Discrepancies Between Surgical Oncologists and Plastic Surgeons in Patient Information Provision and Personal Opinions Towards Immediate 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.

Does Immediate Breast Reconstruction Lead to a Delay in Adjuvant Chemotherapy for Breast Cancer? A Meta-Analysis and Systematic Review

Timely delivery of adjuvant chemotherapy is crucial. With an increasing frequency of immediate breast reconstructions (IBR) following mastectomy (MAS), concerns have arisen regarding its complication rates and effects on time to chemotherapy. The aim was to conduct a systematic review and meta-analysis to determine if there is a prolonged time to chemotherapy (TTC) after IBR and MAS. Electronic databases, reference lists and relevant articles were searched systematically. Eligibility criteria included women receiving adjuvant chemotherapy who underwent either MAS only or MAS and IBR. Random-effects models were used in the analysis. A total of 29 studies were included in qualitative analysis, comprising of 156,000 patients (IBR: 57,159; MAS: 98,841). But 23 studies had sufficient data to be included in the meta-analysis. Sixteen papers concluded there was no difference in TTC compared to MAS. There was a difference of 3.50 days between TTC in IBR versus MAS (95% CI [0.42, 6.57], P value = .0256; IBR = 43.56 days, MAS = 40.38 days). The rate of patients being delayed past 90 days was not significantly higher in IBR (OR = 1.34, 95% CI [0.76, 2.38], P = .310). IBR patients were more likely to have complications compared to the MAS group (OR = 2.04, 95% CI [1.04-4.01], P < .01). We concluded that there is a statistically significant longer time to chemotherapy following IBR of 3.50 days, yet there is no difference in delays past 90 days. Therefore, the longer TTC in IBR is unlikely to be of any clinical significance.

Survey on the Necessity, Sensibility, and Timing of Psycho-Oncological Counseling and the Willingness to Discuss Various Topics During the Inpatient Stay in the Case of Breast Cancer

After the diagnosis of cancer patients require a lot of information because the disease affects all aspects of life. Some important issues regarding optimal counseling remain to be determined. This includes the time-related relevance of various topics and questions regarding who and when to consult on the topics. We analyzed the answers of 155 women with non-metastatic breast cancer undergoing primary surgery, primary chemotherapy, and having completed adjuvant treatment regarding the above-mentioned issues. We found that counseling must consider the treatment situation. Breast cancer patients in the follow-up phase reported that they preferred being counseled by female consultants. Our results largely support a counseling concept which puts the breast care nurse at the center of interest rather than psychologists and social service workers. A breast care nurse centered counseling system for women with non-metastatic breast cancer appears to meet patients' needs best.

Predictors of delayed breast reconstruction in the Netherlands: a 5-year follow-up study in stage I-III breast cancer patients

PURPOSE

Delayed breast reconstruction (DBR) is a valid option for postmastectomy breast cancer patients who have a desire for breast reconstruction but are not considered suitable for immediate breast reconstruction (IBR). The objective of this study was to investigate the clinical practice and predictors of the use of DBR in the Netherlands.

METHODS

Stage I-III breast cancer patients diagnosed from January to March 2012 and treated with mastectomy were selected from the Netherlands Cancer Registry. Routinely collected patient, tumor, treatment and hospital characteristics were complemented with data about DBR up to 2018. Multivariable logistic regression analyses were performed to identify factors independently associated with postmastectomy DBR. Factors associated with time to DBR were identified through Cox regression analyses.

RESULTS

Of all patients who underwent mastectomy (n = 1,415), 10.2% underwent DBR. DBR patients more often received autologous reconstruction compared to IBR patients (37.5% vs 6.2%, p < 0.001). Age below 50 years (age < 35 OR 15.55, age 35-49 OR 4.18) and neoadjuvant and adjuvant chemotherapy (OR 2.59 and OR 2.83, respectively) were significantly associated with DBR. Mean time to DBR was 2.4 years [range 1-6 years]. Time to DBR was significantly associated with age < 35 years (HR 2.22), and a high hospital volume (HR 1.87).

DISCUSSION

The use of DBR after mastectomy could not be fully explained by age below 50 years, chemotherapy, and hospital volume. Treatment with radiotherapy and adjuvant chemotherapy increased time to DBR. More information about patient preferences is needed to understand the use and timing of reconstruction.

The Impact of a Single Dual-Trained Surgeon in the Management of Mastectomy and Reconstruction

BACKGROUND

Oncoplastic breast surgery is typically performed using a two-surgeon, two-team approach. The authors present their experience with patients undergoing mastectomy and immediate reconstruction performed by a single, dual-trained breast surgical oncologist and plastic and reconstructive microsurgeon.

