Yeliz Cemal

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.

Preventative Measures for Lymphedema: Separating Fact from Fiction

Lymphedema is the accumulation of protein rich fluid that occurs when the ability of the lymphatic system to transport interstitial fluid is exceeded. This devastating disorder affects an estimated 3–5 million Americans and a staggering 140–200 million people worldwide 1. In the United States and Western countries, lymphedema occurs most commonly as a complication of lymph node dissection for cancer treatment. It is estimated that as many as 30–50% of patients who undergo lymph node dissection go on to develop lymphedema2, 3. Lymphedema can even occur after less invasive procedures such as sentinel lymph node dissection thereby putting nearly all cancer survivors at risk for this dreaded complication4. Although lymphedema occurs most commonly as a complication of breast cancer management, it is also seen frequently in patients treated for other solid malignancies. In fact, a recent meta-analysis of nearly 8000 patients reported an overall incidence of 16% in patients treated for gynaecological, melanoma, urologic, sarcoma, and head and neck malignancies5. Patients with lymphedema have chronic, progressive swelling, pain, recurrent infections, and significantly decreased quality of life. The swelling can progress to gigantic proportions causing gross disfigurement with severe detrimental effects. In addition, lymphedema is a significant source of biomedical expenditures with one recent study demonstrating a more than

Measuring and managing patient expectations for breast reconstruction: impact on quality of life and patient satisfaction

10,000 increase in the annual treatment costs of cancer survivors with lymphedema as compared with those without lymphedema6. Treatment for lymphedema remains suboptimal and is, in most cases palliative with a goal of preventing disease progression rather than a cure. Medical and surgical treatments have been reported but in general these therapies have been disappointing and the results sometimes difficult to reproduce. In most instances, patients are treated with life-long physical therapy with manual lymphatic drainage and require tight fitting, uncomfortable elastic garments. Due to the expense, time, and discomfort associated with these treatments, there is a high degree of non-compliance and associated disease progression. Despite the morbidity and costs of lymphedema, the mechanisms that regulate its development remain largely unknown. It remains unclear for instance why some patients develop lymphedema and others who are identically treated do not. Similarly, it is unknown why certain risk factors such as radiation, obesity, or infection increase the risk of lymphedema. Perhaps the most perplexing aspect of lymphedema is the fact that it develops in a delayed manner usually 1–5 years after surgery. Sometimes lymphedema can develop even decades after surgery after seemingly trivial trauma. This gap in our knowledge has prevented development of targeted treatment options. Similarly, our lack of understanding of the cellular and molecular mechanisms in the development of lymphedema have complicated effective preventative strategies. In fact, many of the current recommendations for prevention of lymphedema are anecdotal with scant scientific evidence. The current recommendation from the National Cancer Institute 7, The Royal Marsden Hospital (UK) 8 and The National Lymphedema Network (NLN) 9 are presented in table 1. However the NLN state that there is little evidence-based literature with respect to many of these recommendations and the majority of them are based on what is known through decades of clinical experience and comprehension of the pathophysiology by experts in lymphedema. Table 1 Preventative recommendations for lymphedema (adapted from the NCI, The Royal Marsden Hospital and NLN (2, 3, 4). The purpose of this systematic review was to evaluate the current recommendations for prevention of lymphedema and present current scientific evidence supporting or disputing these claims.

Quality of patient‐reported outcome reporting across cancer randomized controlled trials according to the CONSORT patient‐reported outcome extension: A pooled analysis of 557 trials

The goal of postmastectomy breast reconstruction is to restore a woman’s body image and to satisfy her personal expectations regarding the results of surgery. Studies in other surgical areas have shown that unrecognized or unfulfilled expectations may predict dissatisfaction more strongly than even the technical success of the surgery. Patient expectations play an especially critical role in elective procedures, such as cancer reconstruction, where the patient’s primary motivation is improved health-related quality of life. In breast reconstruction, assessment of patient expectations is therefore vital to optimal patient care. This report summarizes the existing literature on patient expectations regarding breast reconstruction, and provides a viewpoint on how this field can evolve. Specifically, we consider how systematic measurement and management of patient expectations may improve patient education, shared medical decision-making and patient perception of outcomes.

Systematic Review of Quality of Life and Patient Reported Outcomes in Patients with Oncologic Related Lower Extremity Lymphedema

The main objectives of this study were to identify the number of randomized controlled trials (RCTs) including a patient‐reported outcome (PRO) endpoint across a wide range of cancer specialties and to evaluate the completeness of PRO reporting according to the Consolidated Standards of Reporting Trials (CONSORT) PRO extension.

