A Systematic Review of the Clinical Evidence to Guide Treatment Recommendations in Breast Reconstruction Based on Patient- Reported Outcome Measures and Health-Related Quality of Life

Postmastectomy Breast Reconstruction in Patients with Non-Metastatic Breast Cancer: A Systematic Review

Breast reconstruction after mastectomy improves the quality of life for many patients with breast cancer. There is uncertainty regarding eligibility criteria for reconstruction, timing (immediate or delayed-with or without radiotherapy), outcomes of nipple-sparing compared to skin-sparing mastectomy, selection criteria and surgical factors influencing outcomes of nipple-sparing mastectomy, prepectoral versus subpectoral implants, use of acellular dermal matrix, and use of autologous fat grafting. We conducted a systematic review of these topics to be used as the evidence base for an updated clinical practice guideline on breast reconstruction for Ontario Health (Cancer Care Ontario). The protocol was registered on PROSPERO, CRD42023409083. Medline, Embase, and Cochrane databases were searched until August 2024, and 229 primary studies met the inclusion criteria. Most studies were retrospective non-randomized comparative studies; 5 randomized controlled trials were included. Results suggest nipple-sparing mastectomy is oncologically safe, provided there is no clinical, radiological, or pathological indication of nipple-areolar complex involvement. Surgical factors, including incision location, may affect rates of complications such as necrosis. Both immediate and delayed reconstruction have similar long-term outcomes; however, immediate reconstruction may result in better short to medium-term quality of life. Evidence on whether radiotherapy should modify the timing of initial reconstruction or expander-implant exchange was very limited; studies delayed reconstruction after radiotherapy by at least 3 months and, more commonly, at least 6 months to avoid the period of acute radiation injury. Radiation after immediate reconstruction is a reasonable option. Surgical complications are similar between prepectoral and dual-plane or subpectoral reconstruction; prepectoral placement may give a better quality of life due to lower rates of long-term complications such as pain and animation deformity. Autologous fat grafting was found to be oncologically safe; its use may improve quality of life and aesthetic results.

Development and validation of a questionnaire to assess health-related quality-of-life in cats with hyperthyroidism

BACKGROUND

Health-related quality-of-life (HRQoL) assessment tools are becoming increasingly important for the assessment of diseases in veterinary medicine.

OBJECTIVES

To develop a tool to assess the HRQoL of hyperthyroid cats and their owners.

ANIMALS

Cats with hyperthyroidism (n = 229) and without hyperthyroidism (n = 322).

METHODS

Cross-sectional study design. A preliminary list of 28 questions relating to the HRQoL of hyperthyroid cats and the influence their cat's disease might have on owners was created. Each question consisted of 2 subquestions: (1) "how often does the item apply"; (2) "how strongly does the item affect HRQoL." The questionnaire was refined based on statistical analysis, including Mann-Whitney-U tests on each item, comparing the results from cats with and without hyperthyroidism. Internal consistency and reliability of the questions were measured by Cronbach's alpha (α). P < .05 was considered significant.

RESULTS

Overall, 25/28 questions were retained within the final HRQoL tool, which had an excellent internal consistency (α = .92). The tool produced a score between 0 and 382 (lower scores meaning better HRQoL). The median HRQoL score was 87.5 (range, 2-348) for cats with hyperthyroidism, and 27 (range, 0-249) for cats without (P < .001), suggesting the HRQoL was poorer in hyperthyroid cats.

CONCLUSIONS AND CLINICAL IMPORTANCE

This validated HRQoL tool is useful to reliably quantify the influence of hyperthyroidism on the quality-of-life of affected cats and their owners. In the future, it could be considered of assistance in the clinical assessment of cats with hyperthyroidism.

Mastectomies for breast cancer: Comparison between peri-operative morbidity after simple mastectomy or after immediate breast reconstruction in a unicentric serie of 210 patients

BACKGROUND

In breast cancer surgery, IBR (immediate breast reconstruction) is widely proposed to patients without indications of adjuvant treatments and without risk factors of surgical complications. New INCa's guidelines (2022) allow the expansion of IBR indications.

