Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors

POST-MASTECTOMY RADIATION THERAPY AFTER BREAST RECONSTRUCTION: FROM HISTORIC DOGMAS TO PRACTICAL EXPERT AGREEMENTS BASED ON A LARGE LITERATURE REVIEW OF SURGICAL AND RADIATION THERAPY CONSIDERATIONS

Breast reconstruction (BR) after mastectomy is important to consider for a woman's body image enhancement and psychological well-being. Although post-mastectomy radiation (PMRT) significantly improves the outcome of patients with high-risk breast cancer (BC), PMRT after BR may affect cosmetic outcomes and may compromise the original goal of improving quality of life (QoL). With the lack of practical guidelines, it seems essential to work on a consensus and provide some "expert agreements" to offer patients the best option for PMRT after BR. We report a global "expert agreement" that results from a critical review of the literature on BR and PMRT during the 6th international multidisciplinary breast conference in March 2023.

Three-dimensional Simulation on Patient-reported Outcomes Following Oncoplastic and Reconstructive Surgery of the Breast: A Randomized Trial

Background

Three-dimensional (3D) imaging using computer simulations is an evolving technology. There is a lack of strong data on the use of this technology for oncoplastic (OP) and reconstructive surgery.

Methods

A prospective, randomized, single-center trial including breast cancer patients undergoing OP or mastectomy with immediate breast reconstruction with implant (IBR) enrolled from November 2019 to October 2021 at the Hospital Nossa Senhora das Graças, Breast Unit in Curitiba, Brazil. Both patients undergoing OP and those in the IBR group were randomized to undergo 3D imaging and simulation of postoperative results (intervention group) or 3D imaging without simulation (control group). All patients were invited to complete a patient-reported outcome (BREAST-Q) expectations module and breast reconstruction or reduction/mastopexy module before and 6 months after surgery.

Results

A total of 96 patients were enrolled. Sixty-nine patients (45 OP and 24 IBR) completed the pre- and postoperative questionnaires and were randomized for the simulation. Women in the OP group had higher expectations for breast appearance when clothed than those in the IBR implant group (93.4 ± 16.3 versus 82.9 ± 26.5; P = 0.03). The intervention group was more satisfied with information than the control group (P = 0.021). Both patients who underwent OP and IBR believed that the 3D simulation helped them understand the surgical process (86.6% and 75%, respectively).

Conclusions

Preoperative 3D simulation significantly improved patient's satisfaction with information and did not decrease postoperative satisfaction with the outcomes. The incorporation of preoperative 3D simulation may be a valuable tool in breast reconstruction.

A Novel Artificial Intelligence Model for Symmetry Evaluation in Breast Cancer Patients

INTRODUCTION

Artificial intelligence (AI) is a milestone for human technology. In medicine, AI is set to play an important role as we progress into a new era. In plastic surgery, AI can participate in breast symmetry assessment, which until now has been mainly subjective, allowing for inconsistencies. This study aims to improve this evaluation process by integrating a novel trained neural network with the breast symmetry calculator, BAS-Calc.

MATERIALS AND METHODS

We combined the BAS-Calc tool with a custom-made neural network trained to automatically detect key features of the breast. This integrated system was tested on 81 images of patients who had undergone breast reconstruction post-breast cancer treatment. Its performance was evaluated against two human observers using statistical analysis.

RESULTS

Our model successfully detected 399/405 (98.51%) of landmarks. Spearman and Pearson correlation indicated a strong positive relationship while Cohen's kappa demonstrated moderate to strong agreement between human observers and AI model. Notably, the average calculation time for the AI was 0.92 seconds, 16 times faster than the 14.09 seconds for humans.

CONCLUSIONS

Our AI model successfully calculated breast symmetry from images of patients who had undergone reconstructive oncological breast surgery, demonstrating high correlation with human assessments and a markedly reduced processing time. As AI continues to evolve, it is poised to become a pivotal tool in Medicine. Therefore, it is crucial for medical professionals to proactively engage in implementing AI technologies safely and effectively. Further studies are required to broaden our understanding and maximize the potential benefits in this area. Takeaway bullet points Artificial intelligence (AI) is an upcoming force to be reckoned with. AI should find its way into practical applications in plastic surgery. AI can be applied to improve patient care and evaluate aesthetic results. In this work, we present a novel AI model that automatically evaluates breast symmetry.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Communication and sexual function and frequency in breast cancer patients 2 years after diagnosis: results from the VICAN 2 study

BACKGROUND

Breast cancer treatments may have impacts on several aspects of sexual health, including psychological, psychosexual, physiological, physical, and relational.

AIM

In this study we sought to assess sexual function and sexual frequency in breast cancer patients 2 years after diagnosis.

METHODS

We selected all breast cancer participants from the the French national VIe après le CANcer 2 (VICAN 2) longitudinal study. Data sources included patient and medical questionnaires, along with medico-administrative databases.

OUTCOMES

Outcomes assessed were the dimensions of sexual function and frequency from the Relationship and Sexuality Scale and communication about sexuality with healthcare providers.

RESULTS

Out of 1350 participating women, 60.2% experienced a decrease in sexual desire, 61.4% reported a lower frequency of intercourse, and 49.5% faced decreased ability to orgasm. In contrast, 64.8% had engaged in sexual intercourse in the previous 2 weeks, 89.5% were "Somewhat" to "Very much" satisfied with the frequency of intimate touching and kisses with their partner, and 81.6% expressed satisfaction with their intercourse frequency. However, a mere 15% of women discussed sexuality with the healthcare providers. Independent factors associated with increased communication about sexuality included age younger than 50 years (OR = 1.90 95% CI [1.28-2.82], P = .001), being in a partner relationship (OR = 2.53 95% CI [1.28-2.82], P = .003), monthly income above 1,500 euros (OR = 1.73 95% CI [1.15-2.60], P = .009), and absence of diabetes (OR = 6.11 95% CI [1.39-26.93], P = .017).

CLINICAL TRANSLATION

The study findings underscore the need for continuing education in oncosexology and dedicated sexual health interventions that should involve a holistic approach that takes into consideration age, treatments, relationship status, and whether the patient has diabetes.

STRENGTHS AND LIMITATIONS

Strengths of the study are the sample size, the national representativeness, and data reliability. However, the cross-sectional design could introduce potential recall, recency, or social desirability biases. Also, social determinants influencing sexual health, such as ethnicity or geographic locations, have not been considered in the analyses.

CONCLUSIONS

This study revealed that sexual disorders persist 2 years after a breast cancer diagnosis, with a noticeable communication gap regarding sexuality between patients and medical teams. These findings underscore the necessity for tailored sexual health interventions, particularly designed for women who are single, older aged, and diabetes patients.

Head-to-Head Analysis of Vertical vs Horizontal Incision Patterns in Breast Reconstruction: Surgical Outcomes and Aesthetic Implications

BACKGROUND

Modern aesthetically optimized breast reconstruction requires collaboration between the patient, breast surgeon, and plastic surgeon. To optimize both surgical outcome and aesthetic results, incision patterns must be carefully planned.

OBJECTIVES

We aimed to determine whether vertical or horizontal orientation of mastectomy incision was preferred in the general population and to analyze corresponding complication profiles.

METHODS

A retrospective review was performed of all patients undergoing bilateral mastectomy followed by autologous breast reconstruction utilizing either vertical or horizontal incision from January 2011 to November 2022. Postoperative complications of the 2 incision patterns were analyzed. Additionally, crowdsourcing was utilized to assess aesthetic implications of horizontal and vertical incision patterns on postoperative pictures of completed breast reconstruction. Survey rater demographics were also analyzed to assess differences in scoring based on voter characteristics.

RESULTS

There were no significant differences in postoperative breast complications between patients with horizontal or vertical incisions when considering wound, infection, seroma, hematoma, fat necrosis, or overall complications (P > .05). Crowdsourcing showed that, regardless of voter demographics, vertical incisions were preferred over horizontal incisions (P < .001). Additionally, voters who knew someone who had undergone breast reconstruction were more likely to rate all incision patterns higher than other voters (P < .001).

CONCLUSIONS

Although there are no significant differences in complication profiles between vertical and horizontal incisions in autologous breast reconstruction patients, vertical incision patterns are preferred aesthetically by the general population.

LEVEL OF EVIDENCE: 4

Examining hypertension risk among Black and White breast cancer survivors

PURPOSE

Breast cancer survivors are at increased risk of cardiovascular dysfunction following their diagnosis; however, hypertension remains underexplored within this context. This retrospective cohort study examined the incidence of hypertension in breast cancer survivors and the association of race with hypertension risk among them.

METHODS

Data for this study were abstracted from the electronic health records of women diagnosed with Stages I-III breast cancer. Incident hypertension diagnosis was identified through International Classification of Diseases codes. Bivariate associations were tested using Student's t-test and chi-squared test of independence. Bivariable Cox regression analysis was used to determine demographic and clinical factors that may have been associated with the development of hypertension.

RESULTS

A total of 664 women were included. Most women were 50 years of age or younger (52.0%), White (33.0% Black), and received a mastectomy (80.6%). Overall, 45.5% of the cohort developed hypertension. The 1-year hypertension-free survival estimates were 47% (95% confidence interval [CI], 41-54) in Black women and 73% (95% CI, 69-77) in White women (p < 0.0001). Besides race, statistically significant predictors of hypertension included: age greater than 50 (vs. ≤50) (adjusted Hazard Ratio [HR]: 1.40; 95% CI, 1.09-1.80) and residing in a non-metropolitan area (vs. metropolitan) (adjusted HR: 1.60; 95% CI, 1.19-2.16).

