Radiation Therapy Versus No Radiation Therapy to the Neo-breast Following Skin-Sparing Mastectomy and Immediate Autologous Free Flap Reconstruction for Breast Cancer: Patient-Reported and Surgical Outcomes at 1 Year—A Mastectomy Reconstruction Outcomes Consortium (MROC) Substudy

Post-mastectomy radiation therapy after breast reconstruction: from historic dogmas to practical expert agreements based on a large literature review of surgical and radiation therapy considerations

Breast reconstruction (BR) after mastectomy is important to consider for a woman's body image enhancement and psychological well-being. Although post-mastectomy radiation (PMRT) significantly improves the outcome of patients with high-risk breast cancer (BC), PMRT after BR may affect cosmetic outcomes and may compromise the original goal of improving quality of life (QoL). With the lack of practical guidelines, it seems essential to work on a consensus and provide some "expert agreements" to offer patients the best option for PMRT after BR. We report a global "expert agreement" that results from a critical review of the literature on BR and PMRT during the 6th international multidisciplinary breast conference in March 2023.

Effects of Elective Revision after Breast Reconstruction on Patient-Reported Outcomes

BACKGROUND

 There has been increasing emphasis on patient-reported satisfaction as a measure of surgical outcomes. While previous research has investigated factors influencing patient satisfaction following breast reconstruction, there are few studies on how patient satisfaction is impacted by revision procedures. The purpose of this study was to investigate whether elective revisions following breast reconstruction are significantly associated with changes in patient-reported outcomes and quality of life.

METHODS

 A retrospective review was conducted of patients who underwent immediate autologous or alloplastic breast reconstruction at a single institution from 2015 to 2021. Patients were included if they had completed BREAST-Q preoperatively, post-initial reconstruction, and post-revision procedures. Patients were excluded if they received adjuvant radiation or if they had previously undergone breast reconstruction procedures. The primary outcome measures were BREAST-Q domains. Demographic, clinical, and surgical variables were also analyzed.

RESULTS

 Of the 123 patients included for analysis, 61 underwent autologous breast reconstruction and 62 underwent alloplastic reconstruction. Mean age was 49.31 ± 11.58 years and body mass index (BMI) was 29.55 ± 5.63 kg/m2. Forty-eight patients underwent no revision procedures and 75 patients underwent at least one revision. Between these two groups, there were no differences in age, BMI, complication rates, socioeconomic status, or preoperative BREAST-Q scores. Patients reported significantly higher satisfaction with outcome after their first revision compared with after initial reconstruction alone (p = 0.04). Autologous reconstruction patients who had at least one revision had significantly higher satisfaction with outcome (p = 0.02) and satisfaction with surgeon (p = 0.05) in the 2-year follow-up period compared with patients who had no revisions.

CONCLUSION

 Revision procedures following autologous breast reconstruction are associated with higher patient satisfaction with outcome. Further research should explore specific factors influencing patient decision-making regarding whether to undergo revisions.

Effect of radiation therapy during surgery on postoperative wound complications after breast reconstruction in patients with breast cancer: A meta-analysis

