Psychological Aspects of Breast Reconstruction after Breast Cancer

Breast-Conserving Therapy Versus Postmastectomy Breast Reconstruction: Propensity Score-Matched Analysis

BACKGROUND

Although studies have compared patient-reported outcomes (PROs) after breast conserving-therapy (BCT) and postmastectomy breast reconstruction (PMBR), they often have been confounded by treatment or other factors that complicate a direct comparison. This study aimed to compare PROs after BCT and PMBR by using propensity score-matching analysis.

METHODS

Patients who underwent BCT or PMBR between 2010 and 2022 and completed the BREAST-Q were identified. Each BCT patient was matched to a PMBR patient using nearest-neighbor 1:1 matching with replacement for each BREAST-Q time point. Outcomes included all prospectively collected BREAST-Q domains preoperatively, at 6 months, and at 1, 2, and 3 years postoperatively. A 4-point difference was considered clinically meaningful.

RESULTS

For this study, 6215 patients (2501 BCT [40.2%] and 3714 PMBR [59.8%] patients) were eligible, and 2616 unique patients were matched. Preoperatively, 463 BCT and 463 PMBR patients were matched for analysis (6 months [443 matched pairs], 1 year [639 matched pairs], 2 years [421 matched pairs], 3 years [254 matched pairs]). At 6 months postoperatively, the BCT patients scored higher on all BREAST-Q domains than the PMBR patients (p < 0.05; differences > 4 points). At 1, 2, and 3 years, the patients who underwent BCT consistently had superior Satisfaction With Breasts, Psychosocial Well-Being, and Sexual Well-Being (p < 0.05), and the differences were clinically meaningful.

CONCLUSION

In this statistically powered study, the BCT patients reported higher quality of life than the PMBR patients in early assessment and also through 3 years of follow-up evaluation. Given the equivalency in survival and recurrence outcomes between BCT and PMBR, patients eligible for either surgery should be counseled regarding the superiority of BCT in terms of PROs.

Analyzing mastectomy and reconstruction weight in immediate autologous breast reconstruction: A preliminary study

BACKGROUND

This study aims to explore the ideal breast size by assessing the relationship between mastectomy to free flap weight ratio and complications as well as patient-reported outcomes in autologous breast reconstruction (ABR).

METHOD

A retrospective review of patients undergoing bilateral immediate ABR with mastectomy and flap weights available was completed. Patients were divided into three groups based on the ratio of mastectomy to flap weights. The patients were grouped as "maintained" if the flap weight was within 10% of the mastectomy weight. Patients with a weight difference greater than 10% were used to declare "downsized" or "upsized." Outcomes included complications and four domains of the BREAST-Q at 1-year postoperatively.

RESULTS

Three hundred and fifty-nine patients were included in the analysis, of which 112 were downsized, 91 maintained, and 156 upsized, respectively. Presence of complications did not significantly differ among the groups. At 1-year postoperatively, Sexual Well-being significantly differed (p = 0.033). Between preoperative and 1 year, patients who upsized experienced an improvement in Satisfaction with Breasts by 16 points (p < 0.001), while patients who downsized experienced a decline in Physical Well-being of the Chest by 7 points (p = 0.016). Multivariable linear regression model showed that Sexual Well-being was 13 points lower in the downsized cohort than in the maintained cohort (β = -13, 95% confidence interval: -21 to -5.4; p = 0.001).

CONCLUSION

Although complication rates do not significantly differ between the three cohorts, patients who downsize may have lower Sexual Well-being postoperatively. Surgeons should consider our preliminary findings to counsel patients preoperatively about the predicted breast size and the impact of downsizing on sexual health.

Outcomes of Implant Exchange and Latissimus Dorsi Flap Replacement After Breast Implant Complications

BACKGROUND

Immediate action is required to address some complications of implant-based reconstruction after mastectomy to prevent reconstruction failure. Implant exchange may be simple but poses the risk of further complications while autologous flap reconstruction seems more complex but may pose less subsequent risk. Which of these is preferable remains unclear.

METHODS

We reviewed thirty-two female breast cancer patients who had serious complications with their breast implants after post-mastectomy reconstruction. Latissimus dorsi flap (LDF) patients underwent explantation and immediate reconstruction with an LDF, while implant exchange (IE) patients underwent immediate implant removal and exchange with an expander followed by delayed reconstruction with silicon or immediately with a smaller size silicone implant.

