Comparing Health Care Resource Use between Implant and Autologous Reconstruction of the Irradiated Breast: A National Claims-Based Assessment

Impact of Neoadjuvant Chemotherapy and Preoperative Irradiation on Early Complications in Direct-to-Implant Breast Reconstruction

Background  Impact of previous radiation therapy and neoadjuvant chemotherapy (NACT) on early complications in direct-to-implant (DTI) breast reconstruction has not been elucidated. This study investigated whether DTI reconstruction is viable in patients with NACT or a history of preoperative chest wall irradiation. Methods  Medical records of breast cancer patients who underwent nipple-sparing or skin-sparing mastectomy with DTI breast reconstruction from March 2018 to February 2021, with at least 1 year of follow-up in a single tertiary center, were reviewed. Demographic data, intraoperative details, and postoperative complications, including full-thickness necrosis, infection, and removal, were reviewed. Risk factors suggested by previous literature, including NACT and preoperative chest wall irradiation histories, were reviewed by multivariate analysis. Results  A total of 206 breast cancer patients were included, of which, 9 were bilateral, 8 patients (3.9%) had a history of prior chest wall irradiation, and 17 (8.6%) received NACT. From 215 cases, 11 cases (5.1%) required surgical intervention for full-thickness necrosis, while intravenous antibiotics or hospitalization was needed in 11 cases (5.1%), with 14 cases of failure (6.5%) reported. Using multivariable analysis, preoperative irradiation was found to significantly increase the risk of full-thickness skin necrosis (OR = 12.14, p  = 0.034), and reconstruction failure (OR = 13.14, p  = 0.005). NACT was not a significant risk factor in any of the above complications. Conclusion  DTI breast reconstruction is a viable option for patients who have received NACT, although reconstructive options should be carefully explored for patients with a history of breast irradiation.

Complications, Costs, and Healthcare Resource Utilization After Staged, Delayed, and Immediate Free-Flap Breast Reconstruction: A Longitudinal, Claims-Based Analysis

BACKGROUND

There is a lack of consensus detailing the optimal approach to free-flap breast reconstruction when considering immediate, delayed, or staged techniques. This study compared costs, complications, and healthcare resource utilization (HCRU) across staged, delayed, and immediate free-flap breast reconstruction.

PATIENTS AND METHODS

Retrospective study using MarketScan databases to identify women who underwent mastectomies and free-flap reconstructions between 2014 and 2018. Complications, costs, and HCRU [readmission, reoperation, emergency department (ED) visits] occurring 90 days after mastectomy and 90 days after free flap were compared across immediate, delayed, and staged reconstruction.

RESULTS

Of 3310 women identified, 69.8% underwent immediate, 11.7% underwent delayed, and 18.5% underwent staged free-flap reconstruction. Staged reconstruction was associated with the highest rate (57.8% staged, 42.3% delayed, 32.0% immediate; p < 0.001) and adjusted relative risk [67% higher than immediate (95% CI: 49-87%; p < 0.001)] of surgical complications. Staged displayed the highest HCRU (staged 47.9%, delayed, 38.4%, immediate 25.2%; p < 0.001), with 16.5%, 30.7%, and 26.5% of staged patients experiencing readmission, reoperation, or ED visit, respectively. The adjusted probability of HCRU was 206% higher (95% CI: 156-266%; p < 0.001) for staged compared with immediate. Staged had the highest mean total cost (staged $106,443, delayed $80,667, immediate $76,756; p < 0.001) with regression demonstrating the adjusted mean cost for staged is 31% higher (95% CI: 23-39%; p < 0.001) when compared with immediate.

CONCLUSIONS

Staged free-flap reconstruction is associated with increased complications, costs, and HCRU, while immediate demonstrated the lowest. The potential esthetic benefits of a staged approach should be balanced with the increased risk for adverse events after surgery.

Commercial Price Variation for Breast Reconstruction in the Era of Price Transparency

Importance

Breast reconstruction is costly, and negotiated commercial rates have been hidden from public view. The Hospital Price Transparency Rule was enacted in 2021 to facilitate market competition and lower health care costs. Breast reconstruction pricing should be analyzed to evaluate for market effectiveness and opportunities to lower the cost of health care.

Objective

To evaluate the extent of commercial price variation for breast reconstruction. The secondary objective was to characterize the price of breast reconstruction in relation to market concentration and payer mix.