Breast remodelling is a major therapeutic choice in radical mastectomy. Breast reconstruction is regarded as a promising option for the treatment of breast cancer. The purpose of this meta-analysis was to investigate the effect of Post mastectomy radiotherapy (PMRT) on postoperative wound complications in breast carcinoma. A comprehensive review of documents was conducted between the date of establishment and the 28th of August 2023. In all of the trials, patients were treated with breast cancer. The researchers chose 11 publications out of 8068 related studies. Two researchers examined these publications to satisfy the inclusion criteria. Among the 516 patients who had received radiation therapy in the course of the operation, 1772 had not received radiation therapy. The impact of radiation therapy and non-radiation therapy in breast cancer patients after breast reconstruction was reported in 8 studies, and the incidence of postoperative wound infection in non-radiation group was significantly lower (OR, 1.95; 95% CI, 1.26-3.02 p = 0.003). In nine studies, There is not considered to have achieved statistical significance between radiation therapy and non-radiation treatment for post-operation wound dehiscence in breast cancer patients who had received chemotherapy (OR, 1.61; 95% CI, 0.70-3.72 p = 0.27). The results of six trials demonstrated that radiation therapy and non-radiation therapy had no statistical significance on post-operation haemorrhage in breast cancer patients (OR, 1.02; 95% CI, 0.42-2.47 p = 0.96). The results of 7 trials demonstrated that radiation therapy and non-radiation therapy had no significant impact on the post-operation of skin necrosis (OR, 1.22; 95% CI, 0.66-2.28 p = 0.53). Two trials demonstrated that those without radiation therapy were less likely than those who received radiation therapy in skin contracture in patients (OR, 7.24; 95% CI, 1.80-29.10 p = 0.005). Regarding the incidence of wound infection and cutaneous contraction was higher in the radiation group.

Trends and issues in clinical research on satisfaction and quality of life after mastectomy and breast reconstruction: a 5-year scoping review

Breast reconstruction (BR) aims to improve the satisfaction and quality of life (QOL) of breast cancer survivors. Clinical studies using patient-reported outcomes (PROs) can therefore provide relevant information to the patients and support decision-making. This scoping review was conducted to analyze recent trends in world regions, methods used, and factors investigated. The literature search was conducted in August 2022. Databases of PubMed, MEDLINE, and CINAHL were searched for relevant English-language studies published from 2017 to 2022. Studies involving women with breast cancer who underwent BR after mastectomy and investigated PROs after BR using BR-specific scales were included. Data on the country, publication year, study design, PRO measures (PROMs) used, time points of surveys, and research themes were collected. In total, 147 articles met the inclusion criteria. BREAST-Q was the most widely used, contributing to the increase in the number and diversification of studies in this area. Such research has been conducted mainly in North America and Europe and is still developing in Asia and other regions. The research themes involved a wide range of clinical and patient factors in addition to surgery, which could be influenced by research methods, time since surgery, and even cultural differences. Recent BR-specific PROMs have led to a worldwide development of research on factors that affect satisfaction and QOL after BR. PRO after BR may be influenced by local cultural and social features, and it would be necessary to accumulate data in each region to draw clinically useful conclusion.

Preoperative Assessment of the Breast Reconstruction Patient

Through a multidisciplinary approach, as well as, a nuanced appreciation of patient goals and setting appropriate expectations, breast reconstruction can significantly improve the quality of life following mastectomy. A thorough review of the patient medical and surgical history in addition to oncologic treatments will facilitate discussion and recommendations for an individualized shared decision-making reconstructive process. Alloplastic reconstruction, although a highly popular modality, has important limitations. On the contrary, autologous reconstruction is more flexible but requires more thorough consideration.

Pre-operative Radiotherapy And Deep Inferior Epigastric Artery Perforator (DIEP) flAp study (PRADA): Aesthetic outcome and patient satisfaction at one year

INTRODUCTION

The optimal combination of radiotherapy and breast reconstruction has not yet been defined. Post-mastectomy radiotherapy (PMRT) has deleterious effects on breast reconstruction, leading to caution amongst surgeons. Pre-operative radiotherapy (PRT) is a growing area of interest, is demonstrated to be safe, and spares autologous flaps from radiotherapy. This study evaluates the aesthetic outcome of PRT and deep inferior epigastric artery perforator (DIEP) flap reconstruction within the Pre-operative Radiotherapy And Deep Inferior Epigastric artery Perforator (DIEP) flAp (PRADA) cohort.

METHODS

PRADA was an observational cohort study designed to evaluate the feasibility and safety of PRT for women undergoing neoadjuvant chemotherapy and DIEP reconstruction. Panel evaluation of 3D surface images (3D-SIs) and patient-reported outcome measures (BREAST-Q) for a subset of women in the study were compared with those of a DIEP-PMRT cohort who had undergone DIEP reconstruction and PMRT.