OBJECTIVE

A retrospective, unicentric and safety study: post-operative complication rate after IBR in comparison with simple mastectomy (SM, reference treatment).

MATERIEL AND METHOD

This retrospective study has included all major patients who have received mastectomy for breast cancer between 2016 and 2020 before application of new guidelines, in Hôpital de la Croix-Rousse, Lyon (France). They were distributed in two groups according to their surgery : IBR and SM. Usual risk factors of post-operative complications were collected (tabacco, obesity…). The primary endpoint was the occurrence of an early post-operative complication (within 3 months after surgery). Two secondary analysis focused on the impact of preoperative risk factors on complications, and the proportion of patients eligibled for an IBR among SM based on new INCA's guidelines.

RESULTS

The study included 185 mastectomies: 153 SM, 32 mastectomies IBR.  IBR's patients presented less risk factors, and few indications of adjuvant treatments. The rate of major complications was identical in the two groups (14 % in SM group, 12 % in IBR group), and there were more minor complications in the SM group than in the IBR group (p 0,01). According to our study, the raw proportion of initially possible IBR was 68 % (36 % of breast reconstruction in this study).

CONCLUSION

This analyse approve IBR in selected patients. In this context, INCa's guidelines (2022) can generalize IBR's proposal to patients. However, the analysis of pre-operative risk factors stay essential in medical care.

Rates of price disclosure associated with the surgical treatment of early-stage breast cancer one year after implementation of federal regulations

PURPOSE

Mastectomy, breast reconstruction (BR) and breast conserving therapy (BCT) are core components of the treatment paradigm for early-stage disease but are differentially associated with significant financial burdens. Given recent price transparency regulations, we sought to characterize rates of disclosure for breast cancer-related surgery, including mastectomy, BCT, and BR (oncoplastic reconstruction, implant, pedicled flap and free flap) and identify associated factors.

METHODS

For this cross-sectional analysis, cost reports were obtained from the Turquoise Health price transparency platform for all U.S. hospitals meeting national accreditation standards for breast cancer care. The Healthcare Cost Report Information System was used to collect facility-specific data. Addresses were geocoded to identify hospital referral and census regions while data from CMS was also used to identify the geographic practice cost index. We leveraged a Poisson regression model and relevant Medicare billing codes to analyze factors associated with price disclosure and the availability of an OOP price estimator.

RESULTS

Of 447 identified hospitals, 221 (49.4%) disclosed prices for mastectomy and 188 42.1%) disclosed prices for both mastectomy and some form of reconstruction including oncoplastic reduction (n = 184, 97.9%), implants (n = 187, 99.5%), pedicled flaps (n = 89, 47.3%), and free flaps (n = 81, 43.1%). Non-profit status and increased market competition were associated with price nondisclosure. 121 hospitals (27.1%) had an out-of-pocket price estimator that included at least one breast surgery.

CONCLUSIONS

Most eligible hospitals did not disclose prices for breast cancer surgery. Distinct hospital characteristics were associated with price disclosure. Breast cancer patients face persistent difficulty in accessing costs.

What affects women's decision-making on breast reconstruction after mastectomy for breast cancer?

PURPOSE

To establish the breast reconstruction rate in a large Dutch teaching hospital, and to gain insight into the motives of women to opt for or reject post-mastectomy breast reconstruction.

METHODS

In a retrospective, cross-sectional study, all consecutive patients who underwent mastectomy for invasive breast cancer or ductal carcinoma in situ (DCIS) were identified and categorized into two groups based on subsequent breast reconstruction or not. Patient-reported outcomes were assessed with the validated Breast-Q and a short survey about the decision-making process in breast reconstruction. These outcomes were compared between the two groups using univariable analyses, multivariable logistic regression, and multiple linear regression analyses. The Breast-Q scores were also compared to Dutch normative values.