Design, Setting, and Participants

This was a cross-sectional study conducted from January to April 2022 using 2021 pricing data made available after the Hospital Price Transparency Rule. National data were obtained from Turquoise Health, a data service platform that aggregates price disclosures from hospital websites. Participants were included from all hospitals with disclosed pricing data for breast reconstructive procedures, identified by Current Procedural Terminology (CPT) code.

Main Outcomes and Measures

Price variation was measured via within- and across-hospital ratios. A mixed-effects linear model evaluated commercial rates relative to governmental rates and the Herfindahl-Hirschman Index (health care market concentration) at the facility level. Linear regression was used to evaluate commercial rates as a function of facility characteristics.

Results

A total of 69 834 unique commercial rates were extracted from 978 facilities across 335 metropolitan areas. Commercial rates increased as health care markets became less competitive (coefficient, $4037.52; 95% CI, $700.12 to $7374.92; P = .02; for Herfindahl-Hirschman Index [HHI] 1501-2500, coefficient $3290.21; 95% CI, $878.08 to $5702.34; P = .01; both compared with HHI ≤1500). Commercial rates demonstrated economically insignificant associations with Medicare and Medicaid rates (Medicare coefficient, -$0.05; 95% CI, -$0.14 to $0.03; P = .23; Medicaid coefficient, $0.14; 95% CI, $0.07 to $0.22; P < .001). Safety-net and nonprofit hospitals reported lower commercial rates (coefficient, -$3269.58; 95% CI, -$3815.42 to -$2723.74; P < .001 and coefficient, -$1892.79; -$2519.61 to -$1265.97; P < .001, respectively). Extra-large hospitals (400+ beds) reported higher commercial rates compared with their smaller counterparts (coefficient, $1036.07; 95% CI, $198.29 to $1873.85, P = .02).

Conclusions and Relevance

Study results suggest that commercial rates for breast reconstruction demonstrated large nationwide variation. Higher commercial rates were associated with less competitive markets and facilities that were large, for-profit, and nonsafety net. Privately insured patients with breast cancer may experience higher premiums and deductibles as US hospital market consolidation and for-profit hospitals continue to grow. Transparency policies should be continued along with actions that facilitate greater health care market competition. There was no evidence that facilities increase commercial rates in response to lower governmental rates.

Artificial Intelligence and Machine Learning in Prediction of Surgical Complications: Current State, Applications, and Implications

Surgical complications pose significant challenges for surgeons, patients, and health care systems as they may result in patient distress, suboptimal outcomes, and higher health care costs. Artificial intelligence (AI)-driven models have revolutionized the field of surgery by accurately identifying patients at high risk of developing surgical complications and by overcoming several limitations associated with traditional statistics-based risk calculators. This article aims to provide an overview of AI in predicting surgical complications using common machine learning and deep learning algorithms and illustrates how this can be utilized to risk stratify patients preoperatively. This can form the basis for discussions on informed consent based on individualized patient factors in the future.

Surgical and Patient-Reported Outcomes of Autologous versus Implant-Based Reconstruction following Infected Breast Device Explantation

BACKGROUND

Implant-based breast reconstruction infections often require implant explantation. Whereas some plastic surgeons pursue autologous reconstruction following the first implant-based breast reconstruction failure caused by infection, others argue that a second attempt is acceptable.

METHODS

The authors conducted a retrospective study of patients who underwent a second reconstruction attempt with implant-based or free flap breast reconstruction following explantation because of infection between 2006 and 2019. Surgical and patient-reported outcomes were compared between the two groups.

RESULTS

A total of 6093 implant-based breast reconstructions were performed during the study period, of which 130 breasts met our inclusion criteria [implant-based, n = 86 (66 percent); free flap, n = 44 (34 percent)]. No significant differences in rates of overall (25 percent versus 36 percent; p = 0.2) or major (20 percent versus 21 percent; p = 0.95) complications were identified between the free flap and implant-based cohorts, respectively. Implant-based breast reconstruction patients were more likely to experience a second infection (27 percent versus 2 percent; p = 0.0007) and reconstruction failure (21 percent versus 5 percent; p = 0.019). Among irradiated patients, reconstruction failure was reported in 44 percent of the implant-based and 7 percent of the free flap cohorts (p = 0.02). Free flap patients reported significantly higher scores for Satisfaction with Breasts (73.7 ± 20.1 versus 48.5 ± 27.9; p = 0.0046).