CONCLUSIONS

This study suggests that breast cancer survivors who are older, Black, or residing in non-metropolitan areas may benefit from added surveillance and hypertension prevention strategies during treatment. Future studies are needed to identify contributors to the observed racial and geographic disparities.

Long-term quality of life after treatment in sinonasal malignancy: A prospective, multicenter study

BACKGROUND

Quality of life (QOL) for individuals with sinonasal malignancy (SNM) is significantly under-studied, yet it is critical for counseling and may impact treatment. In this study we evaluated how patient, treatment, and disease factors impact sinonasal-specific and generalized QOL using validated metrics in a large cohort over a 5-year posttreatment time frame.

METHODS

Patients with SNM who underwent definitive treatment with curative intent were enrolled in a prospective, multisite, longitudinal observational study. QOL was assessed using the 22-item Sino-Nasal Outcome Test (SNOT-22) and University of Washington Quality of Life Questionnaire (UWQOL) instruments at pretreatment baseline and multiple follow-ups through 5 years posttreatment. Multivariable modeling was used to determine demographic, disease, and treatment factors associated with disease-specific and generalized physical and social/emotional function QOL.

RESULTS

One hundred ninety-four patients with SNM were analyzed. All QOL indices were impaired at pretreatment baseline and improved after treatment. SNOT-22 scores improved 3 months and UWQOL scores improved 6 to 9 months posttreatment. Patients who underwent open compared with endoscopic tumor resection had worse generalized QOL (p < 0.001), adjusted for factors including T stage. Pterygopalatine fossa (PPF) involvement was associated with worse QOL (SNOT-22, p < 0.001; UWQOL Physical dimension, p = 0.02). Adjuvant radiation was associated with worse disease-specific QOL (p = 0.03). Neck dissection was associated with worse generalized physical function QOL (p = 0.01). Positive margins were associated with worse generalized social/emotional function QOL (p = 0.01).

CONCLUSION

Disease-specific and generalized QOL is impaired at baseline in patients with SNM and improves after treatment. Endoscopic resection is associated with better QOL. PPF involvement, adjuvant radiation, neck dissection, and positive margins were associated with worse QOL posttreatment.

Racial Disparities in Breast Reconstruction at a Comprehensive Cancer Center

INTRODUCTION

Breast reconstruction after a mastectomy is an important component of breast cancer care that improves the quality of life in breast cancer survivors. African American women are less likely to receive breast reconstruction than Caucasian women. The purpose of this study was to further investigate the reconstruction disparities we previously reported at a comprehensive cancer center by assessing breast reconstruction rates, patterns, and predictors by race.

METHODS

Data were obtained from women treated with definitive mastectomy between 2000 and 2012. Sociodemographic, tumor, and treatment characteristics were compared between African American and Caucasian women, and logistic regression was used to identify significant predictors of reconstruction by race.

RESULTS

African American women had significantly larger proportions of public insurance, aggressive tumors, unilateral mastectomies, and modified radical mastectomies. African American women had a significantly lower reconstruction rate (35% vs. 49%, p < 0.01) and received a larger proportion of autologous reconstruction (13% vs. 7%, p < 0.01) compared to Caucasian women. The receipt of adjuvant radiation therapy was a significant predictor of breast reconstruction in Caucasian but not African American women.

CONCLUSIONS

We identified breast reconstruction disparities in rate and type of reconstruction. These disparities may be due to racial differences in sociodemographic, tumor, and treatment characteristics. The predictors of breast reconstruction varied by race, suggesting that the mechanisms underlying breast reconstruction may vary in African American women. Future research should take a target approach to examine the relative contributions of sociodemographic, tumor, and treatment determinants of the breast reconstruction disparities in African American women.

Sexual Function in Women with Breast Cancer: An Evidence Map of Observational Studies

Breast cancer (BC) is the leading cause of cancer in women, and has implications for sexual function (SF). In this study, we used an evidence map to identify, describe, and organise the current available evidence regarding SF in women with BC. We searched the MEDLINE, PsycINFO, and CINAHL databases for observational studies assessing SF in women with BC published in English, Spanish, Portuguese, and French between 2000 and 2021 (sample ≥ 50 women). Of the 64 included studies (13,257 women with BC), 58 were published since 2010. Women who were married, partnered, or in relationships represented 74.1% of the entire sample. Only a single study was conducted on women representing a sexual minority. We identified 22 assessment instruments and 40 sexual dysfunction (SdF) domains. The number of publications on SF in women with BC has increased in the last 10 years, but still remains low. Some groups of women are underrepresented, and some SdF domains are underdiagnosed, with the assessment instrument used affecting which domains are studied. Women with BC need to be better screened, as their quality of life (QoL) is affected by SdF.

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

BACKGROUND

Postmastectomy immediate breast reconstruction (PMIBR) may improve the quality of life of patients with breast cancer, of whom older women (aged 65 years or more) are a growing proportion. This study aimed to assess PMIBR in older women with regard to underlying impediments (if any).

METHODS

MEDLINE, Embase, and PubMed were searched by two independent researchers up to June 2022. Eligible studies compared PMIBR rates between younger and older women with invasive primary breast cancer.

RESULTS

A total of 10 studies (2012-2020) including 466 134 women were appraised, of whom two-thirds (313 298) were younger and one-third (152 836) older. Only 10.0 per cent of older women underwent PMIBR in contrast to 45.0 per cent of younger women. Two studies explored factors affecting uptake of PMIBR in older women; surgeon-associated (usual practice), patient-associated (socioeconomic status, ethnicity, and co-morbidities), and system-associated (insurance status and hospital location) factors were identified.

CONCLUSION

Uptake of PMIBR in older women is low with definable (and some correctable) barriers.

Clinical and sociodemographic determinants of disease-specific health-related quality of life in long-term breast cancer survivors

PURPOSE

It is important to monitor disease-specific health-related quality of life (HRQoL) in breast cancer (BC) survivors to identify potential unmet supportive care needs. However, previous studies were characterized by small samples of mostly short-term survivors and were limited to certain age ranges, stages and/or treatments.

METHODS

We used data from 3045 long-term BC survivors (5-15 years post-diagnosis) recruited in a German multi-regional population-based study. We assessed disease-specific HRQoL with the EORTC QLQ-BR23, scoring from 0 to 100. Differences in functioning and symptoms according to age at survey, self-reported treatments, stage, and disease status (disease-free vs. active disease) were assessed with multiple regression. Active disease was defined as any self-report of recurrence, metastasis or second primary cancer after the index cancer.

RESULTS

Older BC survivors reported a higher body image and a better future perspective, but lower sexual functioning. Survivors aged 30-49 years who had breast-conserving therapy or mastectomy with breast reconstruction reported a better body image compared to those who had mastectomy only. We also found differences in symptoms according to treatments in some age groups. Stage at diagnosis was not associated with HRQoL overall and in most age subgroups. Disease-free BC survivors aged 30-79 years reported a better future perspective and less systemic therapy side effects than those with active disease.

CONCLUSION

Several treatment-associated symptoms and functioning detriments were found 5-15 years after diagnosis. The results emphasize the need of a comprehensive, individualized survivorship care, recognizing differential needs of long-term BC survivors according to age, treatment modalities, and disease status.

A Novel Validated Breast Aesthetic Scale

BACKGROUND

Breast aesthetics impacts patients' quality of life after breast reconstruction, but patients and surgeons frequently disagree on the final aesthetic evaluation. The need for a comprehensive, validated tool to evaluate breast aesthetics independently from the patient motivated this study.

METHODS

The 13-item Validated Breast Aesthetic Scale was developed after several internal meetings, and worded to be understood by a nonspecialist. Three items are common for both breasts, with the remaining being side-specific. To test the internal consistency of the scale subitems, postoperative photographs after different breast reconstruction techniques were graded by a six-member panel. To test interrater and intrarater correlation across time, four physicians evaluated the results of abdominally based breast reconstructions following nipple-sparing mastectomies.

RESULTS

Graded aesthetic outcomes of 53 patients showed that the Cronbach alpha of the subitems of the scale was 0.926, with no single item that, if excluded, would increase it. Twenty-two patients underwent aesthetic outcomes grading at four different time points. The mean overall appearance was 3.71 ± 0.62. The mean grade for overall nipple appearance was 4.0 ± 0.57. The coefficient alpha of the panel overall aesthetic grade across different time points was 0.957; whereas intragrader reliability for graders 1 through 4 individually showed alpha coefficients of 0.894, 0.9, 0.898, and 0.688, respectively. Similar results were found for the other items of the scale.

CONCLUSIONS

The proposed aesthetic scale evaluates different aspects of the breast reconstruction aesthetic result with excellent internal consistency among its subitems. Grading by a gender-balanced, diverse four-member panel using postoperative photographs showed higher reliability and reproducibility compared to single graders.

Psychological Impact of Type of Breast Cancer Surgery: A National Cohort Study

Background

The present study assessed the impact of different types of breast surgery on rates of psychological disorders in breast cancer patients.