RESULTS

A total of 319 patients were identified of whom 68% had no breast reconstruction. Of the 102 patients with breast reconstruction, the majority (93%) received immediate, instead of delayed breast reconstruction. The survey was completed by 155 (49%) patients. The non-reconstruction group, on average, reported significantly poorer psychosocial well-being, compared to the reconstruction group as well as compared to the normative data. However, the majority of the non-reconstruction group (83%) stated that they had no desire for breast reconstruction. In both groups, most patients stated that the provided information was sufficient.

CONCLUSION

Patients have personal motives to opt for or reject breast reconstruction. It seemed that patients differ in their rating of values that affect their decision since the same arguments were used to opt for or reject reconstruction. Notably, patients were well-informed in their decision making.

Trends and issues in clinical research on satisfaction and quality of life after mastectomy and breast reconstruction: a 5-year scoping review

Breast reconstruction (BR) aims to improve the satisfaction and quality of life (QOL) of breast cancer survivors. Clinical studies using patient-reported outcomes (PROs) can therefore provide relevant information to the patients and support decision-making. This scoping review was conducted to analyze recent trends in world regions, methods used, and factors investigated. The literature search was conducted in August 2022. Databases of PubMed, MEDLINE, and CINAHL were searched for relevant English-language studies published from 2017 to 2022. Studies involving women with breast cancer who underwent BR after mastectomy and investigated PROs after BR using BR-specific scales were included. Data on the country, publication year, study design, PRO measures (PROMs) used, time points of surveys, and research themes were collected. In total, 147 articles met the inclusion criteria. BREAST-Q was the most widely used, contributing to the increase in the number and diversification of studies in this area. Such research has been conducted mainly in North America and Europe and is still developing in Asia and other regions. The research themes involved a wide range of clinical and patient factors in addition to surgery, which could be influenced by research methods, time since surgery, and even cultural differences. Recent BR-specific PROMs have led to a worldwide development of research on factors that affect satisfaction and QOL after BR. PRO after BR may be influenced by local cultural and social features, and it would be necessary to accumulate data in each region to draw clinically useful conclusion.

Who Are We Missing: Does Engagement in Patient-Reported Outcome Measures for Breast Cancer Vary by Age, Race, or Disease Stage?

INTRODUCTION

Patient-reported outcome measures (PROM) are used to assess value-based care. Little is known as to whether PROM response in breast cancer reflects the diverse patient population. The BREAST-Q, a validated measure of satisfaction and quality of life, and Recovery Tracker, a postoperative assessment tool, are PROM routinely delivered to all patients undergoing breast surgery at our institution. Here we determine whether response to PROM differs by age, race, language, or disease stage.

METHODS

All patients who had a breast operation between January 2020 and July 2021 were requested to complete the BREAST-Q and Recovery Tracker. Non-responders did not complete the PROM at any timepoint; responders completed 1 or more. Primary outcomes included rates of non-response versus response overall.

RESULTS

Of 6374 patients identified, 5653 (88.7%) responded to either PROM [4366/4751 (91.9%) BREAST-Q; 2746/3384 (81.1%) Recovery Tracker]. On univariate analysis, non-responders were older (60 years versus 55 years, p < 0.001) and more often non-English speaking (p < 0.001), Hispanic ethnicity (p = 0.031), and Black race (p < 0.001), versus responders. On multivariate analysis, non-responders were significantly more often Black race and non-English speaking (p < 0.001). Non-English speakers were significantly less responsive among all ethnicities and races except Black race. Although breast cancer stage did not reach significance for response, patients with malignant disease and those receiving neoadjuvant chemotherapy responded more often.

CONCLUSIONS

Our findings demonstrate high patient engagement using 2 different PROM following breast surgery, but suggest that PROM results may not reflect the experience of the entire breast cancer population. Care process changes based solely on PROM should consider these findings to ensure that the views of the entire spectrum of patients with breast cancer are represented.