CONCLUSIONS

Following implant-based breast reconstruction explantation because of infection, implant-based and free flap breast reconstruction had similar rates of overall and major complications; however, implant-based breast reconstruction had considerably higher rates of infection and reconstructive failures and lower patient-reported scores for Satisfaction with Breasts. Given the high rates of implant-based breast reconstruction failure in patients with prior radiotherapy and infection-based failure, plastic surgeons should strongly consider autologous reconstruction in this patient population.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Teaching Microsurgical Breast Reconstruction-A Retrospective Cohort Study

Microsurgical breast reconstruction demands the highest level of expertise in both reconstructive and aesthetic plastic surgery. Implementation of such a complex surgical procedure is generally associated with a learning curve defined by higher complication rates at the beginning. The aim of this study was to present an approach for teaching deep inferior epigastric artery perforator (DIEP) and transverse upper gracilis (TUG) flap breast reconstruction, which can diminish complications and provide satisfying outcomes from the beginning. DIEP and TUG flap procedures for breast reconstruction were either performed by a senior surgeon (>200 DIEP/TUG, "no-training&nbsp;group"), or taught to one of five trainees (>80 breast surgeries; >50 free flaps) in a step-wise approach. The latter were either performed by the senior surgeon, and a trainee was assisting the surgery ("passive training"); by the trainee, and a senior surgeon was supervising ("active training"); or by the trainee without a senior surgeon ("after training"). Surgeries of each group were analyzed regarding OR-time, complications, and refinement procedures. A total of 95 DIEP and 93 TUG flaps were included into this study. Before the first DIEP/TUG flap without supervision, each trainee underwent a mean of 6.8 DIEP and 7.3 TUG training surgeries (p > 0.05). Outcome measures did not reveal any statistically significant differences (passive training/active training/after training/no-training: OR-time (min): DIEP: 331/351/338/304 (p > 0.05); TUG: 229/214/239/217 (p > 0.05); complications (n): DIEP: 6/13/16/11 (p > 0.05); TUG: 6/19/23/11 (p > 0.05); refinement procedures (n): DIEP:71/63/49/44 (p > 0.05); TUG: 65/41/36/56 (p > 0.05)), indicating safe and secure implementation of this step-wise training approach for microsurgical breast reconstruction in both aesthetic and reconstructive measures. Of note, despite being a perforator flap, DIEP flap required no more training than TUG flap, highlighting the importance of flap inset at the recipient site.

Protocol for a national cohort study to explore the long-term clinical and patient-reported outcomes and cost-effectiveness of implant-based and autologous breast reconstruction after mastectomy for breast cancer: the brighter study

INTRODUCTION

Breast reconstruction (BR) is offered to improve quality of life for women with breast cancer undergoing mastectomy. As most women will be long-term breast cancer survivors, high-quality information regarding the long-term outcomes of different BR procedures is essential to support informed decision-making. As different techniques vary considerably in cost, policymakers also require high-quality cost-effectiveness evidence to inform care. The Brighter study aims to explore the long-term clinical and patient-reported outcomes (PROs) of implant-based and autologous BR and use health economic modelling to compare the long-term cost-effectiveness of different reconstructive techniques.

METHODS AND ANALYSIS

Women undergoing mastectomy and/or BR following a diagnosis of breast cancer between 1 January 2008 and 31 March 2009 will be identified from hospital episode statistics (HES). Surviving women will be contacted and invited to complete validated PRO measures including the BREAST-Q, EQ-5D-5L and ICECAP-A, or opt out of having their data included in the HES analysis. Long-term clinical outcomes will be explored using HES data. The primary outcome will be rates of revisional surgery between implant-based and autologous procedures. Secondary outcomes will include rates of secondary reconstruction and reconstruction failure. The long-term PROs of implant-based and autologous reconstruction will be compared using BREAST-Q, EQ-5D-5L and ICECAP-A scores. Multivariable regression will be used to examine the relationship between long-term outcomes, patient comorbidities, sociodemographic and treatment factors. A Markov model will be developed using HES and PRO data and published literature to compare the relative long-term cost-effectiveness of implant-based and autologous BR.

ETHICS AND DISSEMINATION

The Brighter study has been approved by the South-West -Central Bristol Research Ethics Committee (20/SW/0020), and the Confidentiality Advisory Group (20/CAG/0021). Results will be published in peer-reviewed journals and presented at national meetings. We will work with the professional associations, charities and patient groups to disseminate the results.