RESULTS

LDF patients underwent a single operation with an average duration of care of 31 days compared to an average 1.8 procedures (p= 0.005) with an average duration of care of 129.9 days (p < 0.001) among IE patients. Seven IE (50%) had serious complications that required subsequent revision while no LDF patients required additional procedures. Patient overall satisfaction and esthetics results were also superior in the LDF group at six months.

CONCLUSION

In patients who want to reconstructively rescue and salvage their severely infected or exposed breast implant, the LDF offers an entirely autologous solution. LDF reconstruction in this setting allows patients to avoid an extended duration of care, reduces their risk of complications, and preserves the reconstructive process.

LEVEL OF EVIDENCE III

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Benefits of Using Magnetic Resonance Imaging During Breast Tissue Expansion: Literature Review and Case Series

Breast cancer results in up to 1.6 million new candidates for yearly breast reconstruction (BR) surgery. Two-stage breast reconstruction surgery with the use of a tissue expander (TE) is a common approach to reconstructing the breast after mastectomy. However, a common disadvantage encountered with the traditional breast TE is the magnetic injection port, which has been reported to cause injuries in patients undergoing magnetic resonance (MR) imaging. Therefore this type of breast TE is labeled "MR unsafe." Recent technological advances have incorporated radio-frequency identification (RFID) technology in the TE to allow for the location of the injection port without magnetic components, resulting in an MR-conditional TE. This paper aims to review the information regarding the safety profile of TEs with magnetic ports and to gather distinct clinical scenarios in which an MR-conditional TE benefits the patient during the BR process. A literature review ranging from 2018 to 2022 was performed with the search terms: "tissue expander" OR "breast tissue expander" AND "magnetic resonance imaging" OR "MRI." Additionally, a case series was collected from each of the authors' practices. The literature search yielded 13 recent peer-reviewed papers, and 6 distinct clinical scenarios were compiled and discussed. Most clinicians find MRI examinations to be the state-of-art diagnostic imaging modality. However, due to the preexisting risks associated with TEs with magnetic ports, the MRI labeling classification should be considered when deciding which TE is the most appropriate for the patient requiring MRI examinations.

LEVEL OF EVIDENCE: 4

What affects women's decision-making on breast reconstruction after mastectomy for breast cancer?

PURPOSE

To establish the breast reconstruction rate in a large Dutch teaching hospital, and to gain insight into the motives of women to opt for or reject post-mastectomy breast reconstruction.

METHODS

In a retrospective, cross-sectional study, all consecutive patients who underwent mastectomy for invasive breast cancer or ductal carcinoma in situ (DCIS) were identified and categorized into two groups based on subsequent breast reconstruction or not. Patient-reported outcomes were assessed with the validated Breast-Q and a short survey about the decision-making process in breast reconstruction. These outcomes were compared between the two groups using univariable analyses, multivariable logistic regression, and multiple linear regression analyses. The Breast-Q scores were also compared to Dutch normative values.

RESULTS

A total of 319 patients were identified of whom 68% had no breast reconstruction. Of the 102 patients with breast reconstruction, the majority (93%) received immediate, instead of delayed breast reconstruction. The survey was completed by 155 (49%) patients. The non-reconstruction group, on average, reported significantly poorer psychosocial well-being, compared to the reconstruction group as well as compared to the normative data. However, the majority of the non-reconstruction group (83%) stated that they had no desire for breast reconstruction. In both groups, most patients stated that the provided information was sufficient.

CONCLUSION

Patients have personal motives to opt for or reject breast reconstruction. It seemed that patients differ in their rating of values that affect their decision since the same arguments were used to opt for or reject reconstruction. Notably, patients were well-informed in their decision making.

Comparative evaluation using PRO of an algorithm of one-stage immediate alloplastic breast reconstruction versus two-stage reconstruction

BACKGROUND

One-stage direct-to-implant (DTI) immediate breast reconstruction has proven to be an oncologically safe technique, but there are some conditions that do not allow its performance. The introduction of new surgical techniques and the recent COVID-19 pandemic have pushed us to introduce a breast reconstruction algorithm in our clinical practice. This allows a one-stage immediate reconstruction for all patients, regardless of their anatomical characteristics, the type of implants used, and the need for postoperative radiotherapy.