[Breast Reconstruction: Impact of the Procedure on Quality of Life]

English Breast cancer and the surgical procedures associated with it have a major impact on the quality of life of affected patients. Research shows that the loss of the breast and the associated change in body image have a major impact on the female self-image for many women. This has a strong negative impact on the quality of life of those affected. With modern clinical outcome research including treatment results from the patient's perspective in the form of patient-reported outcome measures (PROMs), the satisfaction and quality of life of those affected can be measured, analysed and compared. This review examines the extent to which breast reconstruction improves the quality of life for many women and how the different reconstruction methods vary in their impact on quality of life and satisfaction. In addition, the review discusses the importance of standardised recording and analysis of PROMs in combination with objective clinical data and their integration into the treatment process, and it demonstrates implementation options. Such systematic recording of PROMs enables the creation of databases and registers, the evaluation of which provides information that can be used for scientific and clinical purposes. Based on these research results, prognostic models can be created and treatment results can be examined in comparative studies facilitating clinical decision-making and quality controls.

Impact of Immediate and Delayed Breast Reconstruction on Quality of Life of Breast Cancer Patients

A mastectomy affects the psychological, social, and sexual well-being of patients. Research has confirmed that breast reconstruction is important for improving the quality of life in patients with breast cancer. The aim of this study was to assess the quality of life of patients who underwent a mastectomy followed by immediate or delayed breast reconstruction. This prospective study was conducted from January 2018 to March 2020 at the Clinical Hospital Center Osijek, using the health questionnaire SF-36. The study included 79 patients. The results of the study showed that patients who underwent a mastectomy had the lowest scores in the domain of restriction due to physical difficulties, 18.8 (6.3−31.3), in physical functioning and limitation due to emotional difficulties, 16.7 (8.3−33.3), in mental health. In immediate breast reconstruction, patients rated better physical health (p < 0.001), while patients who underwent delayed breast reconstruction rated their mental health worse (p < 0.001) as measured by the SF-36 questionnaire. Conclusion: The results of this study show that patients without breast reconstruction rated their quality of life worse than patients who underwent immediate and delayed breast reconstruction after mastectomy. There is no difference in the quality of life between patients who underwent immediate and delayed breast reconstruction after mastectomy.

Patient-Reported Outcomes and Complications Following Breast Reconstruction: A Comparison Between Biological Matrix-Assisted Direct-to-Implant and Latissimus Dorsi Flap

Background

Implant-based breast reconstruction is increasingly becoming the most common method of postmastectomy breast reconstruction in use today. As the traditional autologous reconstruction technique, latissimus dorsi flap (LDF) is employed by surgeons for reconstruction after breast cancer surgery, including partial mastectomy, modified radical mastectomy, and others. The authors aim to compare patient-reported outcomes (PROs) and complications between the SIS matrix-assisted direct-to-implant (DTI) breast reconstruction and the autologous LDF breast reconstruction.

Methods

Patients undergoing the SIS matrix-assisted DTI reconstruction or mastectomy with LDF reconstruction or partial mastectomy with mini latissimus dorsi flap (MLDF) reconstruction were enrolled in a single institution from August 2010 to April 2019. Patients were included for analysis and divided into three groups: those who underwent LDF reconstruction, those who underwent MLDF reconstruction, and patients who underwent SIS matrix-assisted DTI breast reconstruction. PROs (using the BREAST-Q version 2.0 questionnaire) and complications were evaluated.

Results

A total of 135 patients met the inclusion criteria: 79 patients (58.5%) underwent SIS matrix-assisted DTI, 29 patients (21.5%) underwent LDF breast reconstruction, and 27 patients (20%) underwent MLDF breast reconstruction. PROs and complication rates between LDF reconstruction group and MLDF reconstruction group showed no statistically significant differences. Furthermore, BREAST-Q responses found that patients in the whole autologous LDF reconstruction group had better psychosocial well-being, showing a mean score of 84.31 ± 17.28 compared with SIS matrix-assisted DTI reconstruction, with a mean score of 73.52 ± 19.96 (p = 0.005), and expressed higher sexual well-being (69.65 ± 24.64 vs. 50.95 ± 26.47; p = 0.016). But there were no statistically significant differences between the two groups for postoperative complications.

