Immediate breast reconstruction does not lead to a delay in the delivery of adjuvant chemotherapy

doi:10.1016/j.ejso.2004.04.006

European Journal of Surgical Oncology (EJSO)

Volume 30, Issue 6, August 2004, Pages 624-627

https://doi.org/10.1016/j.ejso.2004.04.006 Get rights and content

Abstract

Immediate breast reconstruction (IBR) has been considered by some to lead to a delay in the delivery of adjuvant chemotherapy. Our aim was to determine whether IBR led to a delay when compared to conservation surgery and non-reconstructive mastectomy. Ninety-five cases of IBR receiving chemotherapy were reviewed. These were compared to 95 consecutively treated patients undergoing conservation surgery and 95 undergoing non-reconstructive mastectomy.

Our data shows that IBR does not lead to a delay in the delivery of adjuvant chemotherapy when compared to standard non-reconstructive surgery and should not adversely affect breast cancer outcome.

Introduction

There has been a dramatic increase in immediate breast reconstruction (IBR) with skin sparing mastectomy over the last 10 years in the United Kingdom.1., 2. These oncoplastic surgical techniques appear both safe³ and reliable and offer women a superior aesthetic reconstruction along with considerable psychological benefit.4., 5., 6. Depending upon the type of immediate reconstruction undertaken, however, these procedures may be lengthy with significant post-operative complications7., 8., 9. and there is concern especially amongst oncologists that IBR may affect survival by delaying adjuvant chemotherapy as a result of increased complications from these more complex surgical procedures.

Current guidelines, which are not evidence based, state that chemotherapy should be administered within 4 weeks of definitive surgery.10., 11. The effect of IBR on the timing of delivery of chemotherapy when compared to standard non-reconstructive methods of breast cancer surgery is unknown and this study aimed to address this issue.

Section snippets

Methods

To address the question of whether IBR led to a delay in the delivery of chemotherapy, we reviewed a database of 255 patients who underwent IBR for prophylaxis, 23, ductal carcinoma in situ, 63, and breast cancer, 162, and seven patients who underwent IBR for other conditions; giant phylloides, etc. at the Canniesburn Plastic Surgical Unit between 1995 and 2000. A total of 95 of the 162 patients with breast cancer received adjuvant chemotherapy according to local protocols. Although the

Results

The median time to the start of chemotherapy in the IBR cohort was 29 days (range 17–55 days) compared to 26 days for conservation surgery (range 20–42 days) and 28 days for non-reconstructive mastectomy (range 16–52 days). These differences were not significant on chi square analysis (P=0.12), Table 1. We had intended to perform a subset analysis to determine if the type of reconstruction carried out influenced the start of chemotherapy. The median time to the start of chemotherapy for each

Discussion

Since the introduction of IBR and skin sparing mastectomy there has been considerable concern that oncological safety may be compromised leading to higher rates of local recurrence, increased difficulty in the future diagnosis and treatment of local recurrence and ultimately even reduced survival. Although a randomised trial comparing reconstructive and non-reconstructive mastectomy will never take place, a body of evidence has developed which has addressed the majority of these oncological

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Cited by (49)