Methods

This nationwide cohort study, based on Korean Health Insurance Review and Assessment Service claims data, included 26,259 breast patients who underwent surgery from June 1, 2017, to December 31, 2018. Associations between the incidence of psychological disorders and variables were evaluated by time dependent Cox regression analyses.

Results

Of the 26,259 patients, 9394 (35.8%) underwent total mastectomy (TM) and 16,865 (64.2%) underwent partial mastectomy (PM); of the former, 4056 (43.2%) underwent breast reconstruction surgery (RS). A total of 4685 patients (17.84%) were newly diagnosed with psychological disorders after surgery. Multivariable analysis showed that axillary lymph node dissection was significantly associated with increased rates of overall psychological disorders (p < 0.0001), depression (p = 0.0462), anxiety (p < 0.0001) and insomnia (p < 0.0001). The rates of overall psychological disorders (p = 0.0002) and insomnia (p = 0.01) were significantly lower in patients who underwent TM than PM. RS tended to associated with reduced rates of overall psychological disorders in patients who underwent TM. Subgroup analysis showed that, compared with PM, RS after TM significantly associated with a reduced incidence of overall psychological disorders and insomnia in younger patients (< 50 years) and those who underwent sentinel lymph node biopsy.

Conclusion

In contrast to general belief, rates of overall psychological disorders and insomnia were lower in patients who underwent TM than PM. Moreover, RS after TM confers psychological benefit in younger patients with early stage breast cancer compared with PM.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06585-y.

Sexual Well-Being After Nipple-Sparing Mastectomy: Does Preservation of the Nipple Matter?

INTRODUCTION

The primary aim of this study was to evaluate patient-reported outcome measures in patients undergoing mastectomy with and without breast reconstruction (immediate or delayed) with and without nipple preservation.

METHODS

All female patients undergoing mastectomy between 2011 and 2015 at Mayo Clinic Rochester were identified and were mailed the BREAST-Q survey. Breast satisfaction, psychosocial well-being, and sexual well-being were evaluated and compared by surgery type using Wilcoxon rank-sum tests for univariate analysis and linear regression for multivariable analysis adjusting for potential confounders.

RESULTS

Of 1547 patients, 771 completed the BREAST-Q survey (response rate 50%). Of these 771 respondents, 237 (31%) did not have reconstruction, 198 (26%) had nipple-sparing mastectomy with reconstruction (NSM), and 336 (44%) had skin-sparing mastectomy with reconstruction (SSM) ± nipple-areolar complex (NAC) reconstruction (via surgery ± tattoo). Patients with breast reconstruction had consistently higher BREAST-Q scores versus those without. Comparing NSM with all SSMs, there was no difference in satisfaction with breasts (mean 71.8 vs. 70.2, p = 0.21) or psychosocial well-being (mean 81.9 vs. 81.3, p = 0.47); however, sexual well-being was significantly higher in the NSM group on univariate (mean 64.5 vs. 58.0, p = 0.002) and multivariable (β = -4.69, p = 0.03) analysis. Sexual well-being scores were similar for NSM and the SSM subgroups with any type of NAC reconstruction.

CONCLUSIONS

This study demonstrates that NSM positively impacts patient sexual well-being after breast reconstruction compared with SSM, particularly SSM without nipple reconstruction or tattoo. SSM with any type of NAC reconstruction achieved similar satisfaction and sexual well-being to those undergoing NSM.

Comparative UK Cross-sectional Study of Breast Cancer Patient-Reported Outcomes for Breast-Conserving Surgery and Immediate Reconstruction, Including Contribution to an International Collaborative Pilot Study

INTRODUCTION

Breast-conserving surgery (BCS) with adjuvant radiotherapy is oncologically comparable to mastectomy with immediate breast reconstruction (IBR) in treating breast cancer. This tertiary UK centre cross-sectional study compared BCS patient-reported outcomes with those of immediate implant-based (IBR) and free flap reconstruction (FFR), and included a contribution to a pilot international collaboration co-ordinated through the Organisation for Economic Cooperation and Development (OECD).

METHODS

Validated BREAST-Q™ 'satisfaction with breasts' modules were administered to 271 consecutive patients for six months after unilateral BCS, IBR, or FFR were conducted between June and October 2018. Risk adjustment data were collected on age, body mass index, smoking, radiotherapy, specimen weight, and tumour burden.

RESULTS

A total of 190 women returned completed questionnaires (131 BCS, 42 IBR, 17 FFR; 70% response rate). BCS scores (mean 68, standard deviation (SD) 23) were higher than those for IR overall (62, SD 23, p=0.04) and IBR (61, 24, p=0.03) but equivalent to those for FFR (66, SD 23, p=0.33). There was no significant difference in Q-Scores between the IBR and FFR groups (p=0.77). Scores were only minimally changed by risk adjustment and comparable to OECD mean international scores for IBR (61) and FFR (66).

CONCLUSIONS

This is the first study to compare BCS and IR outcomes using a validated scale. BREAST-Q™ 'satisfaction with breasts' scores were comparable between BCS and FFR but significantly lower following IBR.

Systematic Review of Breast-Q: A Tool to Evaluate Post-Mastectomy Breast Reconstruction

Purpose

The aim of this systematic review is to update and synthesize new evidence on BREAST-Q questionnaire’s ability to reflect patient-reported outcomes in women who have undergone breast reconstruction surgery (BRS) following mastectomy.

Methods

PubMed, Science Direct, Google Scholar, Cochrane CENTRAL, and Clincaltrial.gov were searched for relevant studies from January 2009 to September 2021. Any interventional or observational studies that used BREAST-Q to assess patient-reported outcomes in the assessment of BRS following mastectomy were included.

Results

A total of 42 studies were eligible for inclusion in the review. Three were randomized controlled trials and 39 were observational studies. Compared with pre-operative scores, there was an improvement in all BREAST-Q outcome domains following BRS including ‘satisfaction with breasts’, “satisfaction with outcome” “psychosocial”, “physical”, and “sexual wellbeing”. Sexual well-being had the lowest BREAST-Q score both pre-and post-operatively (37.8–80.0 and 39.0–78.0, respectively). Autologous BRS reports higher satisfaction and overall wellbeing compared to implant-based BRS. BREAST-Q has a higher and narrow internal consistency of 0.81 to 0.96 compared with other patient-reported outcome measures (PROMs; EORTC-QLQ, FACT-B, BR-23, BCTOS). The BREAST-Q questionnaire is the only PROM which allows patients to reflect on their care, surgical outcomes, and satisfaction collectively.

Conclusion

This review highlights the fact that BREAST-Q can effectively and reliably measure satisfaction and wellbeing of breast cancer patients after BRS. Comparatively, sexual wellbeing shows poorer outcomes following BRS and more longitudinal studies are necessary to understand the basis for these findings. Compared to other PROMs, BREAST-Q is reliable and specific to breast cancer surgery. Overall, BREAST-Q can help clinicians improve their quality of service, understand patient experiences, and may be used as an auditing tool for surgical outcomes.

Association of Local Therapy With Quality-of-Life Outcomes in Young Women With Breast Cancer

Importance

Increasing rates of bilateral mastectomy have been most pronounced in young women with breast cancer, but the association of surgery with long-term quality of life (QOL) remains largely unknown.

Objective

To examine the association of surgery with longer-term satisfaction and QOL in young breast cancer survivors.

Design, Setting, and Participants

This multicenter cross-sectional study of a prospective cohort was conducted from October 2016 to November 2017, at academic and community hospitals in North America. Women 40 years or younger enrolled in the Young Women's Breast Cancer Study were assessed. Data analysis was performed from during a 1- to 2-year period after conclusion of the study.

Exposures

Primary breast surgery, reconstruction, and radiotherapy.

Main Outcomes and Measures

Mean BREAST-Q breast satisfaction and physical, psychosocial, and sexual well-being scores were compared by type of surgery; higher BREAST-Q scores (range, 0-100) indicate better QOL. Linear regression was used to identify demographic and clinical factors associated with BREAST-Q scores for each domain.

Results

A total of 560 women with stage 0 to III breast cancer (median age at diagnosis, 36 years; range, 17-40 years; 484 [86%] with stage 0-II disease) completed the BREAST-Q a median of 5.8 years (range, 1.9-10.4 years) from diagnosis. A total of 290 patients (52%) of patients underwent bilateral mastectomy, 110 patients (20%) underwent unilateral mastectomy, and 160 patients (28%) received breast-conserving therapy. Among mastectomy patients, 357 (89%) had reconstruction and 181 (45%) received radiotherapy. In multivariate analyses, implant-based reconstruction (vs autologous) was associated with decreased breast satisfaction (β = -7.4; 95% CI, -12.8 to -2.1; P = .007) and complex reconstruction (vs autologous) with worse physical well-being (β = -14.0; 95% CI, -22.2 to -5.7; P < .001).

Conclusions and Relevance

These results suggest that local therapy in young breast cancer survivors is persistently associated with poorer scores in multiple QOL domains, particularly among those treated with mastectomy and radiotherapy, irrespective of breast reconstruction. Socioeconomic stressors also appear to play a role.

