition, there has been a publication bias with eggers test (p < 0.0033). However, there were no studies imputed after trim and fill analysis. From the factors, breast cancer patients who had poor financial support were 1.47 (95% CI: 1.02-2.13) times more at risk of developing depression than their counterparts.

Conclusion

The prevalence of depression among breast cancer patients in Sub-Saharan Africa countries were higher than other regions. Thus, Emphasis should be given on developing financial assistance programs designed to cover the medical costs and improving the health care infrastructure.

Prognosis of post-neoadjuvant therapy patients who underwent immediate breast reconstruction: a SEER-based, propensity-matched study

OBJECTIVE

The application of immediate breast reconstruction (IBR) for post-neoadjuvant therapy (NAT) patients was controversial. The aim of this study was to investigate the long-term survival outcomes of IBR for these patients.

METHODS

Data between January 2010 and November 2017 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was performed to reduce the influence of confounding factors between the mastectomy alone group (MA) and the mastectomy with IBR group (IBR). The rates of 5 year breast cancer-specific survival (BCSS) were compared by Kaplan-Meier curves with log-rank test.

RESULTS

The IBR was associated with improved 5-year BCSS in the IBR group before PSM (88.5 vs. 79.1%, P < 0.001). The proportion of IBR increased from 21.5% in 2010 to 28.2% in 2017. After PSM, a total of 9,610 patients were enrolled for survival analysis (4,805 in each group). In the complete response (CR) group, the 5-year BCSS rates did not differ (93.4 vs. 95.6%, P = 0.16). In the non-CR group, the 5-year BCSS rate was higher in patients who received IBR (82.5% 79.4%, P = 0.034).

CONCLUSION

In general, the application of IBR among post-NAT patients has steadily increased from 2010 to 2017. In the CR group, survival outcomes of post-NAT patients who received IBR were similar to those who received mastectomy alone. In the non-CR group, IBR was associated with potential survival benefits. More studies are expected to validate our findings.

A Comparison of Postoperative Outcomes Between Immediate, Delayed Immediate, and Delayed Autologous Free Flap Breast Reconstruction: Analysis of 2010-2020 NSQIP Data

BACKGROUND

 While many factors influence decisions related to the timing between mastectomy and flap-based breast reconstruction, there is limited literature comparing postoperative complications between immediate (IBR), delayed immediate (DIBR), and delayed (DBR) reconstruction modalities. Using the National Surgical Quality Improvement Program (NSQIP), we sought to compare postoperative complication rates of each timing modality.

METHODS

 The NSQIP 2010-2020 database was queried for patients who underwent free flap breast reconstruction. Cases were categorized to include mastectomy performed concurrently with a free flap reconstruction, removal of a tissue expander with free flap reconstruction, and free flap reconstruction alone which are defined as IBR, DIBR, and DBR, respectively. The frequency of postoperative outcomes including surgical site infection (SSI), wound dehiscence, intraoperative transfusion, deep venous thrombosis (DVT), and return to operating room (OR) was assessed. Overall complication rates, hospital length of stay (LOS), and operative time were analyzed. Multivariable regression analysis controlling for age, race, BMI, diabetes, hypertension, ASA class, and laterality was performed.

RESULTS

 A total of 7,907 cases that underwent IBR, DIBR (n = 976), and DBR reconstruction (n = 6,713) were identified. No statistical difference in occurrence of SSIs, wound dehiscence, or DVT was identified. DIBR (9%) and DBR (11.9%) were associated with less occurrences of reoperation than IBR (13.2%, p < 0.001). Univariate and multivariate regression analysis demonstrated that DIBR and DBR were associated with a lower odds of complications and shorter operation time versus IBR. No statistically significant differences between DIBR and DBR in surgical complications, LOS, and operative time were identified.

CONCLUSION

 Awareness of overall complication rates associated with each reconstructive timing modality can be used to help guide physicians when discussing reconstructive options. Our data suggests that DIBR and DBR are associated with less overall complications than IBR. Physicians should continue to consider patients' unique circumstances when deciding upon which timing modality is appropriate.

Bibliometric analysis of global research on breast reconstruction after mastectomy for breast cancer from 2011 to 2021

BACKGROUND

Breast cancer is the most common malignant tumor in the world, and most patients require a mastectomy. Women who have undergone mastectomy often suffer from breast loss that seriously affects their daily life, and breast reconstruction is not only beneficial to patient's quick recovery after surgery, but also their mental health. So, in recent years, more and more female breast cancer patients are receiving breast reconstruction surgery. We aim to map hot trends in breast reconstruction after mastectomy for breast cancer and provide directions for future research.

METHODS

We screened all literature (2011-2021) on breast reconstruction after mastectomy for breast cancer from The Web of Science Core Collection (WoSCC) and analyzed research trends in this field using Vosviewer and CiteSpace.

RESULTS

Based on the search results, a total of 3404 articles related to breast reconstruction after mastectomy for breast cancer were screened. The US (n = 1371) is the country with the highest number of articles, followed by Italy (n = 282) and the UK (n = 277). Harvard University (n = 183) was the institution with the highest number of publications, followed by the University of Texas (n = 141) and Memorial Sloan Kettering Cancer Center (n = 136). Plastic and Reconstructive Surgery is the most published journal in the field. Pusic AL is the most published author in the field, while Matros E is the most cited author on average. Cluster analysis showed that breast reconstruction after mastectomy for breast cancer is a hot topic of research by scholars, and more and more experts recommend breast reconstruction for breast cancer patients.

CONCLUSIONS

This study comprehensively summarizes and analyzes global research trends in breast reconstruction after mastectomy for breast cancer. In the past 10 years, there has been a significant increase in relevant high-quality publications in this field, and the field of breast reconstruction after mastectomy for breast cancer has a promising future.

BREAST-Q Patient-reported Outcomes in Different Types of Breast Reconstruction after Fat Grafting

Breast reconstruction after mastectomy improves patient quality of life. Independently of the type of reconstruction, ancillary procedures are sometimes necessary to improve results. Fat grafting to the breast is a safe procedure with excellent results. We report patient-reported outcomes using the BREAST-Q questionnaire after autologous fat grafting in different types of reconstructed breasts.