Treatment and Outcomes of Women With Large Locally Advanced Breast Cancer

Advances in breast cancer research have made breast cancer a treatable disease. However, there is a population of women who present with large, advanced, or sometimes neglected breast cancers who can prove difficult to treat. These women often require multiple modality treatment including chemotherapy, surgery, and radiation. The purpose of our study is to examine the treatment and outcomes on women with large, locally advanced breast cancers (LABCs).

We identified 8 individuals who presented with LABCs requiring extensive treatment. Patients with inflammatory or metastatic cancer at the time of presentation were excluded. These patients' charts were reviewed and analyzed. Patient demographics, hormone receptor status, stage, types of treatment, presence of metastasis, survival, and presence of barriers for seeking treatment sooner were identified.

The median age at presentation was 65 years old. The patients were equally African American and Caucasian. All patients presented with T4 or stage 3 tumors involving the skin and/or pectoralis muscle. Half of the patients were found to have triple-negative (estrogen receptor, progesterone receptor, Her-2/neu negative) tumors. 87% of the patients received chemotherapy; 1 refused. All 8 patients, either neoadjuvantly or adjuvantly, underwent a modified radical or radical mastectomy. Skin graft or flap coverage was necessary in half of the patients. Postmastectomy radiation was received in 87% of the patients; 1 patient refused the treatment. Half of the patients developed metastatic disease. Thirty-seven percent of the patients have since died with a median survival of 44 months. Reasons for delay in seeking care were monetary or social barriers. Many of the patients finally sought care via the emergency room due to symptoms they could no longer ignore.

Women who present with LABC require complex multidisciplinary treatment consisting of chemotherapy, surgery, and radiation treatments. Many of these patients faced economic and social challenges to accessing care. Better access to care and more prompt connection to breast surgeons are required to assist this patient population.

Breast Reconstruction in the Setting of Stage 4 Breast Cancer: Is It Worthwhile?

BACKGROUND

The role of reconstruction after primary tumor surgery for metastatic breast cancer remains controversial. This report describes the outcomes for patients undergoing mastectomy with and without reconstruction in the setting of de novo stage 4 breast cancer.

METHODS

Using a prospectively maintained institutional breast surgery database, this study identified all patients who presented with de novo stage 4 breast cancer from January 2008 to December 2018. Patients were included if they had undergone mastectomy with or without reconstruction. Patient, surgical characteristics, and survival outcomes were abstracted and analyzed.

RESULTS

The study identified 29 patients: 8 patients (28%) who underwent reconstruction (R) and 21 patients (72%) who did not (NR). Complete clinical response to induction systemic therapy was more frequent among patients in the R group than among those in the NR group for the primary disease (50% in R, 5% in NR), and to a lesser degree for distant disease (63% in R, 39% in NR). No difference in complication rates between the two groups was identified [n = 1 (13%) in R; n = 2 (10%) in NR; p = 1.0]. Overall survival from surgery was longer in the R group (100% at 2 and 5 years) than in the NR group [85%; 95% confidence interval (CI), 68-100% at 2 years vs 50%; 95% CI 27-91% at 5 years] (p = 0.046).

CONCLUSION

Breast reconstruction after mastectomy may be reasonable to consider for appropriately selected patients with de novo stage 4 breast cancer who have excellent responses to systemic therapy and anticipated durable survival.

Outcomes of Immediate Implant-Based Mastectomy Reconstruction in Women with Previous Breast Radiotherapy

BACKGROUND

The objective of this study was to determine whether women with a history of radiation therapy before mastectomy experience a risk for postoperative complications and patient-reported outcomes similar to those of women undergoing postmastectomy radiation therapy in the setting of immediate implant reconstruction.

METHODS

The cohort included patients undergoing immediate implant reconstruction at 11 centers across North America. Women were categorized into three groups: prior breast conservation therapy, postmastectomy radiation therapy, and no radiation therapy. Mixed effect logistic regressions were used to analyze the effects of radiation therapy status on complication rates and patient-reported outcomes.

