Outcomes Vary With Different Breast-Reconstruction Approaches

NEW YORK (Reuters Health) - Long-term satisfaction, quality of life and complication rates differ across various types of postmastectomy breast reconstruction, according to a pair of new studies.

"While the risks and benefits of the various options must be carefully weighed, the 'pros' and 'cons' will not be the same for each woman," said Dr. Edwin G. Wilkins of the University of Michigan, in Ann Arbor, who worked on both of the studies, online June 20 in JAMA Surgery.

"The decision process and the ultimate choice of operation (or option to forgo reconstruction) should be tailored to the individual patient," he told Reuters Health by email.

Earlier short-term studies found that women who chose autologous reconstruction were more satisfied with their breasts and reported greater psychosocial and sexual well-being than did women who chose implant-based reconstruction. But autologous procedures were associated with significantly higher odds of complications.

In one study, Dr. Wilkins and colleagues used data from the Mastectomy Reconstruction Outcomes Consortium (MROC) prospective study to evaluate two-year patient-reported outcomes (PROs) in women who underwent immediate breast reconstruction using implants (n=1,490) or autologous tissue (n=523) after mastectomy for cancer treatment or prophylaxis.

Women who underwent autologous reconstruction reported significantly higher satisfaction with their breasts over time, even though they began the process of reconstruction with lower scores, whereas women who underwent implant-based reconstruction reported relatively stable scores for satisfaction with their breasts at two, three and four years after reconstruction.

Women in both groups had higher psychosocial-wellbeing scores at these points in time as well, compared with baseline, with greater improvements reported by women who underwent autologous reconstruction.

Sexual-wellbeing scores worsened after implant reconstruction, but improved after autologous reconstruction.

In regression models, women who chose autologous reconstruction had significantly higher levels of satisfaction with their breasts, psychosocial wellbeing, physical wellbeing of the chest and sexual wellbeing at two years, compared with women who chose implant reconstruction.

"These findings can inform patients and their clinicians about expected satisfaction and quality of life outcomes of autologous versus implant-based procedures and further support the adoption of shared decision making in clinical practice," the researchers conclude.

In the second MROC-based study, the researchers assessed two-year complication rates across common techniques for postmastectomy reconstruction in 2,343 women.

Overall, 32.9% of women experienced a complication, including 19.3% who had a reoperative complication, 9.8% who had wound infections and 5.4% who had reconstruction failures.

By two years, women undergoing any autologous reconstruction were significantly more likely to have developed a complication compared with those undergoing expander-implant reconstruction.

Older women and those with a higher body mass index (BMI) had greater odds of any complication or a reoperative complication, as did women who had bilateral reconstructions, current smokers and patients undergoing radiotherapy during or after reconstruction.

Women undergoing delayed reconstructions were significantly less likely than women receiving immediate reconstructions to develop any complication, and women who received neoadjuvant and adjuvant chemotherapy had significantly higher odds of developing re-operative complications.

"Both patients and providers should bear in mind that the reconstructive process is not always smooth and that complications are not uncommon," Dr. Wilkins said. "However, the vast majority of women are able to successfully complete their reconstruction and enjoy the quality-of-life benefits provided by these procedures."

"It is our hope that MROC's detailed analyses on the risks and patient-reported outcomes of reconstruction will promote a more evidence-based, tailored decision process for breast cancer patients and their providers," he said.

Dr. David H. Song from MedStar Georgetown University Hospital, in Washington, D.C., who co-authored a linked commentary, told Reuters Health by email, "On first glance the high rate of complications from autologous tissue reconstruction was surprising, but then you delve into the details and find that even minor (nonsurgical) wound issues (which are very common) were reported. The sophisticated reader will then realize that failure rates are really what matters and here autologous reconstructions, true to form, is better."

"Women should find surgeons that are equally adept at both implant-based and DIEP (deep inferior epigastric perforator) flap (autologous reconstruction), as they will find that the robust discussion with a surgeon who is comfortable with all forms of reconstruction will allow women to choose the right one for themselves," he said. "Choosing the right one is better than choosing the option right now. Meaning, many women and many surgeons steer patients towards implants because it's ostensibly easier up front, but the long-lasting implications should be discussed and stressed as well."

"When discussing implants, I always relay to patients and other colleagues that given enough time, 100% of implants will fail," Dr. Song said. "While once you're over the recovery of a DIEP flap, minor complications notwithstanding, the result is for life."

Dr. Mary Politi from Washington University School of Medicine in St. Louis, Missouri, whose team has developed a decision tool for helping women decide whether to have breast reconstruction, when to have it and what type to have, told Reuters Health by email, "Breast reconstruction after mastectomy is a highly personal decision, with no best choice for all patients. Patients and their providers should collaborate together to weigh the pros and cons of options, considering what matters most to patients. The findings from this study can help facilitate those conversations. The study provides some concrete information about possible outcomes associated with the type and timing of breast reconstruction."

"In some of our work, we have found that patients do not always understand the risks associated with breast reconstruction," said Dr. Politi, who was not involved in the new work. "Many physicians only talk about the benefits of the procedure. As this report describes, the risks might outweigh the benefits for some patients. Physicians should be prepared to talk about both the pros and the cons so that patients can make an informed choice."

"The decision support tool is currently being tested in a randomized trial, and we have applied for AHRQ (Agency for Healthcare Research and Quality) funding to engage stakeholders to modify the tool and incorporate it into the electronic health record," she said. "We hope to have it available for public use after the end of this trial (hopefully by the end of this calendar year)."

Dr. David A. Daar from NYU Langone Medical Center, New York, who recently evaluated disparities in postmastectomy breast reconstruction, said, "Proper selection in method of breast reconstruction is a team-based process, and decision-making must include both the patient and the various physicians involved (e.g., surgeon, oncologist, radiation oncologist). There is no 'one-size-fits-all,' and as shown in this study, certain risk factors such as smoking, radiotherapy, and neoadjuvant chemotherapy can help guide treatment choice."

"More research needs to be done looking at the link between patient decision-making process and patient-reported outcomes after breast reconstruction to identify the best method of guiding a patient to the best treatment decision for them," Dr. Daar, who was not involved in the studies, told Reuters Health by email.

SOURCE: https://bit.ly/2MzGbfD, https://bit.ly/2IDpdur and https://bit.ly/2Kio4hC

JAMA Surg 2018.



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