SABCS 2015: Mastectomy Plus Reconstruction Has Higher Complication Rates and Costs Than Lumpectomy Plus Radiation

“Among the various guideline-concordant local therapy options available for women with early-stage breast cancer in the United States, mastectomy plus reconstruction had the highest complication rates and complication-related costs for both younger women with private insurance and older women on Medicare and was the most expensive option for younger women, according to data presented at the 2015 San Antonio Breast Cancer Symposium, held December 8–12 in San Antonio, Texas (Abstract S3-07).

“ ‘Women with early-stage breast cancer have several local therapy options. Although there’s nuance as far as what treatment is best for which patient, there is a large group of patients for whom most, if not all, of these treatment options are considered guideline-appropriate,’ said Benjamin D. Smith, MD, Associate Professor and Research Director of the Breast Radiation Oncology Section in the Department of Radiation Oncology at The University of Texas MD Anderson Cancer Center.”

Risk of Infection is High After Mastectomy and Immediate Reconstruction

“Women undergoing mastectomy with immediate reconstruction were at twice the risk for surgical site infections than women undergoing mastectomy alone, according to researchers from Washington University School of Medicine.

“Although the National Healthcare Safety Network (NHSN) estimates the incidence of surgical site infections (SSIs) following breast operations in the United States to be around 1% to 2%, SSI rates vary widely across institutions. According to Margaret A. Olsen, PhD, MPH, and colleagues, this may be due to ‘the type of breast operation, definitions used for infection, surveillance methods to identify infections, and the length of postoperative follow-up.’

“The researchers examined the incidence of infection in a much larger population of women treated at numerous facilities. Participants included 18,085 women with private health insurance who underwent 18,696 mastectomy procedures with and without immediate implant or flap reconstruction from 2004 to 2011.”

Chemotherapy Can Complicate Immediate Breast Reconstruction after Mastectomy

“Immediate breast reconstruction following mastectomy is becoming more prevalent. However, in breast cancer patients undergoing simultaneous chemotherapy, thrombotic complications can arise that can delay or significantly modify reconstructive plans. Outcomes of cases illustrating potential complications are published in the current issue of Annals of Medicine and Surgery.

“Chemotherapy is increasingly used to treat larger operable or advanced breast cancer prior to surgery. Chemotherapy delivered via the placement of a central venous line that remains in place for the duration of treatment can result in pre-operative thromboembolic events, which can require the administration of anticoagulation agents. This in turn can complicate subsequent surgery and is particularly significant when complex reconstruction is anticipated immediately following the mastectomy.

” ‘There is limited research on the impact of this complication on breast reconstruction pathways and guidance for optimal management of these patients,’ notes Professor Charles M. Malata, FRCS (Plast), who is Consultant Plastic & Reconstructive Surgeon at the Cambridge Breast Unit (Cambridge University Hospitals NHS Foundation Trust) and Professor of Academic Plastic Surgery at the Postgraduate Medical Institute of Anglia Ruskin University. ‘My colleagues and I present our clinical experience over four years of patients with breast cancer who developed thrombotic complications of their neoadjuvant chemotherapy venous lines prior to mastectomy and immediate breast reconstruction.’ “

Evolution: Breast Reconstruction After Mastectomy

“Women who want breast reconstruction after mastectomy have several options with respect to timing, type of procedure, and materials used. Here, plastic surgeon M. Whitten Wise, MD, reviews the options and discusses considerations relevant to each procedure.

“Breast cancer remains a key women’s health issue. When presented with the diagnosis of breast cancer women face the choice of lumpectomy (usually accompanied by breast radiation) versus mastectomy. And while lumpectomy rates remain high, mastectomy numbers are climbing. This is driven in part by several distinct subsets of women: those seeking to avoid radiation therapy, those looking to reduce their risk for disease recurrence, and by a dramatic increase in women seeking prophylactic mastectomy.

“Prophylactic mastectomy may be performed in the contralateral breast or prophylactically in both breasts to help prevent the development of breast cancer (especially among those patients with one of the genetic mutations predisposing women to breast cancer, such as the BRCA gene mutations).