Conclusion

This retrospective study showed no statistically significant differences between LDF breast reconstruction and MLDF breast reconstruction. However, patients in the whole autologous LDF reconstruction group yielded superior PROs than patients in the SIS matrix-assisted DTI reconstruction group in the psychosocial well-being and sexual well-being domains.

Exercise after Breast Reconstruction Surgery: Evaluating Current Trends and Practices of U.S. Plastic Surgeons

Breast cancer patients have reported restricted mobility, pain, lymphedema, and impaired sensation and strength after breast reconstruction surgery. Many studies have demonstrated benefits of early exercise intervention (within the first 2 weeks) for functional recovery after breast surgery. From the surgeon's perspective, there is a concern that early postoperative exercise can potentially lead to complications or even reconstruction failure. The purpose of this study was to evaluate current trends and practices related to patient exercise after breast reconstruction among plastic surgeons in the United States.

Methods

An anonymous, electronic survey was sent to a random cohort of 2336 active members of the American Society of Plastic Surgeons. The survey consisted of 23 questions and was used to assess how plastic surgeons currently manage patients postoperatively after breast reconstruction.

Results

Responses were received from 228 plastic surgeons. Thirty-six (18%) respondents reported never prescribing physical therapy (PT) postoperatively. In total, 154 (76%) prescribe PT to less than 50% of their patients, and those who do most commonly prescribe it more than 3 weeks postoperatively. There was no difference in perceived rate of complications by respondents who prescribe early versus late exercise (χ ² (5) = 8.815, P = 0.117).

Conclusions

Based on our survey results, only a small percentage of plastic and reconstructive surgeons support early initiation of exercise, and PT is being prescribed to a minority of patients. Surgeons and physical therapists must work together to devise a recovery program that maximizes functional outcomes for patients while also limiting complications.

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.

Protocol for a national cohort study to explore the long-term clinical and patient-reported outcomes and cost-effectiveness of implant-based and autologous breast reconstruction after mastectomy for breast cancer: the brighter study

INTRODUCTION

Breast reconstruction (BR) is offered to improve quality of life for women with breast cancer undergoing mastectomy. As most women will be long-term breast cancer survivors, high-quality information regarding the long-term outcomes of different BR procedures is essential to support informed decision-making. As different techniques vary considerably in cost, policymakers also require high-quality cost-effectiveness evidence to inform care. The Brighter study aims to explore the long-term clinical and patient-reported outcomes (PROs) of implant-based and autologous BR and use health economic modelling to compare the long-term cost-effectiveness of different reconstructive techniques.

METHODS AND ANALYSIS

Women undergoing mastectomy and/or BR following a diagnosis of breast cancer between 1 January 2008 and 31 March 2009 will be identified from hospital episode statistics (HES). Surviving women will be contacted and invited to complete validated PRO measures including the BREAST-Q, EQ-5D-5L and ICECAP-A, or opt out of having their data included in the HES analysis. Long-term clinical outcomes will be explored using HES data. The primary outcome will be rates of revisional surgery between implant-based and autologous procedures. Secondary outcomes will include rates of secondary reconstruction and reconstruction failure. The long-term PROs of implant-based and autologous reconstruction will be compared using BREAST-Q, EQ-5D-5L and ICECAP-A scores. Multivariable regression will be used to examine the relationship between long-term outcomes, patient comorbidities, sociodemographic and treatment factors. A Markov model will be developed using HES and PRO data and published literature to compare the relative long-term cost-effectiveness of implant-based and autologous BR.

ETHICS AND DISSEMINATION

The Brighter study has been approved by the South-West -Central Bristol Research Ethics Committee (20/SW/0020), and the Confidentiality Advisory Group (20/CAG/0021). Results will be published in peer-reviewed journals and presented at national meetings. We will work with the professional associations, charities and patient groups to disseminate the results.

