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Hansson E, Löfstrand J, Larsson C, Uusimaki A, Svensson K, Ekman A, Svensson M, Paganini A. Gothenburg Breast reconstruction (GoBreast) II protocol: a Swedish partially randomised patient preference, superiority trial comparing autologous and implant-based breast reconstruction. BMJ Open 2024; 14:e084025. [PMID: 39019639 PMCID: PMC11256070 DOI: 10.1136/bmjopen-2024-084025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 06/27/2024] [Indexed: 07/19/2024] Open
Abstract
INTRODUCTION Although breast reconstruction is an integral part of breast cancer treatment, there is little high-quality evidence to indicate which method is the most effective. Randomised controlled trials (RCTs) are generally thought to provide the most solid scientific evidence, but there are significant barriers to conducting RCTs in breast reconstruction, making both recruitment and achieving unbiased and generalisable results a challenge. The objective of this study is to compare implant-based and autologous breast reconstruction in non-irradiated patients. Moreover, the study aims to improve the evidence for trial decision-making in breast reconstruction. METHODS AND ANALYSIS The study design partially randomised patient preference trial might be a way to overcome the aforementioned challenges. In the present study, patients who consent to randomisation will be randomised to implant-based and autologous breast reconstruction, whereas patients with strong preferences will be able to choose the method. The study is designed as a superiority trial based on the patient-reported questionnaire BREAST-Q and 124 participants will be randomised. In the preference cohort, patients will be included until 62 participants have selected the least popular alternative. Follow-up will be 60 months. Embedded qualitative studies and within-trial economic evaluation will be performed. The primary outcome is patient-reported breast-specific quality of life/satisfaction, and the secondary outcomes are complications, factors affecting satisfaction and cost-effectiveness. ETHICS AND DISSEMINATION The study has been approved by the Swedish Ethical Review Authority (2023-04754-01). Results will be published in peer-reviewed scientific journals and presented at peer-reviewed scientific meetings. TRIAL REGISTRATION NUMBER NCT06195865.
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Affiliation(s)
- Emma Hansson
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Jonas Löfstrand
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Camilla Larsson
- Johanna, Regional branch of the Swedish Breast Cancer Association, Gothenburg, Sweden
| | - Alexandra Uusimaki
- Johanna, Regional branch of the Swedish Breast Cancer Association, Gothenburg, Sweden
| | - Karolina Svensson
- Johanna, Regional branch of the Swedish Breast Cancer Association, Gothenburg, Sweden
| | - Anna Ekman
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Mikael Svensson
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Anna Paganini
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
- Department of Diagnostics, Acute and Critical Care, Institute of Health and Care Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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Hansson E, Larsson C, Uusimäki A, Svensson K, Widmark Jensen E, Paganini A. A systematic review of randomised controlled trials in breast reconstruction. J Plast Surg Hand Surg 2024; 59:53-64. [PMID: 38751090 DOI: 10.2340/jphs.v59.40087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND For preference sensitive treatments, such as breast reconstructions, there are barriers to conducting randomised controlled trials (RCTs). The primary aims of this systematic review were to investigate what type of research questions are explored by RCTs in breast reconstruction, where have they been performed and where have they been published, and to thematise the research questions and thus create an overview of the state of the research field. METHODS Randomised controlled trials investigating any aspect of breast reconstructions were included. The PubMed database was searched with a pre-defined search string. Inclusion and data abstraction was performed in a pre-defined standardised fashion. For the purpose of this study, we defined key issues as comparison of categories of breast reconstruction and comparison of immediate and delayed breast reconstruction, when the thematisation was done. RESULTS A total of 419 abstracts were retrieved from the search. Of the 419, 310 were excluded as they were not RCTs concerning some aspect of breast reconstruction, which left us with 110 abstracts to be included in the study. The research questions of the included studies could more or less be divided into seven different themes inclusive of 2 key issues: Other issues - comparison of different categories of breast reconstruction, comparison of immediate and delayed breast reconstruction, surgical details within a category of breast reconstruction, surgical details valid for several categories of breast reconstruction, donor site management, anaesthetics, and non-surgical details. Only five studies compared key issues, and they all illustrate the challenges with RCTs in breast reconstruction. CONCLUSIONS A total of 110 publications based on RCTs in breast reconstruction have been published. Seven themes of research questions could be identified. Only five studies have explored the key issues. Better scientific evidence is needed for the key issues in breast reconstruction, for example by implementing a new study design in the field.