METHODS

Patients who underwent mastectomy and/or immediate reconstruction performed by the senior author between 2015 and 2019 were divided into single-surgeon or dual-surgeon cohorts, and matched by age, body mass index, reconstruction type, and cancer stage.

RESULTS

The authors included 158 patients in their analysis (single-surgeon, n = 45; dual-surgeon, n = 113). Single-surgeon patients underwent surgery 13.2 days earlier than single-surgeon patients (p < 0.01), and required significantly fewer preoperative (1.9 versus 3.4; p < 0.01) and postoperative visits (6.8 versus 10.7; p < 0.01). Operative duration was comparable (single-surgeon, 245 minutes; dual-surgeon, 245 minutes; p = 0.99). The authors found no significant difference in surgical-site infection, seroma, hematoma, abdominal donor-site healing, or flap and prosthesis loss between the groups. The authors did find that dual-surgeon patients had a significantly higher rate of mastectomy flap necrosis (20 percent versus 4 percent; p = 0.01), which held true on logistic regression when controlling for other variables. BREAST-Q data demonstrated that single-surgeon patients had significantly higher overall scores (p = 0.04), and were significantly more satisfied with their outcomes, surgeon, and the information provided (p = 0.03, p = 0.03, and p = 0.01, respectively).

CONCLUSIONS

The single-surgeon approach has the potential to decrease patient burden by requiring fewer preoperative and postoperative visits without compromising surgical outcomes or oncologic safety. Further investigation is warranted into the financial implications and patient outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Patients' and surgeons' experiences after failed breast reconstruction: A qualitative study

BACKGROUND

The goal of postmastectomy breast reconstruction (BR) is to improve the quality of life of patients. However, complications following autologous BR (A-BR) and implant-based BR (I-BR) occur frequently and may even lead to BR-failure, which can be a distressing event for both patients and surgeons. The current study, therefore, examines the experiences of both patients and surgeons after a BR-failure.

METHODS

Patients with a failed BR from a large multicenter cohort study and participating plastic surgeons were invited to participate in semi-structured interviews focusing on their experiences. The interviews were analyzed according to the principles of grounded theory.

RESULTS

Fourteen patients with a failed I-BR, four patients with a failed A-BR, and four plastic surgeons were participated. Three main categories emerged from the data: personal experiences with BR-failure, the motives for a redo of a failed BR, and patient-surgeon communication. Patients would like to be treated with more attention to their personal feelings and lives, instead of being approached from a purely medical-technical perspective. Surgeons may experience feelings of guilt leading to the strong urge to fix the failed BR, whereas patients may be less inclined to undergo additional operations. Patients want to know what the choice for a particular type of BR would mean to their personal lives. The impact of I-BR-failure may be underestimated and requires the same degree of intensive aftercare and attention.

CONCLUSIONS

Implementing the recommendations of this study in clinical practice may facilitate improvements in how both patients and surgeons cope with a BR-failure.

The added value of immediate breast reconstruction to health-related quality of life of breast cancer patients

BACKGROUND

Postmastectomy immediate breast reconstruction (IBR) may improve the quality of life (QoL) of breast cancer patients. Guidelines recommend to discuss the option IBR with all patients undergoing mastectomy. However, substantial hospital variation in IBR-rates was previously observed in the Netherlands, influenced by patient, tumour and hospital factors and clinicians' believes. Information provision about IBR may have a positive effect on receiving IBR and therefore QoL. This study investigated patient-reported QoL of patients treated with mastectomy with and without IBR.

METHODS

An online survey, encompassing the validated BREAST-Q questionnaire, was distributed to a representative sample of 1218 breast cancer patients treated with mastectomy. BREAST-Q scores were compared between patients who had undergone mastectomy either with or without IBR.

RESULTS

A total of 445 patients were included for analyses: 281 patients with and 164 without IBR. Patients who had received IBR showed significantly higher BREAST-Q scores on "psychosocial well-being" (75 versus 67, p < 0.001), "sexual well-being" (62 versus 52, p < 0.001) and "physical well-being" (77 versus 74, p = 0.021) compared to patients without IBR. No statistically significant difference was found for "satisfaction with breasts" (64 versus 62, p = 0.21). Similar results were found after multivariate regression analyses, revealing IBR to be an independent factor for a better patient-reported QoL.

CONCLUSIONS

Patients diagnosed with breast cancer with IBR following mastectomy report a better QoL on important psychosocial, sexual and physical well-being domains. This further supports the recommendation to discuss the option of IBR with all patients with an indication for mastectomy and to enable shared decision-making.