METHODS

A total of 40 patients were recruited and divided into two cohorts, 20 patients underwent immediate one-stage breast reconstruction in the period between October 2019 and January 2021, and 20 patients completed the two-stage reconstructive process in the period prior to October 2019. During the follow-up at 6 months, all patients who had completed the reconstructive process filled out the Breast-Q Reconstruction Module Pre and Postoperative scales questionnaire. The outcomes of the questionnaires were compared between the two cohorts, and statistical analysis was carried out using SPSS Statistics 20 (IBM Corporation, Armonk, NY, USA).

RESULTS

The analysis of patient-reported outcomes showed that patients from the one-stage group reported better outcomes in all items evaluated. We did not find statistically significant differences concerning the rate of complications and length of hospital stay between the two groups.

CONCLUSIONS

The analysis of the results shows that the outcomes reported by patients who completed breast reconstruction according to our algorithm are statistically better than those with the two-stage technique.

Effectiveness of cognitive-based interventions for improving body image of breast cancer patients: A systematic review and meta-analysis

Objective

Breast cancer patients often suffer from body image disturbance due to impairment of their body/appearance resulting from surgeries, other cancer treatments, and/or their complications. Cognitive-based interventions (CBIs) have recently been adopted for patients having breast cancer but their effects on improving body image are uncertain. This systematic review aimed to examine the effects of CBIs on body image in these patients, identify the optimal dose, characteristics, and/or component(s) of an effective intervention for these patients to inform future research and practice.

Methods

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework, ten online databases and five search engines were used to search for eligible studies. Quality appraisal of included studies and meta-analysis results were conducted using Rob 2 and Grading of Recommendations Assessment, Development and Evaluation profiler Guideline Development Tool, respectively. RevMan and comprehensive meta-analysis software were used to perform data analysis and synthesis.

Results

Eleven eligible randomized controlled trials (RCTs) examining the effects of cognitive behavioral, acceptance and commitment, mindfulness, and self-compassion therapies were reviewed. Results of the meta-analysis showed that CBIs significantly reduced negative body image perception (Standardised Mean Difference, SMD ​= ​-0.49, 95% confidence interval [CI], [-0.87, -0.11], I ²  ​= ​81%, 6 RCTs, 758 participants), when compared to the control groups (mainly usual care) at immediately post-intervention; in which, CBT-based (SMD ​= ​-0.37, 95% CI (-0.60, -0.13), I ²  ​= ​0%) and group-based (SMD ​= ​-0.38, 95% CI (-0.62, -0.13), I ²  ​= ​0%) programs had more consistent and significant effects.

Conclusions

In view of the highly heterogeneous and limited RCTs identified, high-quality controlled trials of CBIs for improving the body image of patients having breast cancer are suggested.

Systematic review registration

PROSPERO, CRD42021259173.

Donor-Site Morbidity and Quality of Life after Autologous Breast Reconstruction with PAP versus TMG Flap

The transverse myocutaneous gracilis (TMG) and the profunda artery perforator (PAP) flap are both safe choices for autologous breast reconstruction originating from the same donor region in the upper thigh. We aimed to compare the post-operative outcome regarding donor-site morbidity and quality of life. We included 18 patients who had undergone autologous breast reconstruction with a PAP flap (n = 27 flaps). Prospective evaluation of donor-site morbidity was performed by applying the same questionnaire that had already been established in a previous study evaluating TMG flap (n = 25 flaps) outcome, and results were compared. Comparison of the two patient groups showed equivalent results concerning patient-reported visibility of the donor-site scar and thigh symmetry. Still, the TMG group was significantly more satisfied with the scar (p = 0.015) and its position (p = 0.001). No difference was found regarding the ability to sit for prolonged periods. Donor-site wound complications were seen more frequently in the PAP group (29.6%) than in the TMG group (4.0%). Both groups expressed rather high satisfaction with their quality of life. Both flaps show minimal functional donor-site morbidity and high patient satisfaction. To minimize wound healing problems in PAP patients, thorough planning of the skin paddle is necessary.