Methods

We performed a single-center, prospective, comparative study that compared patient-reported outcomes using the BREAST-Q in patients after different types of breast reconstruction (autologous, alloplastic, or after breast conserving) who subsequently had fat grafting.

Results

In total, 254 patients were eligible for the study, but only 54 (68 breasts) completed all the stages needed for inclusion. Patient demographic and breast characteristics are described. Median age was 52 years. The mean body mass index was 26.1 ± 3.9. The mean postoperative period at the administration of BREAST-Q questionnaires was 17.6 months. The mean preoperative BREAST-Q was 59.92 ± 17.37, and the mean postoperative score was 74.84 ± 12.48 (P < 0.0001). There was no significant difference when divided by the type of reconstruction.

Conclusion

Fat grafting is an ancillary procedure that improves the outcomes in breast reconstruction independently of the reconstruction type and heightens patient satisfaction, and it should be considered an integral part of any reconstruction algorithm.

Survival Nomogram for Patients With Locally Advanced Breast Cancer Undergoing Immediate Breast Reconstruction: A SEER Population-Based Study

INTRODUCTION/BACKGROUND

This study aimed to construct a nomogram to provide prognostic references for patients with locally advanced breast cancer (LABC) to receive immediate breast reconstruction (IBR).

MATERIALS AND METHODS

All data were obtained from the Surveillance, Epidemiology and End Results (SEER) database. Univariate Cox regression, least absolute shrinkage and selection operator (LASSO) and best subset regression (BSR), separately followed by backward stepwise multivariable Cox, were used to construct the nomogram. Risk stratification was established after validation.

RESULTS

A total of 6,285 patients were enrolled to generate the training group (n = 3,466) and the test group (n = 2,819) by geographical split. Age, marital status, grade, T staging, N staging, radiotherapy, chemotherapy, estrogen receptor status (ER), progesterone receptor status (PR) and human epidermal growth factor receptor type 2 status (HER2) were used to fit the nomogram. The overall Harrell's concordance index (C-index) was 0.772 in the training group and 0.762 in the test group. The area under the receiver operator characteristic curves (AUC) at 3-year and 5-year were respectively 0.824 and 0.720 in the training group, 0.792 and 0.733 in the test group. The calibration curves showed great consistency in both groups. A dynamic nomogram (https://dcpanfromsh.shinyapps.io/NomforLABCafterIBR/) was developed.

CONCLUSION

A nomogram was developed and validated that predicts prognosis more accurately than the AJCC 7th stage and can be used as a reference for decision-making in LABC patients receiving IBR.

Trends and variations in post-mastectomy breast reconstruction rates in Australia over 10 years

BACKGROUND

Offering breast reconstruction (BR) at the time of mastectomy is standard of care in Australia with proven quality-of-life benefits. Previously BR rates in Australia have been low compared to similar countries. Accurate up-to-date information is needed to promote equity in access to BR and inform future planning of services. This study analysed recent trends and variations of BR uptake in Australia.

METHOD

Data from the BreastSurgANZ Quality Audit (BQA) were used to identify patients who underwent mastectomy with or without reconstruction for invasive or in situ breast carcinoma from 2010 to 2019. The association between BR uptake and the variables of jurisdiction (state or territory), age, hospital type and remoteness, and remoteness of patients' home addresses were analysed.

RESULTS

A total 41 880 women underwent mastectomy between 2010 to 2019. The national BR rate steadily increased from 12.8% in 2010 to 29% in 2019, with a 10-year national average of 21.3%. Statistically significant differences in BR uptake (P < 0.001) were found between states with higher rates in New South Wales and Victoria, with BR more likely in private hospitals and in younger women (P < 0.001), and less likely in remote areas (P < 0.001).

CONCLUSION

The Australian BR rate has increased over the 10-year period, but significant variation still exists between states. BR is lower in older women and those living in regional and remote areas. While the steady increase in BR uptake is encouraging, barriers that exist to equitable provision of reconstructive surgical services for all women living with breast cancer still need to be corrected.

COVID-19 Emotional and Mental Impact on Cancer Patients Receiving Radiotherapy: An Interpretation of Potential Explaining Descriptors

Background: Significant changes in the accessibility and viability of health services have been observed during the COVID-19 period, particularly in vulnerable groups such as cancer patients. In this study, we described the impact of radical practice and perceived changes on cancer patients’ mental well-being and investigated potential outcome descriptors. Methods: Generalized anxiety disorder assessment (GAD-7), patient health (PHQ-9), and World Health Organization-five well-being index (WHO-5) questionnaires were used to assess anxiety, depression, and mental well-being. Information on participants, disease baseline information, and COVID-19-related questions were collected, and related explanatory variables were included for statistical analysis. Results: The mean score values for anxiety, depression, and mental well-being were 4.7 ± 5.53, 4.9 ± 6.42, and 72.2 ± 18.53, respectively. GAD-7 and PHQ-9 scores were statistically associated (p < 0.001), while high values of GAD-7 and PHQ-9 questionnaires were related to low values of WHO-5 (p < 0.001).Using the GAD-7 scale, 16.2% of participants were classified as having mild anxiety (GAD-7 score: 5−9).Mild to more severe anxiety was significantly associated with a history of mental health conditions (p = 0.01, OR = 3.74, 95% CI [1.372−10.21]), and stage category (stage III/IV vs. I/II, p = 0.01, OR = 3.83, 95% CI [1.38−10.64]. From the participants, 36.2% were considered to have depression (PHQ-9 score ≥ 5). Depression was related with older patients (p = 0.05, OR = 1.63, 95% CI [1.16−2.3]), those with previous mental health conditions (p = 0.03, OR = 14.24, 95% CI [2.47−81.84]), those concerned about the COVID-19 impact on their cancer treatment (p = 0.027, OR = 0.19, 95% CI [0.045−0.82]) or those who felt that COVID-19 pandemic has affected mental health (p = 0.013, OR = 3.56, 95% CI [1.30−9.72]). Additionally, most participants (86.7%) had a good well-being score (WHO-5 score ≥ 50). Mental well-being seemed more reduced among stage I−III patients than stage IV patients (p = 0.014, OR = 0.12, 95% CI [0.023−0.65]). Conclusion: There is a necessity for comprehensive cancer care improvement. These patients’ main concern related to cancer therapy, yet the group of patients who were mentally affected by the pandemic should be identified and supported.