Oncologic Safety of One-Stage Implant-Based Breast Reconstruction in Breast Cancer Patients With Positive Sentinel Lymph Nodes: A Single-Center Retrospective Study Using Propensity Score Matching
2024, Clinical Breast Cancer
The purpose of this study is to evaluate the oncologic safety of one-stage implant-based breast reconstruction (OIBR) following mastectomy in breast cancer patients with positive sentinel lymph nodes (SLNs).
We collected clinical and pathological data from breast cancer patients with positive SLNs who underwent OIBR or not after mastectomy between January 2015 and December 2018. A total of 194 patients were included, with 130 patients undergoing mastectomy alone (MA) and 64 patients receiving OIBR after mastectomy. The clinical and pathological features, as well as the postoperative oncologic outcomes, of the 2 groups were retrospectively analyzed. Propensity score matching (PSM) was employed to mitigate the effects of data bias and confounding factors.
The median follow-up time was 66 months for the OIBR group and 64 months for the MA group after PSM. The majority of reconstructive surgeries use an approach of prosthetic implantation (52.0%). This is followed by prosthetic implantation combined with a latissimus dorsi (LD) flap (32.0%), and acellular dermal matrix (ADM)-assisted implant placement (16.0%). During the follow-up period, a local recurrence was observed in 1 case, regional recurrence in 3 cases, and distant metastasis leading to death in 3 cases among the OIBR group patients. No significant difference was found between the OIBR and MA groups in disease-free survival (DFS) (P = .66), distant metastasis-free survival (DMFS) (P = .91), locoregional recurrence-free survival (LRRFS) (P = .44), and overall survival (OS) (P = .57).
OIBR is a safe option for breast cancer patients with positive SLNs and does not negatively impact cancer recurrence or overall survival.
Does Immediate Breast Reconstruction Lead to a Delay in Adjuvant Chemotherapy for Breast Cancer? A Meta-Analysis and Systematic Review
2023, Clinical Breast Cancer
Timely delivery of adjuvant chemotherapy is crucial. With an increasing frequency of immediate breast reconstructions (IBR) following mastectomy (MAS), concerns have arisen regarding its complication rates and effects on time to chemotherapy. The aim was to conduct a systematic review and meta-analysis to determine if there is a prolonged time to chemotherapy (TTC) after IBR and MAS. Electronic databases, reference lists and relevant articles were searched systematically. Eligibility criteria included women receiving adjuvant chemotherapy who underwent either MAS only or MAS and IBR. Random-effects models were used in the analysis. A total of 29 studies were included in qualitative analysis, comprising of 156,000 patients (IBR: 57,159; MAS: 98,841). But 23 studies had sufficient data to be included in the meta-analysis. Sixteen papers concluded there was no difference in TTC compared to MAS. There was a difference of 3.50 days between TTC in IBR versus MAS (95% CI [0.42, 6.57], P value = .0256; IBR = 43.56 days, MAS = 40.38 days). The rate of patients being delayed past 90 days was not significantly higher in IBR (OR = 1.34, 95% CI [0.76, 2.38], P = .310). IBR patients were more likely to have complications compared to the MAS group (OR = 2.04, 95% CI [1.04-4.01], P < .01). We concluded that there is a statistically significant longer time to chemotherapy following IBR of 3.50 days, yet there is no difference in delays past 90 days. Therefore, the longer TTC in IBR is unlikely to be of any clinical significance.
Neoadjuvant Chemotherapy for Breast Cancer Treatment and the Evidence-Based Interaction with Immediate Autologous and Implant-Based Breast Reconstruction
2018, Clinics in Plastic Surgery
Barriers, beliefs and practice patterns for breast cancer reconstruction: A provincial survey
2017, Breast
Citation Excerpt :
This may reflect historic approaches limiting breast reconstruction on system level [21]. While the studies showing a slight delay in adjuvant chemotherapy following IBR fuel ongoing debate [44,45], the literature indicates there is no clinically relevant delay in adjuvant therapy following IBR [25–27]. CCO recommendations agree with previous guidelines supporting IBR with adjuvant chemotherapy [10,11,28].
The purpose of this study was to characterize beliefs and practice patterns for breast cancer reconstruction among physicians who treat patients with breast cancer, in order to delineate current clinical practice. This survey was administered prior to Cancer Care Ontario guideline publication.
Survey questions addressed four domains: survival, delayed or obscured recurrence detection, delayed adjuvant therapy, and aesthetics. The survey was administered to 1160 Ontario plastic and general surgeons and radiation and medical oncologists. Data were compared to published guidelines.