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Affiliation(s)
- Emma Hansson
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden.
| | - Camilla Larsson
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Alexandra Uusimäki
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Karolina Svensson
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Emmelie Widmark Jensen
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Anna Paganini
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden; Department of Diagnostics, Acute and Critical Care, Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Hansson E, Brorson F, Löfstrand J, Elander A, Svensson M. Systematic review of cost-effectiveness in breast reconstruction: deep inferior epigastric perforator flap vs. implant-based breast reconstruction. J Plast Surg Hand Surg 2024; 59:1-13. [PMID: 38189784 DOI: 10.2340/jphs.v59.19649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 11/21/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND There are several techniques for reconstructing breasts after mastectomy, but little scientific evidence for which technique is superior. The aim of this systematic review was to compare the cost-effectiveness of implant-based and autologous reconstruction and to evaluate the overall certainty of evidence, as well as the quality of reporting of the included studies. METHODS Studies investigating the cost-effectiveness of breast reconstruction with a deep inferior epigastric perforator (DIEP) flap compared to implant-based reconstruction, meeting criteria defined in a PICO (population, intervention, comparison, and outcome), were included. Medline, PubMed, Embase, Cochrane library, CinahL, EconLit, and NHS EED databases were searched. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence, and the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) 2022 was used to evaluate the quality of reporting. RESULTS AND CONCLUSIONS A total of 256 abstracts were retrieved from the search, and after scrutiny, seven studies were included. The findings of this present systematic review should be interpreted with caution as the overall certainty of evidence is low (GRADE ƟƟОО). The included studies suggest that DIEP-flaps are cost-effective compared with implant-based breast reconstruction when the applied cost-effectiveness thresholds of $50,000 to $100,000 per quality-adjusted life years are used. It is noteworthy that no high level evidence exists regarding cost-effeciency, to support recommendations and decision in breast reconstruction. Methodological issues that can be improved in future studies are presented.
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Affiliation(s)
- Emma Hansson
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden.
| | - Fredrik Brorson
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Jonas Löfstrand
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Anna Elander
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Mikael Svensson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA; School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Kuhlefelt C, Repo JP, Jahkola T, Kauhanen S, Homsy P. Immediate versus delayed breast reconstruction: Long-term follow-up on health-related quality of life and satisfaction with breasts. J Plast Reconstr Aesthet Surg 2024; 88:478-486. [PMID: 38101261 DOI: 10.1016/j.bjps.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 12/17/2023]
Abstract
INTRODUCTION Health-related quality of life (HRQL) can be improved by breast reconstruction following mastectomy. The optimal timing of the reconstruction remains unclear. METHODS A cross-sectional study on 338 women who had undergone immediate or delayed breast reconstruction between 08/2017 and 07/2019 was performed. The postoperative HRQL was assessed using the BREAST-Q Reconstruction Module and the 36-Item Short Form Survey (SF-36). Regression analysis was performed for group-wise comparison. RESULTS A total of 146 (43%) patients participated. Seventy-seven patients (53%) had undergone immediate, and 69 patients (47%) had delayed reconstruction. The median age was 55 years (interquartile ratio [IQR] 50-62) for the Immeda group te, and 60 years (IQR 54-65) for the delayed reconstruction group. The median follow-up time was 2.3 years (IQR 1.8-2.9). No difference between the groups was detected in satisfaction with breasts (median 61, IQR 53-71 vs. 62, IQR 46-71, p = 0.62), physical well-being of the chest (median 100, IQR 80-100 vs. 100, IQR 80-100, p = 0.95) or psychosocial well-being (median 69, IQR 54-83 vs. 62, IQR 54-74, p = 0.19). No difference was detected in the SF-36 domains either. CONCLUSIONS The timing of the breast reconstruction does not affect the postoperative HRQL. Patients with both immediate and delayed breast reconstruction reported high satisfaction with the breast and psychosocial well-being.
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Affiliation(s)
- Charlotta Kuhlefelt
- Division of Musculoskeletal and Plastic Surgery, Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Park Hospital, PB 281, 00029 HUS Helsinki, Finland.
| | - Jussi P Repo
- Unit of Musculoskeletal Disease, Department of Orthopedics and Traumatology, Tampere University Hospital and University of Tampere, PB 2000, FI-33521 Tampere, Finland
| | - Tiina Jahkola
- Division of Musculoskeletal and Plastic Surgery, Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Park Hospital, PB 281, 00029 HUS Helsinki, Finland
| | - Susanna Kauhanen
- Division of Musculoskeletal and Plastic Surgery, Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Park Hospital, PB 281, 00029 HUS Helsinki, Finland
| | - Pauliina Homsy
- Division of Musculoskeletal and Plastic Surgery, Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Park Hospital, PB 281, 00029 HUS Helsinki, Finland
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