Patient Reported Outcome and Quality of Life After Delayed Breast Reconstruction - An RCT Comparing Different Reconstructive Methods in Radiated and Non-radiated Patients

BACKGROUND

Health-related quality of life (HRQoL) is one of the core outcomes for breast reconstruction. The aim of this study was to evaluate whether the method of delayed breast reconstruction affects long-term HRQoL.

METHODS

Participants were divided into 2 arms depending on previous radiotherapy, and subsequently randomized between 2 methods of breast reconstruction: a latissimus dorsi flap or a deep inferior epigastric artery perforator flap in the radiated arm and a thoracodorsal flap and implant or an expander in the non-radiated arm. Validated HRQoL instruments were used: BREAST-Q to evaluate breast specific HRQoL and satisfaction, RAND-36 and EQ-5D to evaluate generic HRQoL, and BDI-21 to measure symptoms of depression and anxiety.

RESULTS

During the recruitment period (2009-2015), 233 patients were randomized. After opt-outs and exclusions, the remaining 107 participants comprise the study sample. Postoperative HrQoL was measured on average 7to 8years post-operatively. Response rates varied between 60 and 82 per cent. The BREAST-Q scores were higher after the reconstruction than before for the great majority of domains in both arms; albeit statistically significant only between the 2 methods for physical well-being chest in the radiated arm. Most participants in both arms had minimal or mild depression both before and after the operation.

CONCLUSION

No distinct differences in long-term HrQoL could be seen for different methods There was a clear improvement in HrQoL compared to pre-reconstruction in all groups, but the effect of specific reconstructive methods on scores could not be reliably demonstrated.

Using a Business Model (the 4 Disciplines of Execution) to Improve Consistency, Efficiency, and Length of Stay in Microvascular Autologous Breast Reconstruction

BACKGROUND

Autologous free tissue transfer is a common method of breast reconstruction in the United States, but it involves many care teams and can incur a large cost on an institution. The consistency and efficiency of performing these procedures can be improved with a method called the 4 disciplines of execution (4DX).

METHODS

Patients that underwent autologous breast reconstruction between 2015 and 2020 were included. Midway through the collection period, several preoperative and intraoperative interventions were implemented using the 4DX. Then, 2 cohorts of patients were analyzed for differences in operative times, length of stay (LOS), and major complications.

RESULTS

Thirty-two total patients were included. The median operative time before interventions were implemented was 828 minutes, and the median operative time after interventions was 619 minutes (P < 0.05). The median LOS in days before interventions was 5 days, and the median LOS after interventions was 3 days (P < 0.05). There were no statistically significant differences in complications before or after the interventions.

CONCLUSIONS

The 4DX successfully improved consistency and efficiency in the process of performing autologous breast reconstruction at our institution, as evidenced by a faster median operative time and shorter patient LOS in the hospital.

Sexual dysfunction as a challenge in treated breast cancer: in-depth analysis and risk assessment to improve individual outcomes

The increasing number of breast cancer survivors has led to a greater emphasis on issues related to quality of life (QoL). Up to 75% of women treated for breast cancer (BC) report sexual disorders. However, most oncologists are not trained to recognize which patients are at high-risk of developing sexual disorders. Female sexual dysfunction (FSD) is common in patients with BC; we found that patients without FSD prior to BC treatment are at risk of developing FSD after treatment. Treatment of early BC relies on the combination of chemotherapy, surgery, and radiation therapy. All these treatments have side effects or sequelae identified as high-risk factors for the development of FSD. The choice of less toxic treatments in each modality could reduce the risk of FSD in some cases, without affecting the risk of recurrence or effectiveness. A comprehensive approach of BC must consider FSD as a determinant factor of QoL in survivors.

[Change of Gaze Pattern depending on the Stage of DIEP Flap Breast Reconstruction: a Preliminary Eye-Tracking Investigation]

BACKGROUND

Breast reconstruction using autologous tissue is an integral part of breast cancer treatment. While many studies have elucidated the impact of breast reconstruction on patients' quality of life, self-esteem, sexuality and more, there is a lack of objective data regarding the effects on external observers. Aim of this study was to investigate the change in gaze pattern of independent observers depending on the stage of DIEP-flap breast reconstruction.

MATERIALS AND METHODS

Eye-tracking technology was utilized to analyze the eye movements of 58 study participants while viewing 2 D photographs of a patient after mastectomy and different stages of DIEP-flap breast reconstruction. Time until first fixation and total time of fixation were recorded and con- secutively analyzed for the right and left breast on each image.

RESULTS

Overall, the total time of fixation of the operated breast decreased significantly over the different stages of breast reconstruction, with p<0.001. At the same time, there was no statistically significant change in total time of fixation of the non-operated breast, with p=0.174. The time until first fixation showed a significant increase over the different stages of reconstruction for the reconstructed breast, with p<0.001, while no significant differences were found for the opposite breast, with p=0.344.

CONCLUSION

Mastectomy and the individual steps of breast reconstruction alter the perception of breast cancer patients. Over the course of breast reconstruction, the deviation of gaze in the direction of the affected breast is reversed.

Patient perspectives on nipple-areola complex micropigmentation during the COVID-19 pandemic

Background

Micropigmentation is a well-recognised option for nipple-areola complex reconstruction, as part of the breast reconstruction pathway for patients following mastectomy. As a part of delayed breast reconstruction, this treatment was put on hold during the COVID-19 pandemic.

Aims

To assess the views of patients regarding micropigmentation in response to the COVID-19 pandemic, and whether their attitudes to seeking out this part of the reconstructive journey had been altered.

Methods

A questionnaire undertaken with 53 patients between August & September 2020 attending the Micropigmentation clinic.

Findings

81.1% of patients reported COVID-19 had not impacted their decision, with a similar proportion happy to proceed with the treatment at the time of questioning.

Conclusions

The results highlight the importance of nipple-areola complex to our patients’ reconstructive journey.

Psychological Impact of Type of Breast Cancer Surgery: A National Cohort Study

Background

The present study assessed the impact of different types of breast surgery on rates of psychological disorders in breast cancer patients.