Innovations for the future of breast surgery

BACKGROUND

Future innovations in science and technology with an impact on multimodal breast cancer management from a surgical perspective are discussed in this narrative review. The work was undertaken in response to the Commission on the Future of Surgery project initiated by the Royal College of Surgeons of England.

METHODS

Expert opinion was sought around themes of surgical de-escalation, reduction in treatment morbidities, and improving the accuracy of breast-conserving surgery in terms of margin status. There was emphasis on how the primacy of surgical excision in an era of oncoplastic and reconstructive surgery is increasingly being challenged, with more effective systemic therapies that target residual disease burden, and permit response-adapted approaches to both breast and axillary surgery.

RESULTS

Technologies for intraoperative margin assessment can potentially half re-excision rates after breast-conserving surgery, and sentinel lymph node biopsy will become a therapeutic procedure for many patients with node-positive disease treated either with surgery or chemotherapy as the primary modality. Genomic profiling of tumours can aid in the selection of patients for neoadjuvant and adjuvant therapies as well as prevention strategies. Molecular subtypes are predictive of response to induction therapies and reductive approaches to surgery in the breast or axilla.

CONCLUSION

Treatments are increasingly being tailored and based on improved understanding of tumour biology and relevant biomarkers to determine absolute benefit and permit delivery of cost-effective healthcare. Patient involvement is crucial for breast cancer studies to ensure relevance and outcome measures that are objective, meaningful, and patient-centred.

Protocol for a multicentre, prospective, cohort study to investigate patient satisfaction and quality of life after immediate breast reconstruction in Japan: the SAQLA study

INTRODUCTION

The aim of breast reconstruction (BR) is to improve patients' health-related quality of life (HRQOL). Therefore, measuring patient-reported outcomes (PROs) would clarify the value and impact of BR on a patient's life and thus would provide evidence-based information to help decision-making. The Satisfaction and Quality of Life After Immediate Breast Reconstruction study aimed to investigate satisfaction and HRQOL in Japanese patients with breast cancer who undergo immediate breast reconstruction (IBR).

METHODS AND ANALYSIS

This ongoing prospective, observational multicentre study will assess 406 patients who had unilateral breast cancer and underwent mastectomy and IBR, and were recruited from April 2018 to July 2019. All participants were recruited from seven hospitals: Okayama University Hospital, Iwate Medical University Hospital, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Showa University Hospital, University of Tsukuba Hospital, Osaka University Hospital and Yokohama City University Medical Center. The patients will be followed up for 36 months postoperatively. The primary endpoint of this study will be the time-dependent changes in BREAST-Q satisfaction with breast subscale scores for 12 months after reconstructive surgery, which will be collected via an electronic PRO system.

ETHICS AND DISSEMINATION

This study will be performed in accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects published by Japan's Ministry of Education, Science and Technology and the Ministry of Health, Labour and Welfare, the modified Act on the Protection of Personal Information and the Declaration of Helsinki. This study protocol was approved by the institutional ethics committee at the Okayama University Graduate School of Medicine, Dentistry, on 2 February 2018 (1801-039) and all other participating sites. The findings of this trial will be submitted to an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

UMIN000032177.

Health-related quality of life in breast cancer patients: review of reviews from 2008 to 2018

BACKGROUND

Breast cancer still is a topic. This overview of the literature aimed to update the current knowledge on quality of life in breast cancer patients.

METHODS

A review of literature in MEDLINE, Cochrane Database of Systematic Reviews and Google Scholar were carried out to identify review papers on health-related quality of life in breast cancer during the 2008 to 2018. All publications were screened using the PRISMA guideline. The methodological quality of reviews was assessed using the AMSTAR. The findings were summarized and tabulated accordingly.