Translating Access to Outcomes: The Impact of Socioeconomic Status on Completion of Breast Reconstruction at a National Cancer Institute (NCI)-Designated Cancer Center: Impact of SES on Completion

The purpose of this study was to determine the impact of socioeconomic status (SES) on the completion of breast reconstruction, as defined by the percent of patients undergoing NAC reconstruction. Patients (n=949) who underwent primary breast reconstruction following a mastectomy recorded from 2007 to 2017 were divided into groups based on the median household income of their residential zip code (>/< $67,640). A three-step protocol was designed to (1) broadly compare between patients of low and high SES who were stratified by race and reconstruction type, (2) compare a smaller subset of low SES and high SES patients via propensity matching for demographic, baseline health, and oncologic factors, and (3) elucidate the strongest predictors of non-completion and delayed completion among low SES patients. Patients of lower SES appear less likely to complete NAC reconstruction, especially following staged reconstruction. That this finding presents in staged, but not immediate reconstruction, and disappears with propensity matching for oncologic factors suggests that reduced completion in patients of low SES may be attributable to advanced cancer staging and aggressive adjuvant therapy. Furthermore, expander conversion to autologous reconstruction significantly increased the likelihood of NAC reconstruction in multivariable analysis, and adjuvant radiation therapy significantly increased the time to NAC reconstruction. Further investigation will solidify the relationship between SES, cancer staging, and completion of reconstruction in a multi-site patient population. Larger multivariable analyses may also uncover other factors that can be modified or addressed to increase completion and optimize reconstruction for patients at risk of discontinuation.

Association of Clinical Complications of Chemotherapy and Patient-Reported Outcomes After Immediate Breast Reconstruction

Importance

Women undergoing immediate breast reconstruction often require chemotherapy. The effects of chemotherapy on reconstruction are not well described.

Objective

To evaluate the association of neoadjuvant and adjuvant chemotherapy with complications and patient-reported outcomes (PROs) in immediate reconstruction.

Design, Setting, and Participants

The Mastectomy Reconstruction Outcomes Consortium Study is a cohort study that prospectively assessed PROs and retrospectively evaluated complications in patients undergoing immediate implant-based or autologous reconstruction at 11 centers from January 1, 2012, to December 31, 2017. Women 18 years or older undergoing immediate reconstruction after mastectomy with 2 years of follow-up were included. Patients were excluded if they had prophylactic mastectomy; delayed reconstruction; mixed-timing reconstruction; mixed reconstruction; a latissimus dorsi, superior gluteal artery perforator, or inferior gluteal artery perforator flap; or both neoadjuvant and adjuvant chemotherapy. Data were analyzed from May 1 to June 30, 2018.

Main Outcomes and Measures

Complications and PROs (satisfaction with breast and physical, psychosocial, and sexual well-being) using the BREAST-Q questionnaire, a validated, condition-specific PRO measure. Baseline patient characteristics were collected.

Results

A total of 1881 women were included in the analysis (mean [SD] age, 49.9 [9.9] years). Of these, 1373 (73.0%) underwent implant-based procedures; 508 (27.0%), autologous reconstruction; 200 (10.6%), neoadjuvant chemotherapy; 668 (35.5%), adjuvant chemotherapy; and 1013 (53.9%), no chemotherapy. Patients without chemotherapy were significantly older (mean [SD] age, 51.6 [9.4] years; P < .001), and patients with chemotherapy were more likely to have received radiotherapy (108 of 200 [54.0%] for neoadjuvant chemotherapy and 321 of 668 [48.1%] for adjuvant chemotherapy; P < .001). Among the cohort undergoing implant-based reconstruction, the rates of any complication were significantly different, with higher rates seen for adjuvant (153 of 490 [31.2%]) and neoadjuvant (44 of 153 [28.8%]) chemotherapy compared with no chemotherapy (176 of 730 [24.1%]; P = .02). On multivariable analysis, these differences were not statistically significant. For autologous reconstruction, no significant differences in complications were observed. Controlling for clinical covariates, no significant differences were seen across chemotherapy groups for the BREAST-Q subscales except for sexual well-being in the implant cohort, in which adjuvant chemotherapy had significantly lower scores (β, -4.97 [95% CI, -8.68 to -1.27]; P = .009).

Conclusions and Relevance

In this cohort study, neither neoadjuvant nor adjuvant chemotherapy was associated with the likelihood of complications in patients undergoing implant-based or autologous reconstruction, and chemotherapy was not associated with patient satisfaction with reconstruction or psychosocial well-being. This information can help patients and clinicians make informed decisions about breast reconstruction in the setting of chemotherapy.

Breast Cancer Treatment Following Health Reform: Evidence From Massachusetts

There are well-documented differences in breast cancer treatment by insurance status. Insurance expansions provide a context to assess the relationship between insurance and patterns of breast cancer care. We examine the association of Massachusetts health reform with use of breast conserving surgery, reconstruction, and adjuvant radiation using data from the Massachusetts Cancer Registry and Surveillance Epidemiology and End Results registries for 2001-2013 and a difference-in-differences approach. We observe statistically significant increases in breast conserving surgery among nonelderly women in Massachusetts relative to trends in states and age groups not affected by health reform. We also observe relative increases in reconstruction and adjuvant radiation, though trends in these outcomes were not the same across states prior to reform, limiting our ability to draw conclusions about the relationship between reform and these outcomes. Our results suggest that health reform was associated with some improvements in breast cancer treatment.

Autologous Breast Reconstruction Trends in the United States: Using the Nationwide Inpatient Sample Database

BACKGROUND

Autologous tissue is the criterion standard in breast reconstruction, but traditionally has been used as a secondary option after implant-based options because of reduced reimbursement relative to effort and required additional technical skill. We intended to evaluate the overall frequency and trends of autologous breast reconstruction (ABR), the trends of ABR in teaching versus nonteaching hospitals and the trends of ABR in different hospital regions in the United States.

METHODS

Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent immediate or delayed ABR from 2009 to 2016 in the United States.

RESULTS

A total of 146,185 patients underwent ABR during this period. The overall rate of ABR increased 112%, from 26.6% to 56.5%. The majority of ABR were delayed reconstructions (62.3%), which increased gradually from 54.9% to 80% during the study period. The overall frequency of flaps included the deep inferior epigastric perforator (32.1%), latissimus dorsi myocutaneous (28.4%), free transvers rectus abdominus myocutaneous (15.9%), pedicled transvers rectus abdominus myocutaneous flap (14.5%), gluteal artery perforator (0.6%), superficial inferior epigastric artery (0.6%), and unspecified-ABR (7.2%). Most ABRs were performed in teaching hospitals (78.6%) versus nonteaching hospitals (21.4%). The teaching hospitals' ABR rate increased from 70.5% to 88.7%. The greatest proportion of ABRs were performed in the south (39.6%) followed by northeast (23.0%), midwest (18.9%), and west (18.5%).

CONCLUSIONS

The deep inferior epigastric perforator flap has become the predominant ABR method in the United States. In addition to more delayed reconstructions being performed in recent years, ABR rates are increasing overall and shifting from pedicled flaps to free flaps.

Immediate breast reconstruction using latissimus dorsi muscular flap: A retrospective study of Chinese patients with breast cancer

Reconstruction of breast defects of patients who underwent mastectomy can be challenging. This study was designed to review a series of 43 breast cancer patients who underwent immediate breast reconstruction (IBR) using the latissimus dorsi myocutaneous flap with/without implants. The demographic characteristics, clinical application feasibility, and the satisfaction rates of the patients were retrospectively collected and evaluated.A total of 43 breast cancer patients who underwent mastectomy between August 2015 and February 2020 were included in the retrospective study. The included patients were subjected to IBR using latissimus dorsi muscular flap (LDMF) with/without implants. The clinical application feasibility and the satisfaction rates of the patients were evaluated.Among these patients, 35 patients underwent nipple-sparing mastectomy and 8 patients underwent skin-sparing mastectomy. Twenty-nine patients underwent IBR using LDMF with implants, and 14 patients underwent IBR using LDMF without implants. Among these patients, 2 patients had partial LDMF necrosis and atrophy, and showed significant shrink of the reconstructed breast. One patient developed seromas, and seromas were improved by active dressing change and sucking out the fluid via the skin using a syringe. Two patients had local skin flap necrosis on the chest, 1 patient had preserved areola and local necrosis of the nipple, and this was healed after dressing change. Based on the Harris method, 27, 9, 5, and 2 cases were evaluated as "excellent," "good," "fair," and "poor," respectively.In the present study, the reconstructed breast has natural shape, good symmetry, and hidden postoperative scars. The aesthetic effect is relatively good, and the use of LDMF may represent an acceptable and valid option for IBR. The success of this procedure depends on the design of the incision, the skill and proficiency of the operation, as well as the correct treatment after surgery.

Impact of Breast Reconstruction Patients on Cosmetic Practice

Postmastectomy breast reconstruction can often restore a patient's self-image. A notable percentage of women will go on to seek elective aesthetic procedures to further improve their perceived appearance. The purpose of this study was to determine the percentage of primary breast reconstruction patients who go on to receive a cosmetic procedure. We identify factors that may increase the likelihood that a patient subsequently chooses to pursue a cosmetic procedure.

Methods

A retrospective review of primary breast reconstruction patients of the two senior authors was conducted from January 2014 through December 2015. Demographics, types of cosmetic procedures received, and time to first cosmetic procedure were obtained. Time to first cosmetic procedure was assessed from date of mastectomy through December 2017. Logistic regression was performed to identify factors associated with obtaining cosmetic procedures.