Methods

This nationwide cohort study, based on Korean Health Insurance Review and Assessment Service claims data, included 26,259 breast patients who underwent surgery from June 1, 2017, to December 31, 2018. Associations between the incidence of psychological disorders and variables were evaluated by time dependent Cox regression analyses.

Results

Of the 26,259 patients, 9394 (35.8%) underwent total mastectomy (TM) and 16,865 (64.2%) underwent partial mastectomy (PM); of the former, 4056 (43.2%) underwent breast reconstruction surgery (RS). A total of 4685 patients (17.84%) were newly diagnosed with psychological disorders after surgery. Multivariable analysis showed that axillary lymph node dissection was significantly associated with increased rates of overall psychological disorders (p < 0.0001), depression (p = 0.0462), anxiety (p < 0.0001) and insomnia (p < 0.0001). The rates of overall psychological disorders (p = 0.0002) and insomnia (p = 0.01) were significantly lower in patients who underwent TM than PM. RS tended to associated with reduced rates of overall psychological disorders in patients who underwent TM. Subgroup analysis showed that, compared with PM, RS after TM significantly associated with a reduced incidence of overall psychological disorders and insomnia in younger patients (< 50 years) and those who underwent sentinel lymph node biopsy.

Conclusion

In contrast to general belief, rates of overall psychological disorders and insomnia were lower in patients who underwent TM than PM. Moreover, RS after TM confers psychological benefit in younger patients with early stage breast cancer compared with PM.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06585-y.

Invited Discussion on: The Impact of Reconstructive Modality and Postoperative Complications on Decision Regret and Patient-Reported Outcomes following Breast Reconstruction

One in eight women will have a lifetime diagnosis of confirmed breast cancer, and one in three of these women will undergo a mastectomy. About half of women undergoing mastectomies will opt for some type of breast reconstruction. Breast cancer itself and breast reconstruction bring physical changes that are accompanied by psychological changes of varying degrees. The decision process about cancer treatment and whether or not to perform breast reconstruction brings suffering. In the case of choosing to perform the reconstruction, deciding when to perform it and which surgical technique to choose from among several available is quite complex, and may result in regret. The author provides a brief literature review on this subject and comments on the work carried out by Cai and Momeni, comparing data and results.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Inaugural roundtable on breast reconstruction practice in Australia: background, process and recommendations

Recommendations from the inaugural roundtable on breast reconstruction held on 9 October 2019 in Queensland, Australia, for improved decision-making and increased funding to support wider, timely access to breast reconstruction.

The effects of the COVID-19 pandemic on psychological stress in breast cancer patients

Background

The majority of breast cancer patients are severely psychologically affected by breast cancer diagnosis and subsequent therapeutic procedures. The COVID-19 pandemic and associated restrictions on public life have additionally caused significant psychological distress for much of the population. It is therefore plausible that breast cancer patients might be particularly susceptible to the additional psychological stress caused by the pandemic, increasing suffering. In this study we therefore aimed to assess the level of psychological distress currently experienced by a defined group of breast cancer patients in our breast cancer centre, compared to distress levels pre-COVID-19 pandemic.

Methods

Female breast cancer patients of all ages receiving either adjuvant, neoadjuvant, or palliative therapies were recruited for the study. All patients were screened for current or previous COVID-19 infection. The participants completed a self-designed COVID-19 pandemic questionnaire, the Stress and Coping Inventory (SCI), the National Comprehensive Cancer Network® (NCCN®) Distress Thermometer (DT), the European Organization for Research and Treatment of Cancer (EORTC) QLQ C30, and the BR23.

Results

Eighty-two breast cancer patients were included. Therapy status and social demographic factors did not have a significant effect on the distress caused by the COVID-19 pandemic. The results of the DT pre and during COVID-19 pandemic did not differ significantly. Using the self-designed COVID-19 pandemic questionnaire, we detected three distinct subgroups demonstrating different levels of concerns in relation to SARS-CoV-2. The subgroup with the highest levels of concern reported significantly decreased life quality, related parameters and symptoms.

Conclusions

This monocentric study demonstrated that the COVID-19 pandemic significantly affected psychological health in a subpopulation of breast cancer patients. The application of a self-created “COVID-19 pandemic questionnaire” could potentially be used to help identify breast cancer patients who are susceptible to increased psychological distress due to the COVID-19 pandemic, and therefore may need additional intensive psychological support.

Trial registration

DRKS-ID: DRKS00022507.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-09012-y.

Post-Mastectomy Patients in an Urban Safety-Net Hospital: How Do Safety-Net Hospital Breast Reconstruction Rates Compare to National Breast Reconstruction Rates?

BACKGROUND

Breast reconstruction (BR) has documented psychological benefits following mastectomy. Yet, racial/ethnic minority groups have lower reported rates of BR. We sought to evaluate the rate, type, and outcome of BR in a racially and ethnically diverse population within a safety-net hospital system.

METHODS

All patients who underwent mastectomy between October 2015 and July 2019 at Harbor-UCLA Medical Center were retrospectively examined. Rates and type of BR were analyzed according to patient characteristics (race/ethnicity, age, and body mass index), smoking status, cancer stage, and presence of diabetes mellitus. Breast reconstruction outcomes were also assessed.

RESULTS

Of the 259 patients that underwent mastectomy, 87 (33.6%) received BR. Immediate BR was performed in 79 (30.5%) patients and delayed BR in 8 (3.1%). Of the 79 patients with immediate BR, 58 (73.4%) received implant-based BR and 21 (26.5%) autologous tissue. The BR failure rate was 10%, all implant-based. Increasing age and smoking negatively impacted BR rates. Black (P =.331) and Hispanic (P =.132) ethnicity were not independent predictors of decreased breast reconstruction.

CONCLUSION

This study demonstrated that the rate, type, and quality of BR in this integrated safety-net hospital within a diverse population are comparable to national rates. When made available, historically underrepresented minority patients of Black and Hispanic ethnicity utilize BR.

