Claudia R. Albornoz

A paradigm shift in U.S. breast reconstruction: Part 2. The influence of changing mastectomy patterns on reconstructive rate and method.

Background: The aims of the current study were to (1) measure trends in the type of mastectomy performed, (2) evaluate sociodemographic/hospital characteristics of patients undergoing contralateral prophylactic mastectomy versus unilateral mastectomies, and (3) analyze reconstruction rates and method used following different mastectomy types. Methods: Mastectomies from 1998 to 2008 were analyzed using the Nationwide Inpatient Sample database. Mastectomies (n = 178,603) were classified as either unilateral, contralateral prophylactic, or bilateral prophylactic. Reconstructive procedures were categorized into either implant or autologous. Longitudinal trends were analyzed with Poisson regression and sociodemographic/hospital variables were analyzed with logistic regression. Results: Unilateral mastectomies decreased 2 percent per year, whereas contralateral and bilateral prophylactic mastectomies increased significantly by 15 and 12 percent per year, respectively (p < 0.01). Independent predictors for contralateral prophylactic mastectomy (compared with unilateral mastectomy) were patients younger than 39 years, Caucasian and Hispanic race, private insurance carriers, treated in teaching hospitals, and from South and Midwest regions. Contralateral prophylactic mastectomy is the only group with increased reconstruction rates throughout the study period (p < 0.01). Although implant use increased for all mastectomy types, it remains greater in bilateral and contralateral prophylactic mastectomy. Conclusions: There is increasing use of bilateral mastectomies in the United States, particularly in patients with unilateral cancer. Although implant use has increased for all mastectomy types, they are used most commonly following bilateral and contralateral prophylactic mastectomies. Changing mastectomy patterns are one factor underlying the paradigm shift away from autologous tissue to implant-based reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Quality of life among breast cancer patients with lymphedema: a systematic review of patient-reported outcome instruments and outcomes.

PurposeLymphedema following breast cancer surgery remains a common and feared treatment complication. Accurate information on health-related quality of life (HRQOL) outcomes among patients with lymphedema is critically needed to inform shared medical decision making and evidence-based practice in oncologic breast surgery. Our systematic review aimed to (1) identify studies describing HRQOL outcomes in breast cancer-related lymphedema (BCRL) patients, (2) assess the quality of these studies, and (3) assess the quality and appropriateness of the patient-reported outcome (PRO) instruments used.MethodsUsing the PRISMA statement, we performed a systematic review including studies describing HRQOL outcomes among BCRL patients. Studies were classified by levels of evidence and fulfillment of the Efficace criteria. PRO instruments were assessed using the COSMIN criteria.ResultsThirty-nine studies met inclusion criteria, including 8 level I and 14 level II studies. Sixteen of 39 studies were compliant with the Efficace criteria. Seventeen HRQOL instruments were used, two specific to lymphedema patients. Exercise and complex decongestive therapy treatment interventions were associated with improved HRQOL.ConclusionsHigh-quality data on HRQOL outcomes is required to inform surgical decisions for breast cancer management and survivors. Of the lymphedema-specific PRO instruments, the Upper Limb Lymphedema 27 (ULL-27) was found to have strong psychometric properties. Future studies should strive to use high-quality condition- specific PRO instruments, follow existing guidelines for HRQOL measurement and to consider economic burdens of BCRL.Implications for Cancer SurvivorsAs lymphedema may develop many years after breast cancer surgery, the ULL-27 may offer greater content validity for use in survivorship research.

The influence of sociodemographic factors and hospital characteristics on the method of breast reconstruction, including microsurgery: a U.S. population-based study.

Background: Microsurgical breast reconstruction has gained popularity because of associations with decreased abdominal morbidity and high satisfaction. Nationwide use of these procedures is unknown. Although many factors can influence the method of breast reconstruction, sociodemographic and hospital characteristics have not been specifically evaluated. The authors studied the importance of microsurgical flaps among the techniques available for breast reconstruction and evaluated the effect of sociodemographic and hospital characteristics on the technique chosen. Methods: A cross-sectional study of breast reconstructions was performed using the Nationwide Inpatient Sample database for 2008. National estimates of breast reconstructive procedures including microsurgery were obtained. Impact of variables on reconstructive method was analyzed using logistic regression. Results: Among women undergoing breast reconstruction in 2008, implants were the most common procedure (60.5 percent), followed by pedicled flaps (34 percent) and microsurgical flaps (5.5 percent). Multivariable analysis showed that women aged 50 to 59 years, treated at teaching hospitals, with private insurance, or undergoing delayed reconstruction were more likely to have autologous than implant reconstruction. Implant use was associated with young patients, Caucasians, Asians, higher income, and all regions except the Northeast. Analysis of autologous reconstructions showed the likelihood for a microsurgical versus a pedicle flap was greater in teaching hospitals, private insurance carriers, and delayed reconstructions. Conclusions: Microsurgical techniques are currently used in only a minority of reconstructions. Sociodemographic variables and teaching hospital status influence the method of breast reconstruction. The presence of disparities in care suggests that current decision making for breast reconstruction is not based solely on patient preference or anatomical features.