“The majority of patients choosing mastectomy are candidates for immediate reconstruction at the time of mastectomy. This allows them to avoid additional surgeries and recovery times. It provides significant psychological benefits by allowing women to feel ‘whole,’ with reduced incidences of depression, anxiety and low self-esteem. Importantly, immediate surgery improves the aesthetic result of the reconstruction by preserving the breast skin envelope to reduce the extent of scarring and to maintain the natural breast shape. This allows the breast reconstruction to replace only the missing breast tissue under the preserved breast skin.”

Most Breast Cancer Patients Who Had Healthy Breast Removed at Peace with Decision

“More women with cancer in one breast are opting to have both breasts removed to reduce their risk of future cancer. New research shows that in the long term, most have no regrets. Mayo Clinic surveyed hundreds of women with breast cancer who had double mastectomies between 1960 and 1993 and found that nearly all would make the same choice again. The findings are published in the journal Annals of Surgical Oncology.

“The study made a surprising finding: While most women were satisfied with their decision whether they followed it with breast reconstruction or not, patients who decided against reconstructive surgery were likelier to say they would choose to have both breasts removed again. In the reconstructive surgery group, women who needed additional operations due to complications, breast implant-related issues or other reasons were likelier to regret their prophylactic mastectomy, though overall, most women with breast reconstructions were satisfied with their choices.

” ‘I think what this study does is adds some literature to the hands of the people counseling patients to say, “Whatever decision you make, you’re very likely to be happy with that in the long run, so listen to yourself, and make the decision that’s best for you,” ‘ says lead author Judy Boughey, M.D., a Mayo breast surgeon.

“Most of those who skipped reconstruction said they felt the same about themselves and their femininity in the long run as they did before their mastectomies and would make the same choices today. Many of those with reconstructive surgery also felt the same about themselves as they did before their mastectomies, but some reported more satisfaction with their appearance, higher self-esteem and feeling more feminine.”

Neoadjuvant Chemotherapy Reduces Postoperative Morbidity in Women With Breast Cancer Undergoing Mastectomy

Editor’s note: Cancer patients sometimes take neoadjuvant therapy—a treatment given before the main treatment to reduce the risk of the cancer returning later (recurrence). In a recent study, researchers looked at the effects of neoadjuvant chemotherapy for breast cancer patients before mastectomy. They measured morbidity, which they defined as a list of various conditions including surgical site infection, pneumonia, and sepsis. The researchers found that neoadjuvant chemotherapy reduced the risk of these conditions.

“In a study reported in JAMA Surgery, Abt et al found that neoadjuvant chemotherapy is safe in women with breast cancer undergoing mastectomy with or without immediate breast reconstruction. Neoadjuvant chemotherapy was an independent predictor of reduced 30-day postoperative morbidity in women undergoing mastectomy without breast reconstruction and in those undergoing immediate tissue expander breast reconstruction…

“The study included women in the American College of Surgeons National Surgical Quality Improvement Program database undergoing mastectomy with or without immediate breast reconstruction from January 2005 through December 2011. Rates of 30-day overall, systemic, and surgical postoperative morbidity were compared between women who did and did not receive neoadjuvant chemotherapy.

“Postoperative morbidity was defined as superficial and deep incisional surgical site infection, organ space surgical site infection, wound dehiscence, pneumonia, unplanned intubation, pulmonary embolism, > 48 hours of ventilatory assistance, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke or cerebrovascular accident, coma > 24 hours, cardiac arrest, myocardial infarction, bleeding requiring transfusion, prosthesis or flap failure, deep vein thrombosis requiring treatment, sepsis, septic shock, and return to the operating room within 30 days.”

PRMA Expands, Bringing Advanced Breast Reconstruction Services to Stone Oak

“PRMA Plastic Surgery, one of the world’s largest breast reconstruction centers, announced today the practice will expand into Stone Oak, opening its doors on April 1st.

“After adding a 7th surgeon late last year and continuing to increase its patient base not only across Texas, but around the country, PRMA surgeons say a second office was inevitable.”