Satisfaction With Expectations-Based Education in Women Undergoing Breast Reconstruction

Women undergoing breast reconstruction sometimes have unrealistic or unformed expectations regarding the reconstructive process and outcomes. The objectives of this study were to assess preoperative expectations in women undergoing mastectomy and initial breast reconstruction, provide expectations-based education, and evaluate satisfaction with education. Fifty-one women undergoing mastectomy and breast tissue expander placement participated in this study. At a preoperative education appointment, participants completed a questionnaire to determine whether their expectations were realistic, unrealistic, or unformed. A nurse practitioner reviewed the results and provided patient-centered, expectations-based education to modify expectations from unrealistic to realistic or to set expectations from unformed to realistic. Four to 6 weeks after surgery, a second questionnaire was provided to assess perceived satisfaction with education. Unrealistic and unformed expectations were identified related to complications, pain, scarring, sensation, symmetry, and aesthetic results. After receiving patient-centered, expectations-based preoperative education, participants agreed they had received the appropriate amount of information and felt well prepared for their surgery and recovery. Most participants reported they were aware of possible complications, had effective tools to manage their pain, and had received adequate information about scarring and sensation changes. Some participants continued to have unrealistic or unformed expectations related to aesthetic results. Women undergoing breast reconstruction often have unrealistic or unformed expectations before surgery. Identifying these expectations and proving expectations-based education resulted in satisfaction with information provided.

Immediate breast reconstruction in locally advanced breast cancer: is it safe?

PURPOSE

Immediate breast reconstruction (IBR) following mastectomy remains controversial for locally advanced breast cancer over concerns regarding recurrence and complications which may delay adjuvant therapies. This study aimed to compare the oncologic outcomes and surgical safety of IBR following mastectomy with mastectomy alone (MA) for locally advanced breast cancer.

METHODS

All patients treated at the Providence Breast Center between 2012 and 2017 for biopsy-proven locally advanced breast cancer, AJCC (8th edition) clinical stages (IIB-IIIC), were included. Primary outcomes were overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS). Secondary outcomes included recurrence rate, adjuvant therapy use, and reoperation.

RESULTS

267 patients (112 IBR, 155 MA) were included. On average, IBR patients were younger (48.82 years vs 61.42 years, P < 0.001). Median study follow-up was 50.7 months. OS was higher among IBR patients (86.6% vs 73.5%, P < 0.05). However, no significant differences were found in DSS (87.5% vs 84.5%, P = 0.34), DFS (79.5% vs 78.7%, P = 0.55), local recurrence (0% vs 1.9%, P = 0.194), adjuvant therapy use (95.5% vs 91.6%, P = 0.155), or reoperation (1.8% vs 1.3%, P = 0.559).

CONCLUSION

IBR is a safe option for patients with locally advanced breast cancer and does not negatively impact survival, cancer recurrence rates, and use of adjuvant therapy.

Effects of antihypertensive drugs on surgical outcomes of breast reconstruction: a nationwide population-based claim study

Background

Experimental studies have reported that angiotensin receptor blockers (ARBs) increase the risk of surgical complications. However, clinical data on their effect on surgical outcomes are limited. The aim of this study was to investigate the impact of perioperative use of ARBs on the outcomes of breast reconstruction using population-based claim data.

Methods

Data of patients who underwent direct-to-implant or abdomen-based autologous breast reconstruction after total mastectomy from April 2015 to December 2018 were obtained from the Health Insurance Review and Assessment Service database. The patients were categorized as ARB, non-ARB, control, and non-hypertension groups. The effects of ARBs on surgical complications, length of hospital stay, and complication-related medical costs were evaluated.

Results

Of the 9,036 patients who met the inclusion criteria, 5,192 underwent direct-to-implant reconstruction, and 3,844 underwent abdomen-based autologous reconstruction. The length of hospital stay was the longest and the surgical complication rate and complication-related medical cost were the highest in the ARB group after both reconstruction methods. Compared with non-treatment with antihypertensive drugs, ARB use was found to be an independent risk factor for surgical complications in direct-to-implant reconstruction [odds ratio (OR), 1.96; 95% confidence interval (CI), 1.09-3.50; P=0.0237] and complication-related medical cost (OR, 1.93; 95% CI, 1.10-3.40; P=0.0221) in abdomen-based autologous reconstruction.

Conclusions

Perioperative ARB use was associated with adverse postoperative breast reconstruction outcomes. These findings might have a significant impact on perioperative antihypertensive management; nevertheless, further studies are warranted to confirm the study findings.

The current progress and critical analysis of three-dimensional scanning and three-dimensional printing applications in breast surgery

Background

Several attempts have been made to develop a tool capable of evaluating breast shape and volume to aid surgical planning and outcome assessment. More recently, newer technologies such as three-dimensional (3D) scanning and 3D printing have been applied in breast assessment. The aim of this study was to review the literature to assess the applicability of 3D scanning and 3D printing in breast surgery.

Methods

A literature search was carried on PubMed, Google Scholar and OVID from January 2000 to December 2019 using the keywords ‘3D’, ‘Three-dimensional’, ‘Three/four dimensions’ and ‘Breast’.

Results

A total of 6564 articles were identified initially; the abstracts of 1846 articles were scanned, and 81 articles met the inclusion criteria and were included in this review. Articles were reviewed and classified according to their aims, study subjects, the software and hardware used, main outcomes and major limitations.

Conclusions

These technologies are fast and easy to use, however, high costs, long processing times and the need for training might limit their application. To incorporate these technologies into standard healthcare, their efficacy and effectiveness must be demonstrated through multiple and rigorous clinical trials.

Satisfaction With Expectations-Based Education in Women Undergoing Breast Reconstruction

Women undergoing breast reconstruction sometimes have unrealistic or unformed expectations regarding the reconstructive process and outcomes. The objectives of this study were to assess preoperative expectations in women undergoing mastectomy and initial breast reconstruction, provide expectations-based education, and evaluate satisfaction with education. Fifty-one women undergoing mastectomy and breast tissue expander placement participated in this study. At a preoperative education appointment, participants completed a questionnaire to determine whether their expectations were realistic, unrealistic, or unformed. A nurse practitioner reviewed the results and provided patient-centered, expectations-based education to modify expectations from unrealistic to realistic or to set expectations from unformed to realistic. Four to 6 weeks after surgery, a second questionnaire was provided to assess perceived satisfaction with education. Unrealistic and unformed expectations were identified related to complications, pain, scarring, sensation, symmetry, and aesthetic results. After receiving patient-centered, expectations-based preoperative education, participants agreed they had received the appropriate amount of information and felt well prepared for their surgery and recovery. Most participants reported they were aware of possible complications, had effective tools to manage their pain, and had received adequate information about scarring and sensation changes. Some participants continued to have unrealistic or unformed expectations related to aesthetic results. Women undergoing breast reconstruction often have unrealistic or unformed expectations before surgery. Identifying these expectations and proving expectations-based education resulted in satisfaction with information provided.