RESULTS

Seventeen out of 33 women from the PRADA study participated in this planned substudy. Twenty-eight women formed the DIEP-PMRT cohort (median follow-up 23 months). The median (inter-quartile range [IQR]) 'satisfaction with breasts' score at 12 months for the PRADA cohort was significantly better than the DIEP-PMRT cohort (77 [72-87] versus 64 [54-71], respectively), p=0.01). Median [IQR] panel evaluation (5-point scale) was also significantly better for the PRADA cohort than for the DIEP-PMRT cohort (4.3 [3.9-4.6] versus 3.6 [2.8-4] p=0.003).

CONCLUSIONS

Aesthetic outcome for the PRADA cohort was reported to be 'good' or 'excellent' in 93% of cases using a bespoke panel assessment with robust methodology. Patient satisfaction at one year is encouraging and superior to DIEP-PMRT at 23 months. Switching surgery-radiotherapy sequencing leads to similar breast aesthetic outcomes and warrants further large-scale, multi-centre evaluation in a randomised trial.

Optimising post-operative radiation therapy after oncoplastic and reconstructive procedures

Surgical techniques for breast cancer have been refined over the past decades to deliver an aesthetic outcome as close as possible to the contralateral intact breast. Current surgery further allows excellent aesthetic outcome even in case of mastectomy, by performing skin sparing or nipple sparing mastectomy in combination with breast reconstruction. In this review we discuss how to optimise post-operative radiation therapy after oncoplastic and breast reconstructive procedures, including dose, fractionation, volumes, surgical margins, and boost application.

Breast Reconstruction: Necessity for Further Standardization of the Current Surgical Techniques Attempting to Facilitate Scientific Evaluation and Select Tailored Individualized Procedures Optimizing Patient Satisfaction

Background

Various breast cancer reconstruction methods and novel surgical techniques include autologous or allogenic procedures, which can increase patient's quality of life and provide options when dealing with patients seen as challenging clinical scenarios.

Summary

Our aim was to review the current literature and present published evidence on innovative standards in whole breast reconstruction. Advances in flap monitoring or newly published data regarding neurotization in breast reconstruction, arm lymphedema management, breast implant-associated anaplastic large cell lymphoma reconstruction treatment, and robotic surgery with regard to radiotherapy define innovative standards in the breast reconstruction setting. The role of meshes/acellular dermal matrix and fat grafting as well as optimal sequencing of postmastectomy radiotherapy in autologous and alloplastic breast reconstruction appear highly debatable also in expert panel meetings rendering further clinical research including RCTs imperative.

Key Messages

There is an abundance of novel available techniques, which mandate further standardization, facilitating scientific evaluation in an attempt to help surgeons select tailored procedures for each patient with the goal to promote informed decision-making in breast reconstruction.

Breast reconstruction using the profunda artery perforator (PAP) flap: Technical refinements and evolution, outcomes, and patient satisfaction based on 116 consecutive flaps

INTRODUCTION

When a deep inferior epigastric artery flap is not suitable, the profunda artery perforator (PAP) flap can be a good alternative for autologous breast reconstruction. Popularity of the PAP flap is expanding, but it is still only slowly being adopted worldwide. We report our experience with 116 consecutive PAP flaps showing refinements and evolution of the technique towards improvement in outcomes and patients' satisfaction.

METHODS

We prospectively collected data from consecutive PAP flap breast reconstructions performed from 2016 to 2019. Patients' demographics, pre-, intra-, postoperative data, and revision procedures were analyzed. The BREAST-Q and a specific questionnaire investigating outcomes at the donor site were completed preoperatively and 12 months postoperatively.