RESULTS

Within over a decade, a total of 974 review papers were identified which according to the study selection criteria finally we have evaluated 82 reviews. Of these about 85% had a reasonable methodological quality. The findings were mainly summarized on several headings including instruments used to measure quality of life, treatment, supportive care, psychological distress, and symptoms. Questionnaires had a good performance to quantify quality of life in breast cancer patients. Most reviews were focused on the impact of treatment including endocrine therapy as well as integrating complementary and alternative medicine into the current practice. According to the reviews, yoga was the most recommended exercise to improve quality of life in breast cancer patients.

CONCLUSION

Overall, the findings from this overview indicated that quality of life in breast cancer patients enhanced during the last decade. Several simple but effective interventions such as physical activity and psychosocial interventions proved to be effective in improving quality of life in this population. However, management of symptoms such as pain, and lymphedema, issues related to worry, sexual function especially for young patients, and the future outlooks all are among topics that deserve further consideration. Also, this overview indicated that methodological issues in measuring quality of life in breast cancer patients improved greatly, but still there is a long way to go to understand what really matter to patients.

The Role of Oncoplastic Surgery for Breast Cancer

OPINION STATEMENT

Oncoplastic surgery (OPS) expands the indications and possibilities of breast-conserving surgery (BCS) by allowing for a wider cancer resection than lumpectomy. Ongoing investigation and reporting of OPS outcomes along with improvements in comprehensive training in breast surgical oncology will impact on awareness and lead to increased adoption of these techniques. Indications for OPS include concern about clear margins, poor tumor location (upper inner pole and lower quadrant), multifocality, need for skin excision, and poor candidacy for mastectomy and reconstruction. OPS has been proven to be oncological safe with comparable rates of complications, positive margins, and re-excisions with BCS. Additionally, OPS has a positive impact on the quality of life and self-esteem when compared with those patients that underwent BCT.

The Value of Morphometric Measurements in Risk Assessment for Donor-Site Complications after Microsurgical Breast Reconstruction

Microsurgical abdominally-based reconstruction is considered the gold standard in autologous breast reconstruction. Despite refined surgical procedures, donor-site complications still occur, reducing patient satisfaction and quality of life. Recent work has outlined the potential of morphometric measurements in risk assessment for postoperative hernia development. With rising demand for personalised treatment, the goal of this study was to investigate their potential in risk assessment for any donor site complication. In this retrospective cohort study, 90 patients were included who each received microsurgical breast reconstruction at the hands of one surgeon between January 2015 and May 2017. Donor-site complications formed the primary outcome and were classified according to Clavien-Dindo. Morphometric measurements were taken on a routinely performed computed tomographic angiogram. Complications occurred in 13 of the 90 (14.4%) cases studied. All patients who developed any type of postoperative donor site complication had a history of abdominal surgery. The risk of postoperative complications increased by 3% with every square centimetre of omental fat tissue (OR 1.03, 95% CI 1.00-1.06, and p-value = 0.022). Morphometric measurements provide valuable information in risk assessment for donor-site complications in abdominally-based breast reconstruction. They may help identify personalised reconstructive options for maximal postoperative patient satisfaction and quality of life.

Use of Postmastectomy Radiation in Patients Treated for Invasive Breast Cancer with Mastectomy and Immediate Reconstruction

Immediate reconstruction after mastectomy helps women manage the psychological impact of deforming surgery. Postmastectomy radiation therapy (PMRT) can negatively impact the aesthetic result after breast reconstruction. We performed this study to achieve a better understanding of how PMRT is used after reconstruction in our institution. We conducted a retrospective review of a pro-spectively maintained database of all women who underwent mastectomy for invasive breast cancer followed by immediate reconstruction from 2006 to 2017. Patients were divided into two groups depending on whether PMRT was included in their treatment, and we compared clinical and pathologic characteristics to determine which factors were likely to lead to PMRT. A total of 315 women treated with mastectomy and immediate reconstruction were identified. A total of 96 were treated with PMRT; 219 had mastectomy and immediate reconstruction without radiotherapy. Tumor characteristics, tumor stage, demographics, and comorbidities did not predict the use of PMRT. Neoadjuvant chemotherapy (NAC) was the most powerful predictor for using PMRT. In 47 of 81 (58%) patients treated with NAC, PMRT was used. Whereas 49 of 234 (21%) patients who did not receive NAC were treated with PMRT ( P = 0.0001, risk ratio 2.77, 95 per cent confidence interval 2.03–3.77). In our institution, patients treated with NAC followed by mastectomy and immediate reconstruction are significantly more likely to receive PMRT. The increased use of PMRTafter NAC should be factored into the preoperative discussion with patients choosing mastectomy and immediate reconstruction.