Results

There were 289 patients in our cohort with ~10% who subsequently sought a cosmetic procedure at our practice. The average time to conversion was ~9 months after mastectomy. The majority (67%) underwent noninvasive procedures only. Patients with lower-staged breast cancers were more likely to undergo a cosmetic procedure (P < 0.042).

Conclusions

At least 10% of patients undergoing primary breast reconstruction over a year period went on to have a cosmetic procedure during the study period. The majority of patients pursued noninvasive cosmetic procedures. Reconstruction of women with higher cancer stages was associated with a lower likelihood of pursuing a cosmetic procedure during the time period studied.

Muscle-Sparing Skin-Reducing Breast Reconstruction with Pre-Pectoral Implants in Breast Cancer Patients: Long-Term Assessment of Patients' Satisfaction and Quality of Life

INTRODUCTION

Breast cancer is the most frequently diagnosed tumor in women; globally, it accounts 23% of all cancer deaths. Breast reconstruction after oncologic surgery has become crucial to enhance patients' quality of life and alleviate the psychological distress related to the disease. The aim of this study was to assess quality of life and esthetic satisfaction of breast cancer patients undergoing muscle-sparing skin-reducing breast reconstruction (MS-SR) with pre-pectoral implants.

METHODS

Sixty-three patients who met definite oncological and reconstructive criteria were enrolled in the study. Specific questionnaires (EORTC QLQ-C30, QLQ-BR23) were administered preoperatively, 1, and 12 months after MS-SR breast reconstruction to evaluate patients' QoL. Satisfaction with procedure and related Quality of Life were assessed through BREAST-Q questionnaire preoperatively and 12 months after surgery.

RESULTS

Sixty-three breast cancer patients underwent MS-SR. Seventy-eight procedures were carried out; in 15 patients a bilateral reconstruction was performed. One month after surgery, both EORTC QLQ-C30 and QLQ-BR23 average scores demonstrated a slight drop since preoperative values, but a significant improvement in QoL was documented 12 months after BR (p < 0.05). BREAST-Q test showed significant psychophysical and esthetic satisfaction 12 months postoperatively.

CONCLUSIONS

Muscle-sparing skin-reducing breast reconstruction is an established and reliable technique. EORTC QLQ-C30, QLQ-BR23 and BREAST-Q scores showed an improvement of patients' QoL and esthetic satisfaction. Reduction of pain and other surgery-related symptoms are cornerstones of patient well-being. Both physicians and patients should build a thorough awareness of the silver lining of muscle-sparing skin-reducing breast reconstruction based on the high safety profile and highly satisfactory patient-reported results.

Comparing the effect of distance to treatment facility on reconstruction and breast conservation therapy for early-stage invasive ductal carcinoma between the nation and the mountain region

BACKGROUND

Our objective is to evaluate the effect of distance to facility on the use of breast conservation therapy and reconstruction for early stage breast cancer.

METHODS

Utilizing the National Cancer Database, we identified females, age <65, with Stage I invasive ductal carcinoma from 2004 to 2015. Using logistic regression, we compared radiation, mastectomy, and reconstruction treatment patterns. A subgroup analysis was performed within the mountain region (MR).

RESULTS

Nationwide, there are decreasing odds of radiation, increasing odds of mastectomy, and increasing odds of reconstruction. Patients living farther were less likely to receive radiation, more likely to undergo mastectomy, with no effect on reconstruction. Within the MR, patients living farther from their facility were less likely to receive radiation, more likely to undergo mastectomy, however, they were less likely to undergo reconstruction.

CONCLUSIONS

Nationwide and within the MR, patients living farther from their facility are less likely to receive radiation and more likely to undergo mastectomy. There is a disparity between the MR and the nation in use of reconstruction for this population.

Cosmetic outcomes following wide local excision of impalpable breast cancer: is radioguided occult lesion localization using iodine-125 seeds better than hookwire localization?

BACKGROUND

Hookwire localization (HWL) is the gold standard for localizing impalpable tumours for breast conserving surgery. An alternative technique, radioguided occult lesion localization using iodine-125 seeds (ROLLIS), has been associated with lower re-excision rates. This paper investigates if cosmetic outcomes differ in women undergoing breast conserving surgery with HWL or ROLLIS.

METHODS

Women who had ROLLIS or HWL guided excision for impalpable breast cancer within a multicentre randomized controlled trial (RCT) (ANZCTR 12613000655741) were recruited. Exclusions were level 2 oncoplasty and mastectomy. Cosmetic outcome was calculated using BCCT.core, the Hopwood Body Image Scale and estimated percentage breast volume excised. Chi-squared analysis was used to determine the difference between the intervention groups.

RESULTS

Analysis was performed for 123 participants (66 ROLLIS and 57 HWL). The cosmetic outcome determined by BCCT.core for all participants was good with no significant difference between the ROLLIS and HWL groups. When reviewing the number of patients who experienced either a good or excellent result, there was a significantly higher number of patients in the ROLLIS group (n = 53, 82%) compared to the HWL group (n = 42, 74%, P = 0.02. There were no differences in Hopwood Body Image Scale or estimated percentage breast volume excised between groups. There was a reduction in the frequency of re-excision in the ROLLIS group (n = 3, 4.5%) versus HWL group (n = 8, 14%); however, this was not significant (P = 0.06).

CONCLUSION

Pre-operative localization of impalpable breast lesions using either ROLLIS or HWL resulted in a good cosmetic outcome with no significant difference between localization techniques.

Breast Reconstruction Completion in the Obese: Does Reconstruction Technique Make a Difference in Its Achievement?

BACKGROUND

 Breast mound and nipple creation are the goals of the reconstructive process. Unlike in normal body mass index (BMI) women, breast reconstruction in the obese is associated with increased risk of perioperative complications. Our aim was to determine if reconstruction technique and the incidence of perioperative complications affect the achievement of reconstruction completion in the obese female.

METHODS

 Consecutive obese women (BMI ≥30) who underwent mastectomy and implant or autologous reconstruction were evaluated for the completion of breast reconstruction.

RESULTS

 Two hundred twenty-five women with 352 reconstructions were included. Seventy-four women underwent 111 autologous reconstructions and 151 women underwent 241 implant-based reconstructions. Chemotherapy, radiation, and delayed reconstruction timing was more common in the autologous patients. Major perioperative complications (requiring hospital readmission or unplanned surgery) occurred more frequently in the implant group (p ≤ 0.0001). Breast mounds were completed in >98% of autologous cases compared with 76% of implant cases (p ≤ 0.001). Nipple areolar complex (NAC) creation was completed in 57% of autologous patients and 33% of implant patients (p = 0.0009). The rate of successfully completing the breast mound and the NAC was higher in the autologous patient group (Mound odds ratio or OR 3.32, 95% confidence interval or CI 1.36-5.28 and NAC OR 2.7, 95% CI 1.50-4.69).

CONCLUSION

 Occurrence of a major complication in the implant group decreased the rate of reconstruction completion. Obese women who undergo autologous breast reconstruction are more likely to achieve breast reconstruction completion when compared with obese women who undergo implant-based breast reconstruction.

A Decision Tree Model for Breast Reconstruction of Women with Breast Cancer: A Mixed Method Approach

The number of breast reconstructions following mastectomy has increased significantly during the last decades, but women are experiencing a number of conflicts with breast reconstruction decisions. The aim of this study was to develop a decision tree model of breast reconstruction and to examine its predictability. Mixed method design using ethnographic decision tree modeling was used. In the qualitative stage, data were collected using individual and focus group interviews and analyzed to construct a decision tree model. In the quantitative stage, the questionnaire was developed questions based on the criteria identified in the qualitative stage. A total of 61 women with breast cancer participated in 2017. Five major criteria: recovery of body image; impact on recurrence; recommendations from others; financial resources; and confirmation by physicians. The model also included nine predictive pathways. It turns out that the model predicted 90% of decisions concerning whether or not to have breast reconstruction. The findings indicate that the five criteria play a key role in decision-making about whether or not to have breast reconstruction. Thus, more comprehensive issues, including these five criteria, need to be integrated into an intervention for women with breast cancer to make their best decision on breast reconstruction.

Development and Usability Testing of a Decision Support App for Women Considering Breast Reconstruction Surgery

Women with breast cancer have difficulty deciding whether to undergo breast reconstruction when mastectomy is necessary. A computer-based decision aid that can be individualized to provide both surgery information and value clarification may be helpful for women considering breast reconstruction surgery. The objectives of this study are to program a prototype of an application (app) with a value clarification exercise and to evaluate the pilot usability, feasibility, and efficacy of the app. In phase 1, a prototype app called Pink Journey for use on the iPhone OS (IOS) platform was created following the framework of shared decision making. In phase 2, 11 women who were given the option of reconstruction by a breast surgeon were recruited from July 2017 to December 2017. A pretest-posttest design was adopted to test the usability and feasibility of the app. The results showed that the women who used the app reported significantly less decisional conflict after intervention on each subscale of the Decision Conflict scale, i.e., "being informed", "uncertainty", "social support", "effective decision", and "value clarification". This research provides preliminary data indicating that Pink Journey holds promise for decreasing decision conflict. Most women felt that the app was both helpful and user-friendly. The app increased their participation in decision making, helped them obtain more accurate risk perceptions, and clarified their values. It also helped the women make decisions regarding breast reconstruction more confidently.