Breast reconstruction following mastectomy in Indian women: a neglected entity

Phyllodes tumour is a rapidly growing neoplasm with a propensity to involve the entire breast tissue. In large tumours, the treatment comprises a wide local excision or a mastectomy. A woman in her 20s from rural India presented with complaints of a recurrent left breast lump. The lump progressed to a large size, limiting her social activities and causing depression. On examination, she had a mass occupying almost the entire left breast, with stretched skin, dilated veins and pressure necrosis. There were no palpable axillary nodes. She was offered a wide local excision and reconstruction with a latissimus dorsi pedicled flap. After much discussion and clarification of some misconceptions around breast reconstruction, she underwent the planned surgery. This was followed by adjuvant radiation therapy as the histopathology was consistent with a complex phyllodes tumour with close margins. She was well at 1-year follow-up and led a good family and social life. Breast conservation and reconstruction are seldom offered as part of cancer treatment in India. All women should be offered surgical options that are oncologically safe while preserving body image, and hence healthcare providers must work towards breaking the barriers that prevent breast reconstruction.

Psychological and Aesthetic Outcomes in Breast Cancer Patients

Background:

Patients who undergo breast cancer treatment require psychosocial and aesthetic rehabilitation. Advantages of breast reconstruction in-patient rehabilitation are well known. Oncoplastic organ-preserving surgery offers aesthetically better results, yet is often considered less safe than more radical procedures. We compared the aesthetic and psychological outcomes in patients undergoing breast reconstruction and oncoplastic breast cancer treatment.

Methods:

In total, 1130 patients who received either breast reconstruction or oncoplastic breast cancer surgery were included in the study. Patients were classified into two groups. Group 1 included 510 patients who received breast reconstruction surgery. Group 2 included 620 patients who received oncoplastic surgery. The following aspects were compared between the two groups: demographics, tumor progression, and immunohistochemical aspects, complications, hospitalization stay, and psychological and aesthetic outcomes.

Results:

Patients in the oncoplastic group showed statistically significant higher psychosocial and aesthetic outcomes, as well as lower incidence of complications, revision rate, disease progression, and recurrence. The majority of oncoplastic patients were treated in early stages of breast cancer.

Conclusion:

Offering superior treatment results, oncoplastic organ-preserving surgery should be favored in patients with earlier stages of cancer progression.

Effects of Surgery on Prognosis of Young Women With Operable Breast Cancer in Different Marital Statuses: A Population-Based Cohort Study

BACKGROUND

The influence of surgical approaches [including mastectomy, breast-conserving therapy (BCT) and post-mastectomy breast reconstruction (PMBR) on prognosis of young women (<40 years old) with operable breast cancer has not been determined yet, and this might vary in patients with different marital statuses. Therefore, we aimed to investigate the effect of surgery on survival outcomes for young women with operable breast cancer in different marital statuses.

METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) database to identify young women with operable breast cancer between 2004 and 2016, who underwent mastectomy, BCT or PMBR. We assessed overall survival (OS) and breast cancer-specific survival (BCSS) using the Kaplan-Meier method and hazard ratios using multivariate Cox proportional hazard regression.

RESULTS

Compared to mastectomy, both of BCT and PMBR conferred better OS (BCT: HR = 0.79, 95%CI: 0.69-0.90, p <0.001; PMBR: HR = 0.70, 95%CI: 0.63-0.78, p <0.001) and BCSS (BCT: HR = 0.79, 95%CI: 0.69-0.91, p = 0.001; PMBR: HR = 0.73, 95%CI: 0.65-0.81, p <0.001), but there was no significant difference of survival between BCT and PMBR group. The survival benefit of BCT compared to mastectomy remained significant in unmarried young women (OS: HR = 0.68, 95%CI: 0.55-0.83, p <0.001; BCSS: HR = 0.69, 95%CI: 0.56-0.86, p = 0.001) but not in the married (OS: HR = 0.89, 95%CI: 0.75-1.05, p = 0.177; BCSS: HR = 0.89, 95%CI: 0.75-1.05, p = 0.161), while no matter married or not, PMBR group had better OS and BCSS than mastectomy group but not BCT group.

CONCLUSION

Both of BCT and PMBR had improved survival compared to mastectomy for young women with operable breast cancer. The survival benefit of BCT compared to mastectomy remained significant in unmarried patients but not in married patients.