ESPRAS Survey on Breast Reconstruction in Europe

BACKGROUND

 The European Leadership Forum (ELF) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) previously identified the need for harmonisation of breast reconstruction standards in Europe, in order to strengthen the role of plastic surgeons. This study aims to survey the status, current trends and potential regional differences in the practice of breast reconstruction in Europe, with emphasis on equity and access.

MATERIALS AND METHODS

 A largescale web-based questionnaire was sent to consultant plastic and reconstructive surgeons, who are experienced in breast reconstruction and with understanding of the national situation in their country. Suitable participants were identified via the Executive Committee (ExCo) of ESPRAS and national delegates of ESPRAS. The results were evaluated and related to evidence-based literature.

RESULTS

 A total of 33 participants from 29 European countries participated in this study. Overall, the incidence of breast reconstruction was reported to be relatively low across Europe, comparable to other large geographic regions, such as North America. Equity of provision and access to breast reconstruction was distributed evenly within Europe, with geographic regions potentially affecting the type of reconstruction offered. Standard practices with regard to radiotherapy differed between countries and a clear demand for European guidelines on breast reconstruction was reported.

CONCLUSION

 This study identified distinct lack of consistency in international practice patterns across European countries and a strong demand for consistent European guidance. Large-scale and multi-centre European clinical trials are required to further elucidate the presented areas of interest and to define European standard operating procedures.

Current physical therapy care of patients undergoing breast reconstruction for breast cancer: a survey of practice in the United Kingdom and Brazil

BACKGROUND

In both the United Kingdom (UK) and Brazil, women undergoing mastectomy should be offered breast reconstruction. Patients may benefit from physical therapy to prevent and treat muscular deficits. However, there are uncertainties regarding which physical therapy program to recommend.

OBJECTIVE

The aim was to investigate the clinical practice of physical therapists for patients undergoing breast reconstruction for breast cancer. A secondary aim was to compare physical therapy practice between UK and Brazil.

METHODS

Online survey with physical therapists in both countries. We asked about physical therapists' clinical practice.

RESULTS

181 physical therapists completed the survey, the majority were from Brazil (77%). Respondents reported that only half of women having breast reconstruction were routinely referred to physical therapy postoperatively. Contact with patients varied widely between countries, the mean number of postoperative sessions was 5.7 in the UK and 15.1 in Brazil. The exercise programs were similar for different reconstruction operations. Therapists described a progressive loading structure over time: range of motion (ROM) was restricted to 90° of arm elevation in the first two postoperative weeks; by 2-4 weeks ROM was unrestricted; at 1-3 months muscle strengthening was initiated, and after three months the focus was on sports-specific activities.

CONCLUSION

Only half of patients having a breast reconstruction are routinely referred to physical therapy. Patients in Brazil have more intensive follow-up, with up to three times more face-to-face contact with a physical therapist than in the UK. Current practice broadly follows programs for mastectomy care rather than being specific to reconstruction surgery.

Higher Risk of Depression After Total Mastectomy Versus Breast Reconstruction Among Adult Women With Breast Cancer: A Systematic Review and Metaregression

This systematic review with a meta-regression was conducted to determine the risk of depression after mastectomy compared to breast reconstruction among women with breast cancer 1 year after surgery. A literature search was conducted according to PRISMA guidelines using 4 databases: Medline (Ovid), Embase, Cinahl, and the Cochrane Library for the period January 2000 to March 2019. Studies that measured the status of depression within 1 year and immediately after surgery were included. Outcomes related to depression were analyzed by using a pool of event rates and a risk ratio of 95% confidence interval (CI), P value, and a fitting model based on the results of a heterogeneity test of mastectomy and BR. The statistical analysis was conducted using Comprehensive Meta-analysis 3.0 software. Nine studies met the inclusion criteria. There were 865 cases of mastectomy only, with a 22.2% risk of depression (95% CI, 12.4-36.2). In 869 women who underwent BR, the risk of depression was 15.7% (95% CI, 8.8-26.2). The depression risk ratio for mastectomy compared to BR was 1.36 (95% CI, 1.11-1.65). Patients with delayed reconstruction exhibited lower levels of depression (risk ratio 0.96, 95% CI 0.57-1.01). The Beck Depression Inventory (BDI) scale showed high sensitivity, and the Hospital Anxiety Depression Scale (HADS) with a cutoff of > 7 could measure even low to moderate depressive symptoms. One in 4 women with breast cancer had symptoms of depression after mastectomy; both surgeries were associated with depression in women 1 year after surgery. Our results will permit the development of proactive treatment plans before and after surgery to mitigate risk and prevent depression through the use of sensitive depression scales like BDI.

Loco-regional recurrence after skin and nipple-sparing mastectomy and immediate breast reconstruction using free flap autologous tissue in a single institution

BACKGROUND

Immediate autologous tissue breast reconstruction after skin- and nipple-sparing mastectomy, is becoming increasingly popular, while the benefits are evident, the concern is in leaving breast tissue under the skin envelope, which could potentially lead to a higher chance of recurrence. We aim to determine the incidence and study the management of loco-regional recurrence (LR) of breast cancer following immediate autologous free flap reconstruction (AFFR) from a 10-year database at a single tertiary breast unit.

METHODS

This is a retrospective analysis of a prospectively maintained database of consecutive patients who underwent AFFR between July 2008 and December 2018. All patients undergoing delayed reconstruction and risk-reducing surgery were excluded, leaving a total of 216 patients. Statistical analysis was performed to determine significance in the prediction of LR. Management and outcome of the LR was also studied.

RESULTS

LR was found in 7/216 cases (3.25%). The median age at surgery for patients with LR, was 45 (range 31-54). Median time to recurrence was 54 months (7-79 months). Three patients presented with self-detected lesions. In all, 6/7 patients were ER/PR positive, 2/7 were HER2 + at recurrence, and 1/7 was triple negative. All patients underwent surgical excision for the LR followed by radiotherapy, either chemotherapy (n-5) and/or hormone therapy (n-2). No patients have developed further LR. Because of low numbers of recurrences, no statistical significance was observed for factors causing recurrence.