Risk Factors Linked to Depression After Treatment in Cancer Survivors in Jeddah, Saudi Arabia

Background

While many cancer patients survive long after diagnosis, one is bound to experience long-term and latent side effects as a result of the treatment. This experience results in a poor quality of life, morbidity, and mortality for cancer survivors. Understanding how to manage these side-effects is quite important and a key to cancer survivorship.

Objective

Given the importance of this area, the main objective of this study seeks to understand the risk factor associated with cancer survivorship.

Methods

A cross-sectional study was conducted among 154 cancer survivors from King Fahad General and Kind Abdul-Aziz hospitals. Descriptive and inferential statistics were used in analyzing the responses. Descriptive statistics were used in understanding the extent of the risk factors while inferential statistics were used to understand the cross-relationships.

Results

This study included 154 cancer survivors aged 18 and above at King Fahad Hospital and King Abdul-Aziz Hospital in Jeddah, Makkah Region, KSA. Thirty-one (20.1%) of the sample were males and 123 (79.9%) were females. Of all the survivors who screened, 111 (72.9%) symptoms occur before treatment, 116 (75.3%) within the treatment, and 57 (37.09%) after treatment. The relationship between Socioeconomic Status Cross Symptoms categories demonstrated below includes accommodation type, education level, age, gender, and job.

Conclusion

The study concludes that post-cancer treatment symptoms are highly affected by other factors such as social-economic status as well as family support. As a result, the study recommends the establishment of educational materials on post-treatment symptoms, care-plans, and support groups for cancer survivors.

Long-Term Dynamic Changes in Cosmetic Outcomes and Patient Satisfaction after Implant-Based Postmastectomy Breast Reconstruction and Contralateral Mastopexy with or without an Ultrapro Mesh Sling Used for the Inner Bra Technique. A Retrospective Correlational Study

Simple Summary

Immediate implant-based postmastectomy breast reconstruction (IPMBR) with contralateral symmetrization has mostly short-term limited evidence of cosmetic outcomes. Ageing after IPMBR and symmetrization may contribute to symmetry worsening. This non-interventional retrospective correlational study presents the clinical and aesthetic results of synthetic ULTRAPRO^® mesh inner bra sling symmetrization mastopexy with standard mastopexies. A total of 59 patients were enrolled in the mesh group (MG), and 58 patients were enrolled in the non-mesh group (NMG). There were no significant differences in surgical complications (p = 0.521; chi-square. The median sternal notch-to-nipple distance difference was 1 cm in the MG and 3.5 cm in the NMG from the last follow-up, and the median nipple-to-inferior mammary fold distance differences were 0.5 cm and 0.75 cm. ULTRAPRO^® mesh sling symmetrization can be successfully used to decrease pseudoptosis and nipple down-migration, offering a safe alternative for long-lasting symmetry and high patient satisfaction.

Abstract

Immediate implant-based postmastectomy breast reconstruction (IPMBR) with contralateral symmetrization has mostly short-term limited evidence of cosmetic outcomes. Because 84% of early-stage breast cancer patients have overall survival of more than 10 years, reconstructed breast symmetry should provide long-lasting results and acceptable patient satisfaction. Ageing, changes in body weight, and biomechanical changes after IPMBR and symmetrization may contribute to symmetry worsening. This non-interventional single-centre retrospective correlational study presents the clinical and aesthetic results of synthetic ULTRAPRO^® mesh inner bra sling symmetrization mastopexy with standard mastopexies. According to the results, a total of 59 patients were enrolled in the mesh group (MG), and 58 patients were enrolled in the non-mesh group (NMG). There were no significant differences in surgical complications (p = 0.521; chi-square). The median sternal notch-to-nipple distance difference was 1 cm in the MG and 3.5 cm in the NMG from the last follow-up, and the median nipple-to-inferior mammary fold distance differences were 0.5 cm and 0.75 cm. The mesh did not hinder the follow-up investigation. In conclusion, ULTRAPRO^® mesh sling symmetrization can be successfully used to decrease pseudoptosis and nipple down-migration, offering a safe alternative for long-lasting symmetry and high patient satisfaction.

Latissimus Dorsi flap enhancement by lipofilling as an immediate breast reconstruction technique for skin-preserving mastectomy

AIM

To evaluate Latissimus Dorsi flap (LD) enhancement by lipofilling as an immediate breast reconstruction technique, for skin-preserving mastectomy regarding oncological safety, fat graft resorption after radiotherapy, and patients' satisfaction.

PATIENTS AND METHODS

This is a prospective study that included female patients complaining of breast cancer. Patients were subjected to skin-preserving mastectomy associated with Latissimus Dorsi flap enhancement by lipofilling using the multisite, and multilayer fat grafting technique of injection. Patients were followed up for early and late postoperative complications including recurrence. Volumetric CT was performed before and after the radiotherapy to detect the percentage of fat resorption. Postoperative patients' satisfaction was assessed using the Kyungpook National University Hospital (KNUH) Breast Reconstruction Satisfaction Questionnaire.

RESULTS

The study included 25 female patients with a mean age of 36.48 ± 5.87 years. The mean period of follow-up was 30.32 ± 5.82 months. Local recurrence was encountered in 1 patient (4%). The mean volume reduction of the injected fat graft was 27.36 ± 8.58%. Twenty-three patients (92%) declared their satisfaction after the operation, one of them was satisfied only after she underwent a second session of lipofilling.

CONCLUSIONS

Skin-preserving mastectomy with the enhancement of the LD by lipofilling for immediate reconstruction of the breast seems to be a safe and simple technique for the achievement of autologous breast reconstruction. It has an acceptance rate of locoregional recurrence and minor postoperative complications. The procedure showed high postoperative patients' satisfaction and a reasonable percentage of fat resorption as confirmed by volumetric CT imaging techniques.

Barriers and facilitators to breast reconstruction in ethnic minority women-A systematic review

INTRODUCTION

Post-mastectomy breast reconstruction (PMBR) is an important component of the multidisciplinary care of breast cancer patients. Despite the improved quality of life, significant racial disparities exist in the receipt of PMBR. Given the increasing population of Black, Asian and minority ethnic (BAME) women in UK, it is important to address this disparity. Our review aims to identify the barriers and facilitators influencing the uptake of PMBR in BAME women and raise awareness for physicians on interventions that could improve uptake of PMBR in BAME women.

METHODS

The methodology outlined by the Cochrane guidelines was used to structure this systematic review. Systematic searches for qualitative studies on barriers and/or facilitators to PMBR in ethnic women published in English were conducted. The following databases were searched from their inception up to June 2019: MEDLINE, EMBASE, PubMed, Cochrane Library, Google Scholar and Scopus. Reference lists of all included articles and relevant systematic reviews were also hand-searched for possible additional publications. Publication year or status restrictions were not applied. Only full text articles published in English and by peer reviewed journals are included. Exclusion criteria were as follows: quantitative studies on barriers and/or facilitators to PMBR, abstracts, conference proceedings, non-English language and non-specific to BAME women. A thematic synthesis approach was used through the development of sub-themes and themes from the findings of the included qualitative studies.

RESULTS

Five studies satisfied the inclusion and exclusion criteria. Three overarching themes emerged from our review: physician-associated factors (physician recommendations), patient-associated factors (knowledge, language, community and cultural, emotions, logistics, patient characteristics) and system-associated factors (insurance coverage, income status).

CONCLUSION

Our systematic review suggests that there is a paucity of data in the literature on the barriers and facilitators to PMBR in BAME women. Considering the expanding population of BAME women and increasing breast cancer incidence, it is imperative that future research in this field is carried out. Physician and patient-associated factors were identified as the most important yet modifiable factors. Adopting a combination of culturally tailored interventions targeting these factors may help improve the access of PMBR in BAME women.

REGISTRATION

Prospero ID: CRD42019133233.

Research trends and performances of breast reconstruction: a bibliometric analysis

Background

The need for postmastectomy breast reconstruction surgery has increased dramatically, and significant progress has been made both in implant and autologous based breast reconstruction in recent decades. In this paper, we performed a bibliometric analysis with the aim of providing an overview of the developments in breast reconstruction research and insight into the research trends.

Methods

We searched the Science Citation Index Expanded database and the Web of Science Core Collection for articles published between 1991 to 2018 in the topic domain, using title, abstract, author keywords, and KeyWords Plus. Four citation indicators TCyear, Cyear, C₀ and CPP_year were employed to help analyse the identified articles.

Results

The number of scientific articles in breast reconstruction in this period steadily increased. It took most articles nearly a decade to hit a plateau in terms of citation counts. Plastic and Reconstructive Surgery, Annals of Plastic Surgery, and Journal of Plastic Reconstructive and Aesthetic Surgery published the largest number of articles on breast reconstruction. Nine of the top ten most prolific publications were based in the USA. The research highlights related to breast reconstruction were implant-based breast reconstruction, deep inferior epigastric perforator (DIEP) flap breast reconstruction, and superficial inferior epigastric artery (SIEA) flap breast reconstruction.

Conclusions

This bibliometric analysis yielded data on citation number, publication outputs, categories, journals, institutions, countries, research highlights and tendencies. It helps to picture the panorama of breast reconstruction research, and guide the future research work.