RESULTS

ONE THOUSAND FIVE HUNDRED NINETY-FOUR: patients were analyzed, including 84 women with prior breast conservation therapy, 329 women who underwent postmastectomy radiation therapy, and 1181 women with no history of radiation therapy. Compared with postmastectomy radiation therapy, breast conservation was associated with lower rates of all complications and major complications (OR, 0.65; 95 percent CI, 0.37 to 1.14; p = 0.13; and OR, 0.61; 95 percent CI, 0.33 to 1.13; p = 0.12). These differences were not statistically significant. Rates of reconstructive failure between the two cohorts were comparable. Before reconstruction, satisfaction with breasts was lowest for women with prior breast conservation therapy (p < 0.001). At 2 years postoperatively, satisfaction with breasts was lower for women with postmastectomy radiation therapy compared with breast conservation patients (p = 0.007).

CONCLUSIONS

Higher postoperative complication rates were observed in women exposed to radiation therapy regardless of timing. Although women with prior breast conservation experienced greater satisfaction with their breasts and fewer complications when compared to women undergoing postmastectomy radiation therapy, there was a similar risk for reconstruction failure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Hospital Variations in Clinical Complications and Patient-reported Outcomes at 2 Years After Immediate Breast Reconstruction

OBJECTIVE

Our objectives were to investigate case-mix adjusted hospital variations in 2-year clinical and patient-reported outcomes following immediate breast reconstruction.

BACKGROUND

Over the past few decades, variations in medical practice have been viewed as opportunities to promote best practices and high-value care.

METHODS

The Mastectomy Reconstruction Outcomes Consortium Study is an National Cancer Institute-funded longitudinal, prospective cohort study assessing clinical and patient-reported outcomes of immediate breast reconstruction after mastectomy at 11 leading medical centers. Case-mix adjusted comparisons were performed using generalized linear mixed-effects models to assess variation across the centers in any complication, major complications, satisfaction with outcome, and satisfaction with breast.

RESULTS

Among 2252 women in the analytic cohort, 1605 (71.3%) underwent implant-based and 647 (28.7%) underwent autologous breast reconstruction. There were significant differences in the sociodemographic and clinical characteristics, and distribution of procedure types at the different Mastectomy Reconstruction Outcomes Consortium Study centers. After case-mix adjustments, hospital variations in the rates of any and major postoperative complications were observed. Medical center odds ratios for major complication ranged from 0.58 to 2.13, compared with the average major complication rate across centers. There were also meaningful differences in satisfaction with outcome (from the lowest to highest of -2.79-2.62) and in satisfaction with breast (-2.82-2.07) compared with the average values.

CONCLUSIONS

Two-year postoperative complications varied widely between hospitals following post-mastectomy breast reconstruction. These variations represent an important opportunity to improve care through dissemination of best practices and highlight the limitations of extrapolating single-institution level data and the ongoing challenges of studying hospital-based outcomes for this patient population.

Comparison of survival outcomes of locally advanced breast cancer patients receiving post-mastectomy radiotherapy with and without immediate breast reconstruction: a population-based analysis

Objective

To compare the survival outcomes in locally advanced breast cancer (LABC) patients receiving post-mastectomy radiotherapy (PMRT) with and without immediate breast reconstruction.

Methods

We used the Surveillance, Epidemiology, and End Results program to include LABC patients who were treated/not treated with immediate breast reconstruction followed by PMRT between 2003 and 2010. Statistical analysis was performed using the chi-squared test, Kaplan–Meier survival analysis, and Cox regression analysis. A 1:1 propensity score matching method was performed to decrease the selection bias.

Results

We identified 1,732 patient-pairs that were completely matched. In the unmatched population, 8,198 and 1,802 patients received mastectomy only and immediate breast reconstruction, respectively. Patients who received immediate breast reconstruction had better breast cancer-specific survival (BCSS) (hazard ratio [HR] 0.880, 95% CI 0.783–0.989, P = 0.032) and overall survival (OS) (HR 0.846, 95% CI 0.758–0.943, P = 0.003) than patients who underwent mastectomy alone. However, in the matched population, there was comparable BCSS and OS between patients who received immediate breast reconstruction and mastectomy alone. Subset analysis in the matched population found that immediate breast reconstruction was associated with better BCSS (HR 0.750, 95% CI 0.614–0.917, P = 0.005) and OS (HR 0.779, 95% CI 0.644–0.942, P = 0.010) compared to patients aged <50 years who received mastectomy alone.

Conclusion

There are comparable survival outcomes in LABC patients who received immediate breast reconstruction or mastectomy alone followed by PMRT. However, patients aged <50 years had a survival advantage after immediate breast reconstruction.