The overall response rate was 48%, with 57% of respondents treating breast cancer. Of those treating breast cancer, 75% are affiliated with an academic center. Immediate breast reconstruction (IBR) is not available to 28%. Autologous reconstruction is thought to interfere with recurrence detection by 23% (oncologists 30%, surgeons 19%, p = 0.04). For patients not expected to require radiation therapy, IBR is not supported by 30%. Autologous IBR is believed to delay delivery of adjuvant chemotherapy by 45% (oncologists 55%, surgeons 41%, p = 0.02). Up to 42% of respondents believe delays in adjuvant therapy delivery following IBR are due to insufficient health care resources (ie. coordinating an oncologic and reconstructive surgeon). Radiation therapy following reconstruction is believed to have negative aesthetic outcomes, and increase the need for revision surgery.
Unfavourable beliefs about certain clinical actions do not align with recent provincial guideline recommendations. Insufficient healthcare resources are perceived to be a significant barrier to IBR and timely care.
Therapeutic mammaplasty - Impact on the delivery of chemotherapy
2014, International Journal of Surgery
Citation Excerpt :
However, the clinical significance of this delay has not been established.10 On the contrary, a recent study performed by Doughty et al. compared 95 patients undergoing immediate breast reconstruction following mastectomy with cohorts having breast-conserving surgery and simple mastectomy with no reconstruction, in which no delay to commencement of adjuvant chemotherapy was noted.13 The majority of case series on TM do not comment on the timing of adjuvant treatments.
Therapeutic mammaplasty allows breast conservation and maintains breast cosmesis in women with larger and ptotic breasts. They are associated with more post-operative complications, potentially delaying adjuvant treatment. Our aim is to investigate the impact of therapeutic mammaplasty on the timing of adjuvant chemotherapy, compared with conventional breast conservation surgery.
Retrospective data collection of breast cancer patients undergoing breast-conserving surgery at a single institution from 2009 to 2013.
1000 patients underwent breast-conserving surgery, 40 underwent therapeutic mammaplasty. Patients with a complication of mammaplasty had no delay to starting chemotherapy compared to those without complication (median 36 vs. 40 days). There was no delay to chemotherapy for patients requiring further breast cancer excision surgery following therapeutic mammaplasty compared with standard breast conservation surgery (36 vs. 39 days).
There is no delay in commencing adjuvant chemotherapy following therapeutic mammaplasty surgery, even if there is a complication of surgery. However, patients with involved margins had a significant delay to chemotherapy whilst awaiting re-excision surgery.
No increase of local recurrence rate in breast cancer patients treated with skin-sparing mastectomy followed by immediate breast reconstruction
2013, Breast
The aim of this study was to evaluate the incidence of local recurrence after SSM with IBR and to determine whether complications lead to postponement of adjuvant therapy.
Patients that underwent IBR after SSM between 2004 and 2011 were included.
A total of 157 reconstruction procedures were performed in 147 patients for invasive breast cancer (n = 117) and ductal carcinoma in situ (n = 40). The median follow-up was 39 months [range 6–97]. Estimated 5-year local recurrence rate was 2.9% (95%CI 0.1–5.7). The median time to start adjuvant therapy was 27.5 days [range 19–92] in 18 patients with complications, and 23.5 days [range 8–54] in 46 patients without complications (p = 0.025).
In our single-institution cohort, IBR after SSM carried an acceptable local recurrence rate. Complications caused a delay of adjuvant treatment but this was within guidelines and therefore not clinically relevant.

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Immediate breast reconstruction does not lead to a delay in the delivery of adjuvant chemotherapy

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Br J Plast Surg

Lancet

Breast reconstruction in the UK and Ireland

Br J Surg

Skin-sparing mastectomy: oncologic and reconstructive considerations

Ann Surg

Patients psychological and cosmetic experience after immediate breast reconstruction

Eur J Surg Oncol

The psychological impact of immediate breast reconstruction for women with early breast cancer

Plast Reconstr Surg

Wound complications in patients receiving adjuvant chemotherapy after mastectomy and immediate breast reconstruction for breast cancer

J Surg Oncol