RESULTS

One-hundred and sixteen PAP flaps were performed in 86 patients, 64 unilateral and 22 bilateral breast reconstructions. Mean body mass index was 24.72 kg/m² (range 18.9-29.2) and mean flap weight was 251.30 g (range 152-455 g). Complications included donor site hematoma (1.7%), seroma (2.6%), fat necrosis (1.7%), and wound dehiscence (2.6%). No arterial/venous thrombosis nor flap losses were recorded. Patients reported high satisfaction in all BREAST-Q domains, with mean postoperative scores being higher than preoperative ones, suggesting a positive effect in quality of life and satisfaction. Scores were significant in the satisfaction with breast domain (p = 0.0016).

CONCLUSIONS

Breast reconstruction with PAP flap yields a high success, low complications, and excellent cosmetic outcomes in the breast and donor sites. It improves patients' satisfaction and quality of life; hence, it can be considered an excellent option for autologous breast reconstruction.

Does post-mastectomy radiation therapy worsen outcomes in immediate autologous breast flap reconstruction? A systematic review and meta-analysis

BACKGROUND

There is great uncertainty regarding the practice of immediate autologous breast reconstruction (IBR) when post-mastectomy radiotherapy (PMRT) is indicated. Plastic surgery units differ in their treatment protocols, with some recommending delayed breast reconstruction (DBR) following PMRT. IBR offers significant cosmetic and psychosocial benefits; however, the morbidity of flap exposure to radiation remains unclear.

OBJECTIVE

The aim of this review was to comprehensively analyze the existing literature comparing autologous flaps exposed to PMRT and flaps with no radiation exposure.

METHODS

A comprehensive search in MEDLINE, EMBASE and CENTRAL databases was conducted in November 2020. Primary studies comparing IBR with and without adjuvant PMRT were assessed for the following primary outcomes: clinical complications, observer-reported outcomes and patient-reported satisfaction rates. Meta-analysis was performed to obtain pooled risk ratios of individual complications.

RESULTS

Twenty-one articles involving 3817 patients were included. Meta-analysis of pooled data gave risk ratios for fat necrosis (RR = 1.91, p < 0.00001), secondary surgery (RR = 1.62, p = 0.03) and volume loss (RR = 8.16, p < 0.00001) favoring unirradiated flaps, but no significant difference was observed in all other reported complications. The no-PMRT group scored significantly higher in observer-reported measures. However, self-reported aesthetic and general satisfaction rates were similar between groups.

CONCLUSION

IBR should be offered after mastectomy to patients requiring PMRT. The higher risks of fat necrosis and contracture appear to be less clinically relevant as corroborated by positive scores from patients developing these complications. Preoperative and intraoperative measures should be taken to further optimize reconstruction and mitigate post-radiation sequel. Careful management of patients' expectations is also imperative.

LEVEL OF EVIDENCE

Level III.

The Effect of Previous Irradiation for Patients With Prosthetic Breast Reconstruction: A Meta-Analysis

BACKGROUND

Results regarding immediate prosthetic breast reconstruction after postmastectomy radiation therapy (PMRT) have been inconsistent.

OBJECTIVES

The authors aimed to assess the efficacy and safety of PMRT before immediate prosthetic breast reconstruction for patients with breast cancer.

METHODS

Electronic databases (PubMed, EmBase, and the Cochrane Library) were systematically searched to identify eligible studies from their inception until March 2020. The pooled odds ratio (OR) with 95% confidence intervals (CIs) was applied as an effect estimate and calculated using the random-effects model.

RESULTS

Nineteen studies including a total of 6757 patients were selected for final meta-analysis. The pooled OR showed that PMRT was associated with a higher incidence of reconstruction failure (OR = 2.57; 95% CI =1.55-4.26; P < 0.001), capsular contracture (OR = 5.99; 95% CI = 3.12-11.47; P < 0.001), and overall complications (OR = 2.52; 95% CI = 1.68-3.79; P < 0.001). It was also associated with a lower incidence of patient satisfaction (OR = 0.29; 95% CI = 0.16-0.52; P < 0.001) and good aesthetic results (OR = 0.25; 95% CI = 0.12-0.52; P < 0.001) compared with those who did not undergo PMRT. These significant associations could be affected by study design, mean age, stage of immediate breast reconstruction, follow-up, and study quality.

