Immediate breast reconstruction uptake in older women with primary breast cancer: systematic review

Is Immediate Breast Reconstruction an Option for Elderly Women? A Comparative Study Between Elderly and Younger Population

OBJECTIVE

To evaluate the incidence of postoperative complications (POC) in elderly patients (EP) compared to younger patients (YP) following immediate breast reconstruction (IBR) after total mastectomy (TM).

METHODS

This retrospective study included patients treated at the Institut Universitaire of Cancer of Toulouse-Oncopole (IUCT-O) between January 2014 and May 2022. The primary outcome was the incidence of POC within 30 days postoperatively. Secondary outcomes included the delay before initiation of adjuvant treatments and re-hospitalization rates.

RESULTS

Elderly patients had a significantly higher rate of POC compared to younger patients, affecting 27.9% of EP and only 14.8% of YP. However, the severity of complications does not differ significantly between YP and EP (69.1% of major POC for YP and 64.7% for EP, P = .6680). Rates of re-hospitalization within 30 days between the 2 groups are similar (67.3% for YP and 61.8% for EP, P = .5962). Most importantly, these complications are not responsible for a delay in initiating adjuvant treatment compared with the younger population. Age ≥ 70 years and obesity (BMI ≥ 30) were identified as independent risk factors for POC.

CONCLUSION

Despite a higher rate of POC, immediate breast reconstruction can be considered for elderly patients, but these patients should be carefully selected and assessed preoperatively to limit the risk of POC.

Cultural Influences on the Receipt of Breast Reconstruction: A Scoping Review

BACKGROUND

Postmastectomy breast reconstruction can provide breast cancer patients with lasting psychosocial, functional, and body image benefits. Although sociodemographic factors affecting the receipt of breast reconstruction have been well studied, the cultural factors influencing patients' decisions to undergo breast reconstruction remain unclear. There are currently no reviews on cultural factors influencing breast reconstruction decision-making. This scoping review aimed to broadly evaluate the current literature on cultural factors that influence the receipt of breast reconstruction in breast cancer patients who have undergone mastectomies.

METHODS

A combination of keywords and subject headings was used to search for articles related to breast reconstruction and decision-making. Databases were searched from inception to November 20, 2023. Screening was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines, and quantitative studies examining the receipt of breast reconstruction in breast cancer patients following mastectomy were evaluated for inclusion.

RESULTS

Of the 4520 studies that were screened, 61 were included in the final review. The majority of studies included in the review were retrospective and performed in the United States. Included studies were evaluated for cultural influences on the receipt of breast reconstruction. Six themes emerged across the included studies: race and ethnicity, language and communication barriers, education and literacy, cultural competency, patient perceptions, and family and relationships.

CONCLUSION

In addition to well-established influences on breast reconstruction such as race and ethnicity, this review broadly identified additional cultural factors that influence patients' decisions to undergo breast reconstruction.

Increasing Rates but Persistent Variability of Immediate Breast Reconstruction: Real-Time Data from a Population-Based Study (2012-2022)

INTRODUCTION

Preserving the breast contour after mastectomy is proven to be beneficial for the quality of life of a large group of patients with breast cancer (BC). The aim of the present study is to provide an up-to-date overview of immediate breast reconstruction (IBR) in hospitals in the Netherlands over the past 10 years.

PATIENTS AND METHODS

Nationwide data of patients with BC who underwent a mastectomy for ductal carcinoma in situ (DCIS) or invasive BC between January 2012 and September 2022 were requested from the Dutch Breast Cancer Audit (NBCA). Primary outcome was the incidence and trend in application of IBR. Secondary outcomes were factors associated with the use of IBR and the variation among Dutch hospitals.

RESULTS

In total, 56,164 patients underwent a mastectomy for DCIS (n = 8334) or invasive BC (n = 47,830) (2012-2022). The use of IBR for DCIS increased from 39 in 2012 to 48% in 2022 (2012-2017; range 0-85% and 2018-2021; range 0-83%). For DCIS, age < 50 years and lower DCIS grade were positively associated with IBR. The use of IBR for invasive BC increased from 16 in 2012 to 29% in 2022 (2012-2017; range 0-74%, 2018-2022; range 0-77%). For invasive BC, age < 40 years, neoadjuvant chemotherapy, and no adjuvant radiotherapy were positively associated with IBR.

CONCLUSION

Despite an overall increase of IBR, national variations remain. Further prospective research is initiated ( www.decidestudie.com ) to investigate this variation, which may lead to a more even distribution of IBR use among hospitals in the Netherlands.

Enhancing breast cancer surgery outcomes: A comprehensive review of oncoplastic techniques, surgical planning, and aesthetic considerations

Breast cancer is one of the most common types of cancer among women in Western countries. Historically treated with radical and modified radical surgeries, breast cancer is now primarily managed with breast-conserving surgery combined with postsurgical radiotherapy. Oncoplastic breast surgery, a technique that integrates aesthetic breast reduction methods with cancer surgery, has been developed as a tumor-specific approach to facilitate breast conservation while removing the tumor. This method allows for higher excision volumes with minimal aesthetic compromise. The main components of oncoplastic surgery are volume displacement and volume replacement techniques. This review discusses the essential role of oncoplastic techniques in breast-conserving surgery (BCS), which has evolved into the standard of care for early-stage breast cancer. Understanding these techniques is critical for all breast surgeons to optimize both aesthetic and oncologic outcomes.