CONCLUSION

The low LR we report demonstrates that immediate AFFR is oncologically safe. Timely recognition through post-reconstruction patient education and appropriate management results in good outcomes.

A Randomized Controlled Trial to Assess the Use of a Virtual Decisional Aid to Improve Knowledge and Patient Satisfaction in Women Considering Breast Reconstruction Following Mastectomy

Background

The decisional process of navigating breast reconstruction surgery is very challenging for patients with a breast cancer diagnosis. This study aims to assess the impact of a virtual breast reconstruction decision aid program on the decision-making process of breast cancer patients considering breast reconstruction. 

Methods

A two-arm, randomized, controlled trial was conducted at the University of Pittsburgh. Patients were blindly assigned to one of two arms: Emmi Decide (Emmi Solutions LLC, Chicago, IL) program prior to traditional consultation (intervention) and traditional consultation alone (control). All patients completed a baseline pre- and post-intervention questionnaire to evaluate knowledge, patient satisfaction, and psychological status. Surgeons' satisfaction and consultation time were also recorded.

Results

A total of 26 patients participated in the study (n=13 in each arm). Patients in the intervention group reported a greater BREAST-Q reconstruction module score (control=47.9±8.2, intervention=56.8±4.2, p=0.0017), lower decisional conflict scale score (control=30.2±11.8, intervention=14.5±8.8, p=0.017), and improved patient knowledge (control=70.8±15.5%, intervention=83.1±13.8%, p=0.018). No difference was noted in consultation time (control=51.0±7.8 min, intervention=47.8±13.7 min, p=0.46) and psychological testing (control=49.7±16.0, intervention=44.6±15.2, p=0.26). However, surgeons reported greater satisfaction with their consultations with interventional group participants (control=3.4±0.7, intervention=4.8±0.4, p=0.000056).

Conclusions

The use of a virtual decisional aid program to assist the decision-making of breast reconstruction patients was shown to significantly benefit both patients and surgeons, by improving patient knowledge and satisfaction without placing an additional psychological burden on them. This supports the notion that this resource is a promising tool that can improve the difficult process of breast reconstruction in the vulnerable population of breast cancer patients. 

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Robotic Surgery: A Novel Approach for Breast Surgery and Reconstruction

Supplemental Digital Content is available in the text.

Background:

Breast cancer is the most prevalent cancer and second leading cause of cancer-related deaths in both the US and UK female population, a prominent cause of morbidity and cost to both health services. All surgically fit patients are offered breast reconstruction following the initial surgery, and this is traditionally an open approach: either implant-based or an autologous tissue flap. Both lead to scarring that is difficult to conceal. This paper aims to evaluate the novel minimally invasive technique of robotic-assisted surgery.

Methods:

A systematic review was conducted using Medline (OvidSP) and Embase (OvidSP) to evaluate the current application of robotic-assisted surgery in breast surgery and reconstruction.

Results:

Twenty-one articles were identified and discussed, composing of level 4 and 5 evidence comparing different surgeons' experiences, techniques, and outcomes. To date, the robotic system has been utilized to harvest the latissimus dorsi muscle for use as a tissue flap (total harvest time of 92 minutes), to perform nipple-sparing mastectomy with immediate breast reconstruction (total operation time 85 minutes) and lately to harvest a deep inferior epigastric perforator flap via an intraabdominal approach.

Conclusions:

Robotic-assisted surgery can successfully and reproducibly perform a nipple-sparing mastectomy with breast reconstruction. It can minimize the size of scarring and is superior to the laparoscopic technique, with improved 3-dimensional visualization, dexterity, and range of motion able to guide around the curvature of the breast. The main limiting factors are the lack of the US Food and Drug Administration approval, cost of the robot, and specialized skills required.

Presentation, tumour and treatment features in immigrant women from Arabic-speaking countries treated for breast cancer in Australia

BACKGROUND

Australia has a large population of immigrant women from Arabic-speaking countries. The aim of this study was to examine breast cancer tumour and surgical treatment features for women born in Arabic-speaking countries and compare them to women born in Australia and other countries. Another aim was to consider how this information can inform clinical care for this multicultural population.

METHODS

This is a retrospective audit of an institutional breast cancer database. Demographic, tumour and surgical treatment data were extracted for the Arab women and compared to Australian-born women (comparison 1) and to women born in all other countries (comparison 2); chi-squared analysis was performed to test for differences between groups.

RESULTS

A total of 2086 cases with country of birth information were identified, of whom 139 women (6.7%) were born in Arabic-speaking countries, 894 (42.8%) were born in Australia and 1053 (50.4%) were born in other countries (71 nations). Arab women tended to be younger (P = 0.013), more disadvantaged (P < 0.001), were more likely to have symptomatic rather than screen-detected breast cancer (P < 0.001), had a higher rate of high grade (P = 0.021), HER2-positive (P = 0.025) breast cancer compared to Australian-born women or others. There was no difference in tumour (pT) stage, rate of breast conservation versus mastectomy, re-excision and contralateral prophylactic mastectomy between groups. Australian-born women were more likely to undergo breast reconstruction after mastectomy (P < 0.001); reconstruction rate was >29% in all groups.

CONCLUSION

Women born in Arabic-speaking countries were younger, more disadvantaged and showed more aggressive tumour features. This has implications for supportive care during treatment and survivorship.

Breast Reconstruction with a Tissue Engineering and Regenerative Medicine Approach (Systematic Review)

Current techniques for breast reconstruction include an autologous-tissue flap or an implant-based procedure, although both can impose further morbidity. This systematic review aims to explore the existing literature on breast reconstruction using a tissue engineering approach; conducted with the databases Medline and Embase. A total of 28 articles were included, mainly comprising of level-5 evidence with in vitro and animal studies focusing on utilizing scaffolds to support the migration and growth of new tissue; scaffolds can be either biological or synthetic. Biological scaffolds were composed of collagen or a decellularized tissue matrix scaffold. Synthetic scaffolds were primarily composed of polymers with customisable designs, adjusting the internal morphology and pore size. Implanting cells, including adipose-derived stem cells, with combined use of basic fibroblast growth factor has been studied in an attempt to enhance tissue regeneration. Lately, a level-4 evidence human case series was reported; successfully regenerating 210 mL of tissue using an arterio-venous pedicled fat flap within a tissue engineering chamber implanted on the chest wall. Further research is required to evaluate whether the use of cells and other growth factors could adjust the composition of regenerated tissue and improve vascularity; the latter a major limiting factor for creating larger volumes of tissue.