Unilateral preoperative chest wall irradiation in bilateral tissue expander breast reconstruction with acellular dermal matrix: a prospective outcomes analysis.

BACKGROUND Lower limb lymphedema (LLL) is a common complication of cancer treatment. The disease is chronic and progressive with no cure. Although a common and significant source of morbidity, the impact of this condition on health-related quality of life (HRQOL) has only recently been addressed. In effort to identify valid treatment strategies for LLL, we performed a systematic review, identifying studies describing HRQOL outcomes in patients with LLL secondary to cancer. METHODS AND RESULTS Seven medical databases were searched to identify reports using validated Patient Reported Outcome (PRO) instruments on patients with cancer-related LLL. Studies were classified by levels of evidence set by the Agency for Healthcare Research and Quality (AHRQ) and evaluated using the Efficace criteria. 25 studies were identified, 6 met inclusion criteria. Levels of evidence included: no level I studies, level II (n=3), level III (n=1), and level 4 (n=2). 50% of studies were compliant with the Efficace criteria. 5 PRO HRQOL instruments were used, but only 1 was specific to cancer-related lymphedema. Treatment strategies assessed included complete decongestive physiotherapy (CDP), exercise, and compression bandaging. CDP yielded significant enhancements in HRQOL. CONCLUSIONS There is a deficit in high quality studies for HRQOL in patients with LLL secondary to cancer. Furthermore, of the studies present, most did not conform to guidelines set for assessment of HRQOL, nor did they use lymphedema condition specific PRO instruments. New measures specific to assessing LLL are necessary to gain more accurate evaluation of how this debilitating disorder affects HRQOL.

Quality of Patient-Reported Outcome (PRO) Reporting Across Cancer Randomized Controlled Trials According to the CONSORT PRO Extension: A Pooled Analysis of 557 Trials

Background: Prior breast irradiation increases the rate of postoperative complications, including capsular contracture, in tissue expander/implant reconstruction. Acellular dermal matrix is heralded to decrease capsular contracture, but recent evidence suggests a possible increase in postoperative complications. The authors evaluated outcomes in patients undergoing bilateral tissue expander/implant reconstruction with acellular dermal matrix in the setting of prior unilateral irradiation. Methods: A case-control study was conducted on all patients undergoing bilateral, acellular dermal matrix–assisted, tissue expander/implant reconstruction with a history of previous unilateral irradiation at Memorial Sloan-Kettering Cancer Center. Complication rates were compared. Results: Twenty-three patients met inclusion criteria and had an average follow-up of 19 months (range, 4 to 60 months). The perioperative infection rate was 21.7 percent (n = 5) in irradiated breasts and 4.3 percent (n = 1) in control breasts (p = 0.079). Mastectomy skin flap necrosis, explantation, hematoma, and seroma rates were not significantly different between the groups. Sixty percent of patients had irradiated breast contracture that was one Baker grade greater than that in the nonirradiated breast. Body mass index greater than 25 and smoking history were significant independent risk factors for early postoperative complications in univariate analysis (p = 0.01). Conclusions: Previous irradiation does not appear to increase the risk of early postoperative complications associated with acellular dermal matrix use in tissue expander/implant breast reconstruction. However, body mass index greater than 25 and smoking history are cause for caution. In addition, acellular dermal matrix does not appear to affect the degree of capsular contracture formation in the setting of prior irradiation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Unilateral Preoperative Chest Wall Irradiation in Bilateral Tissue Expander/Implant Breast Reconstruction with Acellular Dermal Matrix: Complications and Outcomes

The main objectives of this study were to identify the number of randomized controlled trials (RCTs) including a patient‐reported outcome (PRO) endpoint across a wide range of cancer specialties and to evaluate the completeness of PRO reporting according to the Consolidated Standards of Reporting Trials (CONSORT) PRO extension.

Successful Salvage of Late Anastomotic Thrombosis after Free Tissue Transfer

IntroductIon: Prior breast irradiation is known to increase rates of post-operative complications in tissue expander/implant (TE/I) reconstruction (1-3). Acellular dermal matrix (ADM) is a popular adjunct heralded to decrease capsular contracture; however, recent studies suggest possible increases in rates of early postoperative complications with its use. We aimed to evaluate complication rates, capsular contracture, and aesthetic outcomes in patients undergoing bilateral, TE/I reconstruction with ADM and prior unilateral irradiation.