Oncoplastic breast surgery combining partial mastectomy with V-rotation mammoplasty for breast cancer on the upper inner area of the breast

The treatment of early breast cancer using breast conservation therapy (BCT) commonly ensures local control and acceptable cosmetic results. We herein report a useful technique for obtaining symmetry of the breast shape and a level inframammary line and nipple-areola that achieved excellent results. Four Japanese patients with early breast cancer located on the upper inner area of the breast were enrolled into this study. De-epithelialized skin close to the resected area and skin from the epigastric area with subdermal fatty tissue were moved to repair the defect. Oncoplastic breast surgery (OBS) combining partial mastectomy with the V-rotation mammoplasty technique was useful for patients with breast cancer on the upper inner area of minimal ptotic breasts.

Impact of overweight/obesity on the development of hematoma following tissue expander-based breast reconstruction

BACKGROUND

Overweight and obesity are well-known risk factors for postoperative complications; however, their impacts on hematoma formation have not been clarified. Several studies have suggested that overweight/obesity could have procoagulative effects, potentially reducing a risk for developing postoperative bleeding complications. This study aimed to investigate the effects of overweight/obesity on hematoma formation following tissue expander-based breast reconstruction.

METHOD

Patients who underwent immediate tissue expander-based unilateral breast reconstruction between January 2010 and November 2018 were reviewed. They were categorized into four groups according to body mass index (BMI): underweight (<18.5 kg/m2), normal weight (18.5-25.0 kg/m2), overweight (25.0-30.0 kg/m2), and obesity (>30.0 kg/m2). The outcome was major postoperative hematoma, defined as one requiring emergent surgical intervention. Independent impacts of variables on hematoma development were evaluated via uni- and multivariable analyses.

RESULTS

A total of 1,431 patients were analyzed, including 133 cases (9.3%) with underweight, 952 (66.5%) with normal weight, 302 (21.1%) with overweight, and 44 (3.1%) with obesity. Postoperative major hematoma developed in 29 cases (2.0%). The rate of hematoma formation was 2.3%, 2.6%, 0.3%, and 0% in the underweight, normal weight, overweight, and obesity groups, respectively, showing a significantly decreasing trend (p = 0.009), while those of other complications including seroma and mastectomy flap necrosis revealed the opposite trends, being significantly elevated as patient BMI increased. Multivariate analyses found overweight to be an independent protector against major hematoma compared with normal weight (p = 0.014; odds ratio=0.071).

CONCLUSION

Overweight/obesity might have a protective effect on development of major bleeding complications following tissue expander-based breast reconstruction.

Exploring the Role of Partner Satisfaction in Predicting Patient Satisfaction Regarding Post-mastectomy Breast Reconstruction

Supplemental Digital Content is available in the text.

Qualitative studies have suggested that perceived partner satisfaction is an important predictor of patient satisfaction in post-mastectomy breast reconstruction. To better characterize these relationships, a couple-based study employing a quantitative analysis was conducted.

The Impact of Mastectomy on Women's Visual Perception of Breast Aesthetics and Symmetry: A Pilot Eye-Tracking Study

BACKGROUND

Little is known about breast cancer survivors' perception of breast attractiveness. A better understanding of this subjective concept could contribute to the improvement of patient-reported outcomes after reconstructive surgeries and facilitate the development of new methods for assessing breast reconstruction outcomes.

OBJECTIVES

The aim of this eye-tracking (ET)-based study was to verify whether mastectomy altered women's visual perception of breast aesthetics and symmetry.

METHODS

A group of 30 women after unilateral mastectomy and 30 healthy controls evaluated the aesthetics and symmetry of various types of female breasts displayed as highly standardized digital images. Gaze patterns of women from the study groups were recorded using an ET system and subjected to a comparative analysis.

RESULTS

Regardless of the study group, the longest fixation duration and the highest fixation number were found in the nipple-areola complex. This area was also the most common region of the initial fixation. Several significant between-group differences were identified; the gaze patterns of women after mastectomy were generally characterized by longer fixation times for the inframammary fold, lower pole, and upper half of the breast.

CONCLUSIONS

Mastectomy might affect women's visual perception patterns during the evaluation of breast aesthetics and symmetry. ET data might improve our understanding of breast attractiveness and constitute the basis for a new reliable method for the evaluation of outcomes of reconstructive breast surgeries.

Omitting surgery for early breast cancer showing clinical complete response to primary systemic therapy

Breast cancer is highly sensitive to systemic therapy. High probability of pathological complete response suggests a clinical question that omitting surgery is an effective alternative to surgery in breast cancer showing clinical complete response to primary systemic therapy. However, the validity of omitting surgery for early breast cancer after primary systemic therapy has not been sufficiently established; thus, even if pathological complete response is expected in patients showing clinical complete response, excision of the primary tumor site remains the standard treatment of breast cancer. Inappropriate omitting surgery increases the incidence of local recurrence, which can be the risk of a subsequent distant metastasis and reduced overall survival. To achieve acceptable local control rate, omitting surgery should be investigated in patients with early breast cancer where a high percentage of pathological complete response, a high concordance rate between clinical complete response and pathological complete response and an acceptable local control rate are expected. This review presents concept and ongoing clinical trials for omitting surgery for patients with breast cancer showing clinical complete response to primary systemic therapy.

Postmastectomy Reconstruction is Associated with Improved Survival in Patients with Invasive Breast Cancer: A Single-institution Study

Breast reconstruction after mastectomy positively affects psychosocial well-being; however, the influence of reconstruction on cancer outcomes is unknown. The objective of our study was to compare survival in reconstructed versus nonreconstructed patients after mastectomy. All consecutive female patients diagnosed with invasive breast cancer and treated with mastectomy between 2002 and 2011 were identified from our single-institution database. All cancer operations were performed by two surgeons. Survival was calculated using the Kaplan-Meier method and compared using the log-rank test. To identify the effect of reconstruction on survival, a multivariate Cox regression analysis was performed. Of 474 patients treated, 340 (71.7%) underwent breast reconstruction. At a mean follow-up 3.3 years, reconstructed patients had a longer 5-year survival (91 vs 74%, P < 0.001). After controlling for age, race, payer source, cancer stage, triple negative status, and receipt of radiation or chemotherapy, reconstructed patients maintained a survival advantage over nonreconstructed patients (hazard ratio, 0.47; 95% confidence interval, 0.25 to 0.88; P = 0.02). Patients with breast cancer who undergo reconstruction have longer survival than nonreconstructed patients. The explanation for this finding may be related to improved psychosocial qualities of life versus possible antitumorigenic effects of implants.

Oncoplastic breast surgery combining partial mastectomy with a triangular skin resection and re-centralization of the nipple-areola

The treatment of early breast cancer using breast conservation therapy (BCT) commonly ensures local control and acceptable cosmetic results. We herein report a useful technique to obtain symmetry of the breast shape and a level inframammary line and nipple-areola, which achieved excellent results. Six Japanese patients with early breast cancer located on the upper area of the breast were enrolled into this study. A triangle-shaped area of skin was removed together with cancerous and healthy-surrounding breast tissue. Two crescents were designed and de-epithelialized in the directions of 9 o'clock and 3 o'clock. The width of the crescent was decided to be the same as a half or the length of the base of a triangle to be removed. After partial mastectomy, the inner and outer glandular flaps were horizontally sutured. The operations were simple to perform and were not associated with any postoperative complications. Oncoplastic breast surgery combining partial mastectomy with triangular skin resection and re-centralization of the nipple-areola was useful for patients with breast cancer on the upper quadrant area of non-ptotic breasts.

Quality-of-Life and Surgical Outcomes for Breast Cancer Patients Treated with Therapeutic Reduction Mammoplasty Versus Mastectomy with Immediate Reconstruction

BACKGROUND

Therapeutic reduction mammoplasty (TRM) is a safe and effective surgical technique that has oncologic outcomes comparable with those achieved by mastectomy. This study aimed to compare surgical and patient-reported outcomes between breast cancer patients treated with TRM and those who had mastectomy with immediate reconstruction (MIR).

METHODS

A 4-year, single-institution, retrospective cohort study analyzed breast cancer patients undergoing TRM and MIR. Patient characteristics and perioperative data were collected from electronic records. Patient-reported outcome data were collected via BREAST-Q questionnaires preoperatively, then 3 months and 12 months postoperatively. A subgroup analysis was performed on locally advanced breast cancer (LABC) patients for TRM and MIR.

RESULTS

The study included 249 breast reconstructions, of which 77 (31%) were TRM and 172 (69%) were MIR. The mean follow-up time was 2.4 ± 1.2 years. Compared with MIR, TRM had significantly lower major complication rates (9% vs 21%; p = 0.02) and fewer revisionary surgeries (5% vs 37%; p < 0.0001). At 1 year postoperatively, TRM had a significantly greater change in satisfaction with breasts, (+ 27.7 vs + 4.6; p < 0.01) and sexual well-being (+ 20.0 vs - 5.5; p = 0.02) than MIR.

CONCLUSION

For select breast cancer patients, TRM continues to be a safe and effective alternative to mastectomy. The current study demonstrated that TRM patients had fewer major complications and revisionary surgeries, as well as better patient-reported outcomes than MIR.