Depression is associated with worse outcomes among women undergoing breast reconstruction following mastectomy

BACKGROUND

The causes of depression after breast reconstruction include worse outcomes, longer recovery times, and, sometimes, additional operations. Despite a plethora of data examining the effect of depression after breast reconstruction, there is little information to assess if concurrent depression affects patient outcomes in a similar manner. Thus, we sought to answer this question: Do depressed women undergoing breast reconstruction have worse outcomes?

METHODS

The United States National Inpatient Sample was queried during 2010-2013 for all patients undergoing breast reconstruction after mastectomy. Patients with a diagnosis of depression at the time of breast reconstruction were compared to those who did not have depression at the time of breast reconstruction; patients who had any of the corresponding ICD-9 procedure codes for breast reconstruction and the single diagnostic code for depression included in their electronic medical record were included in the database sample. Significance testing and risk-adjusted multivariate logistic regression were performed with SPSS.

RESULTS

A total of 175,508 patients were included in this study, of which 35,473 had depression at the time of breast reconstruction and 140,035 did not. Depression was associated with an increased age, length of stay, greater cost of care, more comorbidities, and higher incidence of pulmonary, hematologic, gastrointestinal, infectious, wound, and venous thromboembolic complications, p<0.05. Pulmonary, genitourinary, and hematologic complications, infection, VTE, wound, and transfusion were associated with depression when a multivariate risk-adjusted regression was performed.

CONCLUSION

A co-morbid diagnosis at the time of breast reconstruction should prompt the breast reconstruction team to ensure that depressed patients have their depression managed and all co-morbidities optimized and treated prior to undergoing breast reconstruction to ensure optimal patient outcomes.

Outcomes of music therapy interventions in cancer patients-A review of the literature

BACKGROUND

Effectiveness of music-based interventions (MI) on cancer patients' anxiety, depression, pain and quality of life (QoL) is a current research theme. MI are highly variable, making it challenging to compare studies.

OBJECTIVE AND METHODS

To summarize the evidence on MI in cancer patients, 40 studies were reviewed following the PRISMA statement. Studies were included if assessing at least one outcome among anxiety, depression, QoL and pain in patients aged ≥ 18, with an active oncological/onco-haematological diagnosis, participating to any kind of Music Therapy (MT), during/after surgery, chemotherapy or radiotherapy.

RESULTS

A positive effect of MI on the outcomes measured was supported. Greater reductions of anxiety and depression were observed in breast cancer patients. MI involving patients admitted to a hospital ward were less effective on QoL.

CONCLUSION

The increasing evidence about MI effectiveness, tolerability, feasibility and appreciation, supports the need of MI implementation in Oncology, Radiotherapy and Surgery wards, and promotion of knowledge among health operators.

Current Resources for Evidence-Based Practice, March 2019

A review of new resources to support the provision of evidence-based care for women and infants.

Silicone breast implants and depression, fibromyalgia and chronic fatigue syndrome in a rheumatology clinic population

INTRODUCTION

Silicone breast implants (SBI) may induce systemic autoimmune disease as part of autoimmune syndrome induced by adjuvants (ASIA). This syndrome bears similarities to fibromyalgia and chronic fatigue syndrome (CFS). We sought to determine whether there are any associations between SBI and depression, fibromyalgia and CFS in a rheumatology clinic population.

METHODS

The electronic files of rheumatology clinic patients at the Royal Adelaide Hospital between 2000 and 2017 were searched for patients who had received SBI prior to rheumatological diagnosis. Demographics, diagnosis, implant history and whether the patient had depression, fibromyalgia or CFS were recorded. Controls were rheumatology clinic patients, half of whom had systemic sclerosis (SSc) and the other half had systemic lupus erythematosus (SLE). They were matched to cases 3:1 for age (within 2 years) and gender.

RESULTS

Thirty patients had received SBI (mean age 47.9, 100% female). Twelve had a diagnosis of depression, 6 of fibromyalgia and 3 of CFS. Implant rupture was not associated with any of these (p = 1). There was no difference in the incidence of depression (p = 1), fibromyalgia (p = 0.76) or CFS (p = 0.3) between cases and SLE controls. When compared with SSc controls, there were significantly more patients with fibromyalgia and/or CFS in the case group (20.0% of cases vs 2.2% of SSc controls, p = 0.01) but no difference in depression (p = 0.12).

CONCLUSION

Fibromyalgia and CFS are more common in patients with silicone implants than SSc controls but not SLE controls. Prospective study of development of depression, fibromyalgia and CFS in recipients of SBI is required.

[Assessment of patient satisfaction following nipple-areolar complex tattooing after breast reconstruction.]

INTRODUCTION

Nipple-areolar complex tattooing often completes the breast mound reconstruction process after cancer surgery. However, there have been few studies evaluating patient satisfaction with this technique.

OBJECTIVE

To assess patients' esthetic satisfaction with the results of tattooing performed by nurses.

METHOD

Ninety-eight women participated in the study. Overall satisfaction with reconstruction and satisfaction with the tattoo's color, dimension, position, and form were determined using questionnaires completed by patients and a professional jury.

RESULTS

97% of patients reported overall satisfaction with the results of nipple-areolar reconstruction. The satisfaction rate with the tattoo's color was 67%, with dimension 96%, with form 95%, and with position 94%. The satisfaction rates of the jury were as follows: nipple-areolar reconstruction 79%; color 52%; dimension 77%; form 75%; and position 69%.

DISCUSSION

On the whole, the patients were satisfied with the results one year after tattooing and their satisfaction rate was higher than that of the jury's. Only 6.1% of women required a second tattoo because of discoloration.

CONCLUSION

Nipple-areolar complex tattooing has a high rate of patient esthetic satisfaction and can be performed by a trained nurse without the need for hospital admission.