Factors Leading to Decreased Rates of Immediate Postmastectomy Reconstruction

Oncological status is not a determinant of refraining from breast reconstruction among 490 candidates for mastectomy and post-mastectomy radiotherapy

BACKGROUND

Although breast reconstruction in the setting of post-mastectomy radiotherapy (PMRT) is controversial, we offer nipple-sparing mastectomy and immediate implant-based breast reconstruction ([N]SSM/IIBR) to women needing primary mastectomy regardless of PMRT. Nevertheless, some of these women have no reconstruction.

PURPOSE

To assess the uptake of breast reconstruction in women who undergo PMRT and the patient characteristics associated with such uptake. Additionally, we assessed the determinants of forgoing breast reconstruction.

METHODOLOGY

Demographic, physical and oncological characteristics of women who underwent mastectomy, PMRT and breast reconstruction were compared to the characteristics of those who did not undergo breast reconstruction from 2013 through 2018. As determinants of delaying or refraining from breast reconstruction, we distinguished between an oncological reason, patient's preference, patient's co-morbidity, combined tobacco abuse and obesity and the need for PMRT.

RESULTS

490 women received PMRT. Of these, 396 women (81%) underwent combined [N]SSM/IIBR and PMRT or mastectomy and PMRT with delayed breast reconstruction. Ninety-four additional women (19%) did not undergo breast reconstruction. The latter group differed significantly from those who did in demographic and physical characteristics but not in terms of oncological diagnosis and history. Patient's preference was the single most frequent determinant of not performing either immediate or delayed breast reconstruction among these 94 women. Oncological status was not a major determinant in refraining from reconstruction.

CONCLUSION

The significant difference in non-oncological characteristics between the reconstructed and non-reconstructed women confirms the importance of these characteristics in the preference for either reconstruction or non-reconstruction.

Frailty is the New Age: A Retrospective Study of Modified Frailty Index for Preoperative Risk Assessment in Autologous Breast Reconstruction

BACKGROUND

 Age is a poor predictor of postoperative outcomes in breast reconstruction necessitating new methods for risk-stratifying patients preoperatively. The 5-item modified frailty index (mFI-5) is a validated measure of frailty which assesses patients' global health. The purpose of this study was to compare the effectiveness of mFI-5 and age as independent predictors of 30-day postoperative complications following autologous breast reconstruction.

METHODS

 Patients who underwent autologous breast reconstruction between 2005 and 2019 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Patients were stratified based on presence of major, minor, both minor and major, and no complications. Univariate and multivariate logistic regression were performed to determine the predictive power of mFI-5, age, and other preoperative risk factors for development of minor and major 30-day postoperative complications in all patients and stratified by flap type.

RESULTS

 A total of 25,215 patients were included: 20,366 (80.8%) had no complications, 2,009 (8.0%) had minor complications, 1,531 (6.1%) had major complications, and 1,309 (5.2%) had both minor and major complications. Multivariate regression demonstrated age was not a predictor of minor (odds ratio [OR]: 1.0, p = 0.045), major (OR: 1.0, p = 0.367), or both minor and major (OR: 1.0, p = 0.908) postoperative complications. mFI-5 was a significant predictor of minor complications for mFI-5 scores 1 (OR: 1.3, p < 0.001), 2 (OR: 1.8, p < 0.001), and 3 (OR: 2.8, p = 0.043). For major complications, mFI-5 was a significant predictor for scores 1 (OR: 1.2, p = 0.011) and 2 (OR: 1.3, p = 0.03).

CONCLUSION

 Compared with age, mFI-5 scores were better predictors of 30-day postoperative complications following autologous breast reconstruction regardless of flap type. Additionally, higher mFI-5 scores were associated with increased odds of minor and major complications. Our findings indicate that reconstructive breast surgeons should consider using the mFI-5 in lieu of age to risk-stratify patients prior to autologous breast reconstruction surgery.

Safety and efficacy of immediate autologous breast reconstruction after mastectomy in patients undergoing neoadjuvant chemoradiotherapy for locally advanced breast cancer

PURPOSE

Immediate autologous breast reconstruction (IABR) offers fewer surgeries with better psychosocial, quality of life and aesthetic outcomes. In high-risk patients or those with locally advanced breast cancer (LABC), adjuvant postmastectomy radiotherapy decreases local recurrence and improves survival. However, it has negative effects on the reconstructed flap. Reversing the treatment protocol using neoadjuvant radiotherapy may minimise the negative effects on the reconstructed breast in women requesting IABR. We assessed the safety and efficacy of women who underwent mastectomy and IABR post-neoadjuvant chemoradiotherapy (NACRT) for LABC.

METHODOLOGY

A cohort study using a retrospective and prospective analysis was performed on women with LABC who underwent mastectomy and IABR post-NACRT between 1998 and 2018. All reconstructions were performed by oncoplastic breast surgeons from a single unit. Outcome measures analysed included surgical complications, flap failure, loco-regional recurrence, overall and disease-free survival. This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the institutional review board.

RESULTS

A total of 28 women with a median age of 50 (33-64) were included. 25% underwent TRAM flap and 75% underwent LD flap reconstruction. The median period of follow-up was 61 months. Post-NACRT, 35.7% achieved complete pathological response (PCR). 3/28 (10.7%) had early complications (2 implant and 1 donor site infection). 7% underwent revision surgery. There was no flap loss. 1/28 (3.5%) had loco-regional recurrence, 3.2% had distant metastasis, and 2.5% had breast cancer related mortality.

CONCLUSION

In women with LABC, NACRT followed by mastectomy and IABR is safe and may not compromise oncological and cosmetic outcomes. If offers the benefits of immediate breast reconstruction and avoids delaying adjuvant therapy.