What Is the Optimum Timing of Postmastectomy Radiotherapy in Two-Stage Prosthetic Reconstruction: Radiation to the Tissue Expander or Permanent Implant?

Background: Postmastectomy radiotherapy is increasingly common for patients with advanced breast cancer. The optimal timing and sequence of mastectomy, reconstruction, and radiotherapy remains unresolved for patients choosing immediate two-stage prosthetic reconstruction. Methods: Long-term outcomes were compared for all patients with prosthetic-based reconstruction without radiation, radiation to the tissue expander, or to the permanent implant from 2003 to 2012 performed by the senior author (P.G.C.). Surgeon-evaluated outcomes included reconstructive failure, aesthetic results, and capsular contracture. Odds of failure with radiotherapy at different times were evaluated with logistic regression and Kaplan-Meier analysis. Patient-reported outcomes were assessed using the BREAST-Q. Results: A total of 1486 reconstructions without radiation, 94 reconstructions with tissue expander radiation, and 210 reconstructions with permanent implant radiation were included. Six-year predicted failure rates were greater for patients with tissue expander radiation than for patients with permanent implant radiation (32 percent versus 16.4 percent; p < 0.01). Patients undergoing radiation to the tissue expander had a greater proportion of very good to excellent aesthetic results compared to patients with permanent implant radiation (75.0 percent versus 67.6 percent; p < 0.01) and lower rates of grade IV capsular contracture (p < 0.01). BREAST-Q scores were similar for patients with the different radiation timings. Conclusions: Although the risk of reconstructive failure is significantly higher for patients with tissue expander radiation compared to patients with permanent implant radiation, the aesthetic results and capsular contracture rates are slightly better. Patient reported outcomes do not differ between patients with tissue expander or permanent implant radiation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Bilateral Mastectomy versus Breast-Conserving Surgery for Early-Stage Breast Cancer: The Role of Breast Reconstruction.

Background: Although breast-conserving surgery is oncologically safe for women with early-stage breast cancer, mastectomy rates are increasing. The objective of this study was to examine the role of breast reconstruction in the surgical management of unilateral early-stage breast cancer. Methods: A retrospective cohort study of women diagnosed with unilateral early-stage breast cancer (1998 to 2011) identified in the National Cancer Data Base was conducted. Rates of breast-conserving surgery, unilateral and bilateral mastectomy with contralateral prophylactic procedures (per 1000 early-stage breast cancer cases) were measured in relation to breast reconstruction. The association between breast reconstruction and surgical treatment was evaluated using a multinomial logistic regression, controlling for patient and disease characteristics. Results: A total of 1,856,702 patients were included. Mastectomy rates decreased from 459 to 360 per 1000 from 1998 to 2005 (p < 0.01), increasing to 403 per 1000 in 2011 (p < 0.01). The mastectomy rates rise after 2005 reflects a 14 percent annual increase in contralateral prophylactic mastectomies (p < 0.01), as unilateral mastectomy rates did not change significantly. Each percentage point of increase in reconstruction rates was associated with a 7 percent increase in the probability of contralateral prophylactic mastectomies, with the greatest variation explained by young age(32 percent), breast reconstruction (29 percent), and stage 0 (5 percent). Conclusions: Since 2005, an increasing proportion of early-stage breast cancer patients have chosen mastectomy instead of breast-conserving surgery. This trend reflects a shift toward bilateral mastectomy with contralateral prophylactic procedures that may be facilitated by breast reconstruction availability.

A nationwide analysis of the relationship between hospital volume and outcome for autologous breast reconstruction.