Updates and Future Directions for the Nottingham Research Programme on Primary Breast Cancer in Older Women

The global population is ageing and the risk of breast cancer increases with age. Therefore, we can expect an increase in the number of cases of breast cancer worldwide in the next 20 years. Currently, there are few age-specific guidelines for the management of breast cancer in older women. The International Society of Geriatric Oncology and European Society of Breast Cancer guidelines on this topic were last updated in 2021 and provide some recommendations, although it is worth noting that, generally, the level of evidence pertaining to older women is low. The Nottingham research team on older women with primary breast cancer is working on three main aims in this cohort: (1) understand the unique biological differences between breast cancer in older compared to younger women, (2) explore the unique psycho-social factors that may be present in this population and differ from those found in younger women, as well as how this may influence treatment decisions, and (3) the cost-effectiveness of various treatment strategies in this cohort. This paper will outline key studies published by the Nottingham team in these areas to gather data and highlight future directions for the research group.

Age Impacts Clinical and Patient-Reported Outcomes following Postmastectomy Breast Reconstruction

BACKGROUND

Although the current literature indicates that age should not be a deterring factor in postmastectomy breast reconstruction, the true impact of increasing age on postoperative outcomes remains unknown. The purpose of this study is to understand the impact of age on complications and patient-reported outcomes (PROs) using the BREAST-Q longitudinally 5 years after postmastectomy breast reconstruction.

METHODS

The authors conducted a retrospective analysis of patients who underwent autologous (ABR) or implant-based reconstruction (IBR). Age was studied as both a categorical and a continuous variable. Outcome measures included complications and BREAST-Q scores preoperatively, at 6 months, and 1 to 5 years postoperatively.

RESULTS

A total of 4730 patients were included, of which 1536 (32.5%) underwent ABR and 3194 (67.5%) underwent IBR. Older age was significantly associated with increased risk of developing mastectomy skin flap/nipple necrosis, infection, and seroma. Older age was negatively correlated with Satisfaction with Breasts (β = -0.06 [95% CI, -0.12 to -0.01]; P = 0.033) and positively correlated with Psychosocial Well-being (β = 0.14 [95% CI, 0.09 to 0.20]; P < 0.001). Older age was not correlated with Physical Well-being of the Chest (β = -0.03 [95% CI, 0.08 to 0.02]; P = 0.2) or Sexual Well-being (β = -0.04 [95% CI, -0.12 to 0.02]; P = 0.2). Subgroup analyses of ABR and IBR patients demonstrated different complications and PRO profiles.

CONCLUSIONS

The authors' analysis of the impact of age on surgical outcomes and PROs suggests that complication rates increase with age, and older age is negatively correlated with Satisfaction with Breasts but positively correlated with Psychosocial Well-being. Overall, older patients should be informed about the potential associated risks and anticipated PROs.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Long-term Donor Site-related Quality of Life after Deep Inferior Epigastric Perforator Flap Breast Reconstruction

Background

Current knowledge about patients' perceptions of the donor site following abdominal-based breast reconstruction and its effect on health-related quality of life (HRQoL) several years after breast reconstruction is limited. This study aimed to assess the long-term effects of deep inferior epigastric perforator (DIEP) flap breast reconstruction on HRQoL, specifically focusing on the abdomen and donor site aspects.

Methods

This retrospective cohort study compared 66 women who underwent DIEP breast reconstruction between 2000 and 2007 with a matched control cohort of 114 women who underwent therapeutic mastectomies without reconstruction in the year 2005. The DIEP cohort of patients completed the BREAST-Q Reconstruction module during an outpatient visit in 2015-2016. The control cohort completed the same questionnaire online in 2016.

Results

The follow-up time was at least 8 years (mean 11.4 ± 1.6 years) postreconstruction for the DIEP cohort and 10 years postmastectomy (mean 11.0 ± 0.3 years) for the control cohort. In the DIEP cohort, 93% reported no donor site pain, 89% had no difficulty sitting up, and 91% had no activity limitations 2 weeks before completing the survey. Patients undergoing DIEP were more satisfied with their abdominal appearance than the control group (adjusted OR, 5.7; 95% confidence interval 1.8-17.6).

Conclusions

A decade postoperatively, DIEP breast reconstruction yields high abdominal donor site satisfaction, with comparable abdominal physical well-being to nonreconstructed women.

Oncoplastic breast surgery in older women with primary breast cancer: systematic review

BACKGROUND

Oncoplastic procedures allow excision of larger breast tumours, or unfavourable tumour/breast ratio lesions while achieving a good cosmetic outcome. This increases the pool of patients eligible for breast conservation over mastectomy, reducing the need for more extensive surgery in older women and potentially improving their quality of life. Nonetheless, studies to date suggest a poor uptake of oncoplastic breast surgery in the older group. This review aimed to establish whether a disparity in uptake of oncoplastic breast surgery exists between older and younger women, and to explore the underlying reasons for this.

METHODS

A literature search was conducted on 17 January 2022 using MEDLINE and Embase. Eligible studies comprised full-text articles of patients who underwent oncoplastic breast surgery for primary invasive breast cancer, and included those aged at least 65 years.

RESULTS

Ten published studies were identified. One study was ranked as providing level 2 evidence, and the remainder were level 3. A total of 567 women underwent oncoplastic breast surgery for primary breast cancer, of whom only 61 (10.8 per cent) were aged 65 years or older. None of the studies directly compared younger with older women, or explored the underlying factors contributing to this discrepancy in uptake.

CONCLUSION

This review has demonstrated a lower uptake of oncoplastic breast surgery in older compared with younger women. Given the increasing number of older women living with breast cancer who may be eligible for breast-conserving surgery, further research into this area is required.