CONCLUSIONS

Although PMRT is the standard adjuvant therapy for mastectomy patients treated with immediate implant-based breast reconstruction, PMRT for patients undergoing immediate implant-based breast reconstruction has been associated with high risks of reconstruction failure, capsular contracture, and overall complications as well as low incidences of patient satisfaction and good aesthetic results.

LEVEL OF EVIDENCE: 4

A multidisciplinary approach for autologous breast reconstruction: A narrative (re)view for better management

Breast reconstruction and oncoplastic surgery have become an important part of breast cancer care. The use of autologous breast reconstruction (ABR) has evolved significantly with advances in microsurgery, aiming to reduce donor site complications and improve cosmesis. For years, immediate-ABR was considered a contraindication if postmastectomy irradiation (PMRT) was planned. As a result of de-escalation of axillary surgery the indication of PMRT are increasing along-side with observations that PMRT in the setting of ABR is not contraindicated. Surgical techniques may result in different amount and areas of breast residual glandular tissue and patient selection is important to reduce potential residual disease. Meticulus radiation planning is important to potentially reduce complications without compromising oncologic outcomes. Surgical techniques change constantly in aim to improve aesthetic results but should most importantly maintain priority to the oncological indications. By multidisciplinary team work with a comprehensive understanding of each discipline, we can preserve the accomplishments of breast surgery in the setting of PMRT, without compromising disease control.

A multidisciplinary view of mastectomy and breast reconstruction: Understanding the challenges

The current review paper was written in collaboration with breast cancer surgeons from the European Breast Cancer Research Association of Surgical Trialists (EUBREAST), a breast pathologist from the Danish Breast Cancer Group (DBCG), and representatives from the European SocieTy for Radiotherapy & Oncology (ESTRO) breast cancer course. Herein we summarize the different mastectomies and reconstruction procedures and define high-risk anatomical areas for breast cancer recurrences, to further specify the challenges in the surgical procedure, histopathological evaluation, and target volumes in case of postmastectomy irradiation, as recommended by the ESTRO guidelines according to the surgical procedure. The paper has original figures and illustrations for all disciplines for in-depth understanding of the differences between the procedures.

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Mastectomy techniques and reconstruction evolved to improve cosmetic outcomes.

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Different techniques maybe associated with different amount of residual breast tissue.

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More data is needed to estimate who are the patients at risk for residual disease or recurrence.

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Multidisciplinary work needed to individualise treatment for optimal oncological outcomes while maintaining the significant improvements in achieving better cosmesis for these patients.

Utility of the Patient-Reported Outcomes Measurement Information System (PROMIS) to measure primary health outcomes in cancer patients: a systematic review

OBJECTIVE

To systematically review the literature on how the Patient-Reported Outcomes Measurement Information System (PROMIS) measure system is used to assess patient-reported outcomes (PROs) in cancer patients.

METHODS

We conducted a systematic review following the PRISMA guidelines. Articles were identified through searches of PubMed, EMBASE, and additional manual review of the publications listed on the PROMIS website. We included studies measuring outcomes, including physical function, fatigue, pain, anxiety, and depression in cancer patients. Eligible articles included interventional and observational studies published in English between 2009 and 2019.

