Mark Sisco

Have We Expanded the Equitable Delivery of Postmastectomy Breast Reconstruction in the New Millennium? Evidence from the National Cancer Data Base

BACKGROUND Studies examining patterns of cancer care before 2000 have shown underuse of postmastectomy breast reconstruction as well as racial and socioeconomic disparities in its delivery. These findings prompted legislation designed to broaden use at the turn of the millennium. However, little is known about trends in these findings over the past decade. STUDY DESIGN Patients who underwent mastectomy for stage 0 to III breast cancer between 1998 and 2007 (n = 452,903) were studied using the National Cancer Data Base to evaluate trends in the receipt of immediate and early delayed breast reconstruction. Those who underwent mastectomy between 1998 and 2000 (n = 150,177) and between 2005 and 2007 (n = 123,518) were compared using logistic regression to identify factors influencing the use of breast reconstruction and how they changed over time. RESULTS The use of postmastectomy breast reconstruction increased from 13% to 26% from 1998 to 2007. This increase was statistically significant in almost all patient subsets. Independent factors associated with breast reconstruction included age less than 50 years old; higher census-derived household income; private or managed care insurance; non-African American race; and treatment in an academic hospital setting. Treatment in an academic hospital and higher income became stronger predictors of breast reconstruction over the study period, while age became less of a predictor. CONCLUSIONS Although the use of breast reconstruction has increased from 1998 to 2007, it is still underused among many patient populations. Furthermore, racial and socioeconomic disparities in its delivery have persisted or widened. Additional effort is necessary to broaden the use of breast reconstruction and to ensure equitable access to it.

Advanced age is a predictor of 30-day complications after autologous but not implant-based postmastectomy breast reconstruction

Background: Older breast cancer patients undergo postmastectomy breast reconstruction infrequently, in part because of a perception of increased surgical risk. This study sought to investigate the effects of age on perioperative complications after postmastectomy breast reconstruction. Methods: The American College of Surgeons National Surgery Quality Improvement Program Participant Use Files from 2005 to 2012 were used to identify women with breast cancer who underwent unilateral mastectomy alone or with immediate reconstruction. Thirty-day complication rates were compared between younger (<65 years) and older (≥65 years) women after implant-based reconstruction, autologous reconstruction, or mastectomy alone. Linear and logistic regression models were used to control for differences in comorbidities and age. Results: A total of 40,769 patients were studied, of whom 15,093 (37 percent) were aged 65 years or older. Breast reconstruction was performed in 39.5 percent of younger and 10.7 percent of older women. The attributable risks of breast reconstruction, manifested by longer hospital stays (p < 0.001), more frequent complications (p < 0.001), and more reoperations (p < 0.001), were similar in older and younger women. There were no differences in the adjusted complication rates between older and younger patients undergoing implant-based reconstruction. However, older women undergoing autologous reconstruction were more likely to suffer venous thromboembolism (OR, 3.67; p = 0.02). Conclusions: The perioperative risks attributable to breast reconstruction are similar in older and younger women. Older patients should be counseled that their age does not confer an increased risk of complications after implant-based breast reconstruction. However, age is an independent risk factor for venous thromboembolism after autologous reconstruction. Special attention should be paid to venous thromboembolism prophylaxis in this group. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Postoperative Pain and Length of Stay Lowered by Use of Exparel in Immediate, Implant-Based Breast Reconstruction.

Background: Patients undergoing mastectomy and prosthetic breast reconstruction have significant acute postsurgical pain, routinely mandating inpatient hospitalization. Liposomal bupivacaine (LB) (Exparel; Pacira Pharmaceuticals, Inc., Parsippany, N.J.) has been shown to be a safe and effective pain reliever in the immediate postoperative period and may be advantageous for use in mastectomy and breast reconstruction patients. Methods: Retrospective review of 90 immediate implant-based breast reconstruction patient charts was completed. Patients were separated into 3 groups of 30 consecutively treated patients who received 1 of 3 pain treatment modalities: intravenous/oral narcotic pain control (control), bupivacaine pain pump, or LB injection. Length of hospital stay, patient-reported Visual Analog Scale (VAS) pain scores, postoperative patient-controlled analgesia usage, and nausea-related medication use were abstracted and subjected to analysis of variance and multiple linear-regression analysis, as appropriate. Results: Subjects were well-matched for age (P = 0.24) regardless of pain-control modality. Roughly half (53%) of control and pain pump–treated subjects had bilateral procedures, as opposed to 80% of LB subjects. Mean length of stay for LB subjects was significantly less than control (1.5 days vs 2.00 days; P = 0.016). LB subjects reported significantly lower VAS pain scores at 4, 8, 12, 16, and 24 hours compared with pain pump and control (P < 0.01). There were no adverse events in the LB group. Conclusion: Use of LB in this group of immediate breast reconstruction patients was associated with decreased patient VAS pain scores in the immediate postoperative period compared with bupivacaine pain pump and intravenous/oral narcotic pain management and reduced inpatient length of stay.

The quality‐of‐life benefits of breast reconstruction do not diminish with age

Older women rarely receive post‐mastectomy breast reconstruction (PMBR). While there is a perception that PMBR is less beneficial in this age group, quality‐of‐life (QOL) data related to PMBR in older women remain scarce.