Background: The volume-outcome relationship has not been specifically measured for U.S. autologous breast reconstruction. The authors studied whether there is a relationship between hospital procedural volume and perioperative complication rates. Methods: The authors identified (1) patients who underwent total mastectomy with immediate autologous reconstruction from 1998 to 2010 and (2) a subset of microsurgical cases from 2008 to 2010. Hospitals were categorized into quartiles based on number of yearly procedures. Outcomes included surgery-specific and systemic complications. A multivariable model was used to analyze the volume-outcome relationship after adjusting for other variables. Results: Over the 13-year study period, 21,016 immediate autologous reconstructions were recorded. Surgery-specific and systemic complication rates were 13.0 and 7.5 percent, respectively. Ninety-two percent of centers perform a very low (fewer than nine cases per year) or low (nine to 20 cases per year) number of procedures. The highest-volume centers (>44 cases per year) are located in metropolitan areas. An inverse relationship between reconstructive volume and surgery-specific and systemic complications was identified (p < 0.01). In the multivariable analysis, centers with very low, low, and medium case volumes were more likely to have surgery-specific complications than high-volume centers (p < 0.01). Very-low-volume compared with high-volume centers were more likely to have systemic complications (p < 0.01). Conclusions: Higher volume autologous breast reconstruction centers have lower complication rates. The volume-outcome relationship is stronger for surgery-specific than for systemic complications. Geographic disparities are present in the distribution of high-volume centers. Such information can be used to inform best practices and improve access to care. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Patient-Reported Outcomes 1 Year After Immediate Breast Reconstruction: Results of the Mastectomy Reconstruction Outcomes Consortium Study

Purpose The goals of immediate postmastectomy breast reconstruction are to minimize deformity and optimize quality of life as perceived by patients. We prospectively evaluated patient-reported outcomes (PROs) in women undergoing immediate implant-based or autologous reconstruction. Methods Women undergoing immediate postmastectomy reconstruction for invasive cancer and/or carcinoma in situ were enrolled at 11 sites. Women underwent implant-based or autologous tissue reconstruction. Patients completed the BREAST-Q, a condition-specific PRO measure for breast surgery patients, and Patient-Reported Outcomes Measurement Information System-29, a generic PRO measure, before and 1 year after surgery. Mean changes in PRO scores were summarized. Mixed-effects regression models were used to compare PRO scores across procedure types. Results In total, 1,632 patients (n = 1,139 implant, n = 493 autologous) were included; 1,183 (72.5%) responded to 1-year questionnaires. After analysis was controlled for baseline values, patients who underwent autologous reconstruction had greater satisfaction with their breasts than those who underwent implant-based reconstruction (difference, 6.3; P < .001), greater sexual well-being (difference, 4.5; P = .003), and greater psychosocial well-being (difference, 3.7; P = .02) at 1 year. Patients in the autologous reconstruction group had improved satisfaction with breasts (difference, 8.0; P = .002) and psychosocial well-being (difference, 4.6; P = .047) compared with preoperative baseline. Physical well-being of the chest was not fully restored in either the implant group (difference, -3.8; P = .001) or autologous group (-2.2; P = .04), nor was physical well-being of the abdomen in patients who underwent autologous reconstruction (-13.4; P < .001). Anxiety and depression were mitigated at 1 year in both groups. Compared with their baseline reports, patients who underwent implant reconstruction had decreased fatigue (difference, -1.4; P = .035), whereas patients who underwent autologous reconstruction had increased pain interference (difference, 2.0; P = .006). Conclusion At 1 year after mastectomy, patients who underwent autologous reconstruction were more satisfied with their breasts and had greater psychosocial and sexual well-being than those who underwent implant reconstruction. Although satisfaction with breasts was equal to or greater than baseline levels, physical well-being was not fully restored. This information can help patients better understand expected outcomes and may guide innovations to improve outcomes.

Economic implications of recent trends in U.S. immediate autologous breast reconstruction.

Background: Recent trends in U.S. breast oncology and autologous reconstruction, such as greater use of contralateral prophylactic mastectomies and microsurgery, may have increased reconstructive complication rates and costs. Simultaneously, with the increased complexity of autologous reconstruction in the setting of declining reimbursement, there may be market concentration of these procedures to specialized high-volume centers. This study aimed to (1) measure cost of autologous reconstruction in the setting of microsurgical technique, contralateral prophylactic mastectomies, and high-volume centers; and (2) analyze trends in market share of these procedures. Methods: Inflation-adjusted hospital charges were analyzed for autologous procedures using the Nationwide Inpatient Sample database (1998 to 2010), including a subgroup of microsurgical cases. Median charges were adjusted by patient case mix and analyzed by outcome, procedure type, and hospital volume using the Mann-Whitney test. Market share was evaluated through examination of trends in hospitals performing autologous reconstruction and procedures at high-volume centers. Results: Median charges for 21,016 autologous reconstructions were

Diminishing Relative Contraindications for Immediate Breast Reconstruction: A Multicenter Study

22,198. Costs were higher for bilateral reconstruction (

Diminishing relative contraindications for immediate breast reconstruction.

34,202) and microsurgical cases (