RESULTS

A total of 1789 records were identified and screened by three reviewers, 118 articles were reviewed in full text, and 42 articles met the inclusion criteria. The majority of studies used the PROMIS measure system to prospectively assess longitudinal changes in PROs; the number of measurements ranges from 2 to 4 with the time points of follow-up set at 3, 6, and 12 months after the baseline assessment. Depression and fatigue were the most frequently measured outcomes. Fixed-length short forms with four items were the most common measure types. A transition toward utilizing a web- or smartphone-based electronic tool was observed to limit the burden of the conventional paper-based survey to collect and store PROs.

CONCLUSION

The PROMIS measure system is increasingly popular to measure PROs in cancer patients with acceptance of its various short forms and electronic-based systems to administer data electronically. Findings from this review highlight various aspects of PROMIS and may help health professionals in their choice of PRO tools for optimizing care and support for cancer patients.

A Meta-Analysis of Autologous Microsurgical Breast Reconstruction and Timing of Adjuvant Radiation Therapy

BACKGROUND

 Postmastectomy radiation therapy (PMRT) decreases loco-regional recurrence and improves survival in patients with locally advanced breast cancer. Autologous free flap reconstruction, while more durable in the setting of radiation than alloplastic reconstruction, is still susceptible to radiation-induced fibrosis, contracture, fat necrosis, volume loss, and distortion of breast shape. Options for reconstruction timing (immediate vs. delayed) have been discussed to mitigate these effects, but a clear optimum is not known.

METHODS

 A systematic review of the literature was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using search terms "breast reconstruction AND (radiation OR irradiation OR radiotherapy)" were used. Inclusion criteria consisted of studies reporting complications for free flap breast reconstruction in the setting of PMRT. Patients who underwent PMRT were pooled into two groups: those who underwent immediate free flap reconstruction prior to PMRT and those who underwent delayed reconstruction after PMRT.

RESULTS

 Out of the 23 studies, 12 focused on immediate reconstruction, seven focused on delayed reconstruction, and four studies included both groups. Overall, 729 patients underwent immediate reconstruction, while 868 underwent delayed reconstruction. Complete and partial flap loss rates were significantly higher in patients undergoing delayed reconstruction, while infection and wound-healing complication rates were higher in those undergoing immediate reconstructions. Rates of unplanned reoperations, vascular complications, hematoma/seroma, and fat necrosis did not differ significantly between the two groups. However, rates of planned revision surgeries were higher in the delayed reconstruction group.

CONCLUSION

 Immediate free flap breast reconstruction is associated with superior flap survival compared with delayed reconstruction. Rates of complications are largely comparable, and rates of revision surgeries are equivalent. The differences in long-term aesthetic outcomes are not, however, clearly assessed by the available literature. Even in the face of PMRT, immediate free flap breast reconstruction is an effective approach.

Identifying factors impacting the efficacy of postmastectomy radiotherapy in patients with early-stage breast cancer and one to two positive lymph nodes

INTRODUCTION

In women with T1-2 breast cancer and one to two positive axillary lymph nodes (LN) at low risk for recurrence, postmastectomy radiation therapy (PMRT) may provide insufficient benefit to justify its toxicity. This study evaluated the interaction of factors associated with overall survival (OS) after PMRT in these patients.

METHODS

The National Cancer Database was queried for women with T1-2 breast cancer undergoing mastectomy with one to two positive LN identified on lymphadenectomy. Patients were grouped according to number of positive LN and then stratified by PMRT use. Differences in OS were evaluated.

RESULTS

Multivariable modeling demonstrated an interaction effect of age on the efficacy of PMRT. In patients more than or equal to 60 years old, PMRT was associated with improved survival when adjusting for age and tumor grade in patients with 1 to 2 positive LN (risk ratio = 0.62, 95% confidence interval = 0.40-0.93, P = .018). In patients less than 60 years old, tumor size and grade, but not PMRT, were associated with improved OS.

CONCLUSION

For women with T1-2 breast cancer and one to two positive LN, PMRT's association with OS is influenced by age, tumor grade, and number of positive LN. PMRT appears to be associated with improvements in OS in older patients, but not younger patients, regardless of tumor size or nodal status.