Contralateral prophylactic mastectomy: current perspectives

There has been an increasing trend in the use of contralateral prophylactic mastectomy (CPM) in the United States among women diagnosed with unilateral breast cancer, particularly young women. Approximately one-third of women <40 years old are undergoing CPM in the US. Most studies have shown that the CPM trend is mainly patient-driven, which reflects a changing environment for newly diagnosed breast cancer patients. The most common reason that women choose CPM is based on misperceptions about CPM’s effect on survival and overestimation of their contralateral breast cancer (CBC) risk. No prospective studies have shown survival benefit to CPM, and the CBC rate for most women is low at 10 years. Fear of recurrence is also a big driver of CPM decisions. Nonetheless, studies have shown that women are mostly satisfied with undergoing CPM, but complications and subsequent surgeries with reconstruction have been associated with dissatisfaction with CPM. Studies on surgeon’s perspectives on CPM are sparse but show that the most common reasons surgeons discuss CPM with patients is because of a suspicious family history or for a patient who is a confirmed BRCA mutation carrier. Studies on the cost–effectiveness of CPM have been conflicting and are highly dependent on patient’s quality of life after CPM. Most recent guidelines for CPM are contradictory. Future areas of research include the development of interventions to better inform patients about CPM, modification of the guidelines to form a more consistent statement, longer term studies on CBC risk and CPM’s effect on survival, and prospective studies that track the psychosocial effects of CPM on body image and sexuality.

Patient satisfaction with nipple-sparing mastectomy: A prospective study of patient reported outcomes using the BREAST-Q

The authors sought to study patient‐reported outcomes following nipple‐sparing mastectomy (NSM).

Nipple-sparing mastectomy: A contemporary perspective.

Increasing numbers of women are undergoing nipple‐sparing mastectomy, and evidence to support its use for cancer treatment and prophylaxis is expanding. An understanding of technical aspects and pitfalls of the procedure is paramount to ensure that the best results are attained. J. Surg. Oncol. 2016;113:883–890.

Survey of the deficits in surgeons' knowledge of contralateral prophylactic mastectomy

Author Contributions: Dr Benharash had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Toppen, Sareh, Satou, Benharash. Acquisition, analysis, or interpretation of data: Toppen, Sareh, Johansen, Genovese, Shemin, Benharash. Drafting of the manuscript: Toppen, Sareh, Genovese, Satou. Critical revision of the manuscript for important intellectual content: Toppen, Sareh, Johansen, Genovese, Shemin, Benharash. Statistical analysis: Toppen, Sareh, Johansen, Shemin. Administrative, technical, or material support: Satou, Shemin, Benharash. Study supervision: Benharash.

Advanced Age Does Not Worsen Recovery or Long-Term Morbidity after Postmastectomy Breast Reconstruction

PurposeDespite evidence that older women have quality-of-life outcomes similar to younger women after postmastectomy breast reconstruction (PMBR), they rarely receive it. There is a perception that PMBR in older women may result in significant physical morbidity. However, the effects of age on physical morbidity after PMBR have not been studied. This study sought to assess perceptions of recovery from surgery and long-term chest and upper body morbidity in older women who receive PMBR. MethodsWomen with American Joint Committee on Cancer stage 0-III breast cancer who underwent a mastectomy with PMBR between 2005 and 2011 were surveyed to assess their functional health status (DUKE), physical well-being (BREAST-Q), and perceptions of recovery from surgery. Patients were stratified into 2 age groups: older (≥65 years) and younger (<65 years). Outcome scores were compared by mastectomy laterality, reconstruction type, and between age groups. Data were analyzed using &khgr;2 and t tests. ResultsOne hundred eight older and 103 younger patients returned surveys (response rate, 75.4%). The median time from mastectomy to survey was 4 years (range, 1–7). Younger women were more likely to undergo bilateral mastectomy than older women (65.7% vs 32.2%, P < 0.001). Some women (66.9%) underwent implant-only reconstruction and 33.1% underwent autologous reconstruction; there were no significant differences in reconstruction type between age groups. Patients who underwent unilateral and bilateral mastectomy had similar mean BREAST-Q physical well-being scores (79.4 vs 78.9, respectively, P = 0.85). There was no difference in mean physical well-being scores between older and younger patients (80.0 vs 78.5, respectively, P = 0.61). In addition, older patients were less likely to perceive their recovery from PMBR as being difficult than younger patients, though this was not statistically significant (48.2% vs 64.3%, P = 0.07). ConclusionsOlder women who undergo PMBR have physical and upper body well-being that is similar to younger women. In addition, their perception of recovery from PMBR is at least as good as that seen in younger women. Older women contemplating PMBR should be counseled that they are not at higher risk for long-term physical and upper body morbidity from PMBR than are younger women.

The effect of contralateral prophylactic mastectomy on breast-related charges: A 5-year analysis: SMITH et al.

The purpose of this study was to determine charges following unilateral mastectomy (UM) and bilateral mastectomy (BM) for patients with unilateral breast cancer (UBC). We hypothesized that BM may be associated with fewer charges over time.