DELAY RECONSTRUCTION AFTER MASTECTOMY

Mastectomy patients who are obese, who smoke, who have diabetes, or who require adjuvant cancer therapy should be advised to delay implant breast reconstruction rather than opt for immediate reconstruction, say researchers.

Even in women without these high-risk characteristics, immediate implant reconstruction is associated with a significantly increased risk for serious wound complications, subsequent breast surgeries, and 2- to 3-week delays in adjuvant therapy, they warn.

The warning comes from a large retrospective cohort study conducted by Margaret A. Olsen, PhD, MPH, of the Departments of Surgery and Medicine at Washington University School of Medicine, St. Louis, Missouri, and colleagues in a report published online July 18 in JAMA Surgery.

"This is a situation that clearly warrants shared decision making between women and their physicians," Dr Olsen told Medscape Medical News. "Ultimately, a woman may decide she is willing to accept the increased risk of complications in order to begin the process of breast reconstruction immediately after mastectomy rather than waiting for a delayed procedure. It is important, however, that women understand their personalized risk of complications in order to make a truly informed decision regarding the type and timing of reconstruction. [The] bottom line is to take the whole picture into perspective and balance the benefits of skin-preserving oncologic procedures with that of life-preserving oncologic treatment."

Results from their study reveal that the incidence of surgical site infections and noninfectious wound complications was significantly higher for patients who underwent immediate implant reconstruction (8.9%) than it was for those who underwent delayed (5.7%) or secondary implant reconstruction (3.2%).

Similar results were demonstrated for noninfectious wound complications, in spite of the higher-risk profile of the women undergoing delayed reconstruction.

"The risk for complications should be carefully balanced with the psychosocial and technical benefits of IR [immediate reconstruction]," Dr Olsen and colleagues emphasize. "Our finding of poorer outcomes associated with IR complications, including increased wound complication rates after the next reconstruction procedure, more subsequent breast procedures, and delay of the start of adjuvant treatment, underscores the need to communicate individualized complication risk to women considering IR. Select high-risk patients may benefit from consideration of delayed rather than immediate implant reconstruction to decrease breast complications after mastectomy."

The authors say that a prospective, multicenter study tracking individual outcomes in all settings is needed to confirm these results.

Study Details

For the study, the team abstracted data from a commercial insurance claims database for 17,293 women aged 18 to 64 years who underwent mastectomy from January 1, 2004, through December 31, 2011, in 12 states. The mean age of the patients was 50 years, and 61% of the women received either immediate breast reconstruction within 7 days of mastectomy or delayed reconstruction 7 days after mastectomy. Surgery was considered secondary in patients who underwent immediate reconstruction after mastectomy.

The study showed there was a median 2-week delay in chemotherapy and 3-week delay in radiotherapy for women with complications compared to those without. Therefore, clinicians need to spell out the repercussions should complications arise. Coauthor Ida K. Fox, MD, who is in the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, recommends that patients be given advice such as the following: " 'As a reconstructive surgeon and your physician, I would hate it if infection or wound healing complications delayed the chemotherapy or radiation treatment that will help you fight this cancer.' "

The study also shows that women who developed a surgical site infection after immediate implant reconstruction were significantly more likely than their counterparts without an infection to have another infection after secondary reconstruction (11.4% vs 2.7%). They were also more likely to have noninfectious wound complications (5.8% vs 2.5%) and were significantly more likely to require more breast procedures after immediate reconstruction, whether they underwent immediate implant reconstruction or immediate autologous reconstruction (mean of 1.92 and 1.11 procedures, respectively).

By comparison, women who did not develop any post-mastectomy wound complications underwent a mean of 1.37 procedures after immediate implant reconstruction and a mean of 0.87 procedures after immediate autologous reconstruction.

The trend with autologous tissue flap reconstruction was somewhat different. The incidence of surgical site infection was similar after immediate autologous reconstruction (9.8%), delayed reconstruction (13.9%), and secondary reconstruction (11.6%) procedures, although the number of procedures was smaller.

For women who received adjuvant radiotherapy after secondary implant reconstruction, the incidence of surgical site infection and noninfectious wound complications was also higher (6.3% and 2.9%, respectively). There were no increase in the rate of surgical site infection or noninfectious wound complications after adjuvant radiotherapy in women who underwent subsequent autologous reconstruction, however. This finding is in keeping with earlier reports that found no association between radiotherapy and outcomes in women undergoing autologous reconstruction.

There is a lack of consistency in the literature regarding complication rates after immediate vs delayed autologous tissue flap and implant reconstructions, say Dr Olsen and colleagues. However, they point out, since the late 1990s, the proportion of women with high-risk characteristics who undergo immediate implant breast reconstruction — including those who are elderly, have advanced breast cancer, or comorbidities and those who need adjuvant radiotherapy — has increased threefold.

The fact that lower rates of wound complications were seen in women who underwent delayed reconstruction compared to those who underwent immediate reconstruction is important, because in the former group, there was a higher risk for surgical site infection. For women living in a rural area who smoke, immediate rather than delayed reconstruction was associated with even higher wound complication rates, the study authors note.

These trends in breast reconstruction complication rates could be explained by the large and highly vascularized "dead space" into which the implant is placed or the longer surgery times required when reconstruction is immediate, Dr Olsen and colleagues suggest. Women who develop wound complications after immediate implant reconstruction may have a prolonged risk for complications after subsequent procedures because of an inherently higher risk for complications, continuing low-level infection, or deterioration of the soft-tissue envelope.

This study was supported by the National Institutes of Health, the Centers for Disease Control and Prevention (CDC), and the Prevention Epicenters Program. Dr Olsen has relationships with Merck, Pfizer, Sanofi Pasteur, and Cubist Pharmaceuticals. Dr Fox has disclosed no relevant financial relationships. Coauthor Anna E. Wallace, MPH, is an employee of HealthCore, a subsidiary of Anthem Inc, and participates in an employee stock purchase plan. Coauthor Victoria J. Fraser, MD, has relationships with the Doris Duke Foundation, the CDC, and the Foundation for Barnes-Jewish Hospital. 

JAMA Surg. Published online July 19, 2017. Abstract