Health-related quality of life following breast reconstruction compared to total mastectomy and breast-conserving surgery among breast cancer survivors: a systematic review and meta-analysis

The present review evaluated health-related quality of life (HR-QoL) outcomes in surgical breast cancer survivors who received breast reconstruction (BR), breast-conservation surgery (BCS) or mastectomy (M), and whether HR-QoL domains across generic and disease/surgery-specific questionnaires are compatible. Six electronic databases were searched for appropriate observational studies. Standardized scores for different HR-QoL domains in the BR, BCS, and M treatment groups were extracted from each study for the purpose of a meta-analysis. Using Stata version 14.0, a random-effects meta-analysis model was adopted for each outcome variable to estimate the effect size, 95% CI-confidence intervals, and statistical significance. Sixteen of the 18 eligible studies with BR (n = 1474) and BCS (n = 2612) or M (n = 1458) groups were included in the meta-analysis. The BR group exhibited a better physical health (k = 12; 0.1, 95% CI 0.04, 0.24) and body image (k = 12; 0.50, 95% CI 0.10, 0.89) than the M group. However, the two groups exhibited comparable social health (k = 13; 0.1, 95% CI -0.07, 0.37), emotional health (k = 13; -0.08, 95% CI - 0.41, 0.25), global health (k = 7; 0.1, 95% CI - 0.01, 0.27), and sexual health (k =11; 0.2, 95% CI - 0.02,0.57). There was no clear evidence of the superiority of BR to BCS for all the six domains. These results suggest that HR-QoL outcomes in BR and BCS groups are better than the M group. Therefore, women opting for BR or BCS are likely to report fairly better HR-QoL outcomes than M. However, due to the significant heterogeneity observed in most BR versus BCS outcomes, developing a unified questionnaire incorporating both breast/surgery-specific and generic HR-QoL domains is warranted.

Effects of neoadjuvant chemotherapy on operative adverse events and chemotherapy and radiotherapy in patients undergoing immediate breast reconstruction

BACKGROUND

Immediate breast reconstruction (IBR) has been become a standard treatment for patients with breast cancer undergoing mastectomy. However, whether IBR is appropriate in patients undergoing neoadjuvant chemotherapy (NAC) is still unclear. Therefore, in this study we examined the rates of operative adverse events (AEs), risk factors for operative AEs, and effects on chemotherapy and radiotherapy of IBR with NAC.

METHODS

Between January 2012 and March 2018, 593 patients underwent IBR at the Aichi Cancer Center Hospital. We retrospectively obtained clinical data of all these patients from their medical records and identified 56 patients (65 breasts) who had received NAC (NAC group) and 537 patients (568 breasts) who had not (non-NAC group). We compared the rates of operative AEs, risk factors for operative AEs, chemotherapy-related AEs, and duration to radiotherapy between the NAC and non-NAC cohorts.

RESULTS

The rate of operative AEs was significantly higher in the NAC than the non-NAC group (35% vs. 22%, p < 0.05). However, axillary lymph node dissection was the most influential risk factor, and NAC was not identified as a risk factor for operative AEs in patients who had undergone IBR. Additionally, there were no statistically significant differences in chemotherapy-related AEs or interval between surgery and postoperative radiotherapy between the NAC and non-NAC groups.

CONCLUSIONS

NAC remains likely to contribute to increased postoperative AEs in patients undergoing IBR; however, it does not affect postoperative treatment and IBR is appropriate for patients undergoing NAC.

Exploring Women's Support Needs After Breast Reconstruction Surgery: A Qualitative Study

BACKGROUND

The procedures for breast reconstruction (BR) after mastectomy frequently initiate a difficult recovery period. A better understanding of women's support needs after surgery would improve patient care.

OBJECTIVE

The aim of this study was to identify patients' support needs after BR.

METHODS

In a retrospective study design, 21 participants described their support experiences after BR, including their sources of support and the impact of support on their recovery in a semistructured interview. Transcriptions of the interviews were analyzed using thematic analysis.

RESULTS

Four support needs were identified and were composed of elements of instrumental, emotional, and informational support. These needs were addressed to varying degrees by healthcare providers, family members, and other women who had BR experience.

CONCLUSION

Women's experience of BR and their ability to cope are markedly better when their support needs are effectively addressed. Greater attention to their needs for support has the potential to improve patient care.

IMPLICATIONS FOR PRACTICE

Nurses play a pivotal role in providing information to women who are recovering from BR. Improved access to communication channels between nurses and patients would likely improve patients' support experiences. In addition, nurses can assess the women's specific support needs and partner with families to help them understand how best to support women during recovery.

[Comparing outcomes of Immediate Breast reconstruction with and without use of radiotherapy]

BACKGROUND

Breast cancer and its treatment remains a public health problem. There is still a lack of epidemiological data concerning complications and aesthetic results bound to radiotherapy after an immediate breast reconstruction. The objective of this study was to compare outcomes of immediate breast reconstruction regardless to the use of radiotherapy (history of radiotherapy or adjuvant radiation therapy), in order to determine risk factor of complications and bad aesthetic results.

METHODS

We conducted a retrospective study between January 2014 and December 2016 at the hospital "Gustave Roussy" in Paris, concerning breast cancer patients who needed immediate breast reconstruction after total mastectomy. The primary endpoint was to assess the failure rate of reconstruction and the aesthetic result, the secondary endpoint assessed the early and late rate of complications. We realized a multivariate analysis in order to identify risks factors that may predict complications.

RESULTS

Three hundred and thirty three patients have been included: 157 in the "radiotherapy group" compared to 176 in the "no radiotherapy group". Preoperative characteristics were comparable. Average follow-up was between 1 and 3years without missing. Patients who benefited from radiotherapy had an equal risk failure of reconstruction. The subgroup analysis revealed non-significant differences: 12.7% failure rate reconstruction in the "radiotherapy group" vs. 12.5%. We could notify a better rate of "excellent results" in the "no radiotherapy group": 35% vs. 8.2%. Secondary outcomes were comparable.

CONCLUSIONS

Radiotherapy related to immediate breast reconstruction didn't increase the failure rate of reconstruction or aesthetic results, comparatively to non-irradiated patients. It is therefore permissible to suggest an immediate breast reconstruction to any patients which would benefit from a total mastectomy followed by radiotherapy; in order to prevent them from a secondary breast reconstruction, who could be physically and psychologically more impactful.

Expectations of breast-conserving therapy: a qualitative study

Background

Early-stage breast cancer is often treated with breast-conserving therapy (BCT), including lumpectomy with radiation therapy. Patients’ expectations of BCT remain largely unknown. Expectations affect perceptions of treatment-related experiences and health-related quality of life (HR-QOL) outcomes. Our primary aim was to describe expectations of BCT among patients with early breast cancer through qualitative methods. Our secondary aim was to inform preoperative patient education and improve the patient experience through knowledge.

Methods

We used a grounded-theory approach to investigate a convenience sample of 22 women with stage I and II breast cancer who were treated with BCT at a single hospital in New York City between May and August 2016. Semi-structured interviews were conducted in person and by telephone. Open-ended questions covered participants’ expectations of treatment experiences and outcomes. Data was analyzed in a line-by-line approach to identify emergent themes related to patient expectations. Interviews continued until no new themes emerged.

Results

Analysis of data identified the following themes related to patient expectations of BCT: experience of cancer care, recovery, appearance, and HR-QOL. Despite preoperative informed consent and teaching, participants expressed few expectations preoperatively, owing to a lack of knowledge about the process of care. Lack of expectations preoperatively was compensated with available care and resources postoperatively.

Conclusions

Patients in our sample had a surprisingly limited understanding of what to expect during treatment with BCT. Despite available information and preoperative teaching, patients have a clear knowledge gap regarding BCT. These findings suggest patients often undergo cancer treatment with trust rather than complete understanding of the process. This data may be used to enhance preoperative discussions aimed at preparing patients for surgery and treatment.

Immediate Breast Reconstruction in The Netherlands and the United States: A Proof-of-Concept to Internationally Compare Quality of Care Using Cancer Registry Data

BACKGROUND

Studies based on large-volume databases have made significant contributions to research on breast cancer surgery. To date, no comparison between large-volume databases has been made internationally. This is the first proof-of-concept study exploring the feasibility of combining two existing operational databases of The Netherlands and the United States, focusing on breast cancer care and immediate breast reconstruction specifically.313/291 METHODS:: The National Breast Cancer Organization The Netherlands Breast Cancer Audit (NBCA) (2011 to 2015) and the U.S. Surveillance, Epidemiology, and End Results (SEER) database (2010 to 2013) were compared on structure and content. Data variables were grouped into general, treatment-specific, cancer-specific, and follow-up variables and were matched. As proof-of-concept, mastectomy and immediate breast reconstruction rates in patients diagnosed with invasive breast cancer or ductal carcinoma in situ were analyzed.

RESULTS

The NBCA included 115 variables and SEER included 112. The NBCA included significantly more treatment-specific variables (n = 46 versus 6), whereas the SEER database included more cancer-specific variables (n = 74 versus 26). In patients diagnosed with breast cancer or ductal carcinoma in situ, immediate breast reconstruction was performed in 19.3 percent and 24.0 percent of the breast cancer cohort and 44.0 percent and 35.3 percent of the ductal carcinoma in situ cohort in the NBCA and SEER, respectively. Immediate breast reconstruction rates increased significantly over time in both data sets.

CONCLUSIONS

This study provides a first overview of available registry data on breast cancer care in The Netherlands and the United States, and revealed limited data on treatment in the United States. Comparison of treatment patterns of immediate breast reconstruction showed interesting differences. The authors advocate the urgency for an international database with alignment of (treatment) variables to improve quality of breast cancer care for patients across the globe.