Immediate and delayed autologous abdominal microvascular flap breast reconstruction in patients receiving adjuvant, neoadjuvant or no radiotherapy: a meta-analysis of clinical and quality-of-life outcomes

BACKGROUND

Effects of postmastectomy radiotherapy (PMRT) on autologous breast reconstruction (BRR) are controversial regarding surgical complications, cosmetic appearance and quality of life (QOL). This systematic review evaluated these outcomes after abdominal free flap reconstruction in patients undergoing postoperative adjuvant radiotherapy (PMRT), preoperative radiotherapy (neoadjuvant radiotherapy) and no radiotherapy, aiming to establish evidence-based optimal timings for radiotherapy and BRR to guide contemporary management.

METHODS

The study was registered on PROSPERO (CRD42017077945). Embase, MEDLINE, Google Scholar, CENTRAL, Science Citation Index and ClinicalTrials.gov were searched (January 2000 to August 2018). Study quality and risk of bias were assessed using GRADE and Cochrane's ROBINS-I respectively.

RESULTS

Some 12 studies were identified, involving 1756 patients (350 PMRT, 683 no radiotherapy and 723 neoadjuvant radiotherapy), with a mean follow-up of 27·1 (range 12·0-54·0) months for those having PMRT, 16·8 (1·0-50·3) months for neoadjuvant radiotherapy, and 18·3 (1·0-48·7) months for no radiotherapy. Three prospective and nine retrospective cohorts were included. There were no randomized studies. Five comparative radiotherapy studies evaluated PMRT and four assessed neoadjuvant radiotherapy. Studies were of low quality, with moderate to serious risk of bias. Severe complications were similar between the groups: PMRT versus no radiotherapy (92 versus 141 patients respectively; odds ratio (OR) 2·35, 95 per cent c.i. 0·63 to 8·81, P = 0·200); neoadjuvant radiotherapy versus no radiotherapy (180 versus 392 patients; OR 1·24, 0·76 to 2·04, P = 0·390); and combined PMRT plus neoadjuvant radiotherapy versus no radiotherapy (272 versus 453 patients; OR 1·38, 0·83 to 2·32, P = 0·220). QOL and cosmetic studies used inconsistent methodologies.

CONCLUSION

Evidence is conflicting and study quality was poor, limiting recommendations for the timing of autologous BRR and radiotherapy. The impact of PMRT and neoadjuvant radiotherapy appeared to be similar.

International multidisciplinary expert panel consensus on breast reconstruction and radiotherapy

BACKGROUND

Conflicting evidence challenges clinical decision-making when breast reconstruction is considered in the context of radiotherapy. Current literature was evaluated and key statements on topical issues were generated and discussed by an expert panel at the International Oncoplastic Breast Surgery Meeting in Milan 2017.

METHODS

Studies on radiotherapy and breast reconstruction (1985 to September 2017) were screened using MEDLINE, Embase and CENTRAL. The literature review yielded 30 controversial key questions. A set of key statements was derived and the highest levels of clinical evidence (LoE) for each of these were summarized. Nineteen panellists convened for dedicated discussions at the International Oncoplastic Breast Surgery Meeting to express agreement, disagreement or abstention for the generated key statements.

RESULTS

The literature review identified 1522 peer-reviewed publications. A list of 22 key statements was produced, with the highest LoE recorded for each statement. These ranged from II to IV, with most statements (11 of 22, 50 per cent) supported by LoE III. There was full consensus for nine (41 per cent) of the 22 key statements, and more than 75 per cent agreement was reached for half (11 of 22).

CONCLUSION

Poor evidence exists on which to base patient-informed consent. Low-quality studies are conflicting with wide-ranging treatment options, precluding expert consensus regarding optimal type and timing of breast reconstruction in the context of radiotherapy. There is a need for high-quality evidence from prospective registries and randomized trials in this field.