Breast-contour preserving procedures for early-stage breast cancer: a population-based study of the trends, variation in practice and predictive characteristics in Denmark and the Netherlands

PURPOSE

Breast-contour preservation (BCP) is possible for most women treated for early-stage breast cancer. BCP can be defined as primary breast-conserving treatment (BCT), neoadjuvant chemotherapy (NAC) followed by BCT and immediate postmastectomy breast reconstruction (IBR). This study provides insight in current BCP strategies in Denmark and the Netherlands and aims to identify opportunities for improvement within both countries.

METHODS

A total of 92,881 patients with early-stage breast cancer who were operated in Denmark and the Netherlands between 2012 and 2017 were selected from the Danish Breast Cancer Group and the Dutch National Breast Cancer Audit databases. BCP procedures and predictive factors were analyzed within and between both countries.

RESULTS

BCP was achieved in 76.7% (n = 16,355) of the Danish and in 74.5% (n = 53,328) of the Dutch patients. While BCP rate did not change significantly over time in Denmark (p = 0.250), a significant increase in BCP rate from 69.5% in 2012 to 78.5% in 2017 (p < 0.001) was observed in the Netherlands. In both countries, variation in BCP rates between hospitals decreased over time. NAC followed by BCT and postmastectomy IBR was substantially more often used in the Netherlands compared to Denmark, specifically in patients younger than 50 years.

CONCLUSIONS

In more than 75% of all Danish and Dutch patients, surgically treated for early-stage breast cancer, the breast-contour was preserved. The different use of BCP strategies within Denmark and the Netherlands and the differences observed between hospitals in both countries emphasize the need for more (inter)national consensus on treatment modalities.

Autologous versus implant-based breast reconstruction: A systematic review and meta-analysis of Breast-Q patient-reported outcomes

OBJECTIVE

Breast reconstruction following mastectomy can increase the quality of life of patients. Reconstruction methods can broadly be divided into implant-based and autologous tissue reconstruction. Patient-reported outcomes following breast reconstruction are one of the most important success parameters. In this systematic review and meta-analysis, we aimed to compare the two methods using the recognized Breast-Q questionnaire.

METHODS

We performed a systematic search in PubMed and EMBASE databases. Meta-analysis was performed on the five most commonly reported Breast-Q modules. RevMan 5.3 was used for statistical analysis. Methodological quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies.

RESULTS

The search strategy resulted in 219 studies of which nine studies were included in the analysis, yielding 2129 implant-based and 825 autologous breast reconstructions. Overall satisfaction with outcome as well as breast was significantly higher among patients with autologous breast reconstructions (mean Breast-Q difference between the two groups was 9.82 [3.09, 16.54], p = 0.004, and 10.33 [95% CI 5.93, 14.74], p<0.00001, respectively). Sexual and psychosocial well-being was higher among autologous breast reconstructions. There was no difference in the physical well-being.

CONCLUSION

This is the first systematic review and meta-analysis to compare patient-reported outcomes of implant-based and autologous breast reconstruction. We found that autologous reconstruction yields a higher satisfaction with overall outcome and breast. These findings can aid clinicians when discussing breast reconstruction options with patients.

Breast-Contour-Preserving Procedure as a Multidisciplinary Parameter of Esthetic Outcome in Breast Cancer Treatment in The Netherlands

BACKGROUND

The rate of breast-conserving surgery (BCS) is used as an esthetic outcome parameter, while other treatments contribute also, such as neoadjuvant chemotherapy (NAC) enabling BCS or immediate breast reconstruction (IBR). This study explores these efforts to preserve the patient's breast contour.

PATIENTS AND METHODS

All patients who underwent surgery for invasive breast cancer in The Netherlands between January 2011 and December 2015 were selected from the Dutch national breast cancer audit (n = 61,309). The breast-contour-preserving procedures (BCPP) rate was defined as the rate of primary BCS, BCS after NAC, or mastectomy with IBR. BCPP rates were calculated and compared by year of diagnosis, age categories, and individual hospitals.

RESULTS

The rate of primary BCS remained stable (53%) while the BCPP rate increased from 63% in 2011 to 71% in 2015 due to an increase in patients receiving BCS after NAC and mastectomy with IBR. Primary BCS rates increased with age (from 17% in patients aged < 30 years to 63% in patients aged 60-69 years), while the proportion of patients undergoing mastectomy with IBR decreased from 44% in patients < 30 years to 1% in patients ≥ 70 years. The BCPP rate was similar for all age groups except for patients > 70 years. BCPP rates varied between the different hospitals in The Netherlands, ranging from 47 to 88%.

CONCLUSIONS

The chance of preserving the breast contour for patients with breast cancer has increased substantially over recent years. BCPP provides a comprehensive parameter of esthetic outcome of breast cancer surgery.