Immediate and delayed autologous abdominal microvascular flap breast reconstruction in patients receiving adjuvant, neoadjuvant or no radiotherapy: a meta-analysis of clinical and quality-of-life outcomes

BACKGROUND

Effects of postmastectomy radiotherapy (PMRT) on autologous breast reconstruction (BRR) are controversial regarding surgical complications, cosmetic appearance and quality of life (QOL). This systematic review evaluated these outcomes after abdominal free flap reconstruction in patients undergoing postoperative adjuvant radiotherapy (PMRT), preoperative radiotherapy (neoadjuvant radiotherapy) and no radiotherapy, aiming to establish evidence-based optimal timings for radiotherapy and BRR to guide contemporary management.

METHODS

The study was registered on PROSPERO (CRD42017077945). Embase, MEDLINE, Google Scholar, CENTRAL, Science Citation Index and ClinicalTrials.gov were searched (January 2000 to August 2018). Study quality and risk of bias were assessed using GRADE and Cochrane's ROBINS-I respectively.

RESULTS

Some 12 studies were identified, involving 1756 patients (350 PMRT, 683 no radiotherapy and 723 neoadjuvant radiotherapy), with a mean follow-up of 27·1 (range 12·0-54·0) months for those having PMRT, 16·8 (1·0-50·3) months for neoadjuvant radiotherapy, and 18·3 (1·0-48·7) months for no radiotherapy. Three prospective and nine retrospective cohorts were included. There were no randomized studies. Five comparative radiotherapy studies evaluated PMRT and four assessed neoadjuvant radiotherapy. Studies were of low quality, with moderate to serious risk of bias. Severe complications were similar between the groups: PMRT versus no radiotherapy (92 versus 141 patients respectively; odds ratio (OR) 2·35, 95 per cent c.i. 0·63 to 8·81, P = 0·200); neoadjuvant radiotherapy versus no radiotherapy (180 versus 392 patients; OR 1·24, 0·76 to 2·04, P = 0·390); and combined PMRT plus neoadjuvant radiotherapy versus no radiotherapy (272 versus 453 patients; OR 1·38, 0·83 to 2·32, P = 0·220). QOL and cosmetic studies used inconsistent methodologies.

CONCLUSION

Evidence is conflicting and study quality was poor, limiting recommendations for the timing of autologous BRR and radiotherapy. The impact of PMRT and neoadjuvant radiotherapy appeared to be similar.

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.

Chinese multicentre prospective registry of breast cancer patient-reported outcome-reconstruction and oncoplastic cohort (PRO-ROC): a study protocol

INTRODUCTION

Available patient-reported outcome (PRO) studies are mainly from single institution or of small sample size, and the variations across hospitals and regions were not fully analysed. A multicentre, prospective, patient-reported outcome-reconstruction and oncoplastic cohort (PRO-ROC) will be planned to assess the PROs of Chinese patients with breast cancer who will undergo breast reconstruction (BR) or oncoplastic breast-conserving surgery (OBCS).

METHODS AND ANALYSIS

The inclusion criteria are female patients with breast cancer aged >18 years old who will undergo BR or OBCS. This cohort will include at least 10 000 consecutive patients (about 5000 patients who will undergo BR and 5000 patients who will undergo OBCS). The exposures were surgery types: BR and OBCS regardless of the techniques and materials used. The primary endpoint will be PROs, which include BREAST-Q and quality of life (European Organisation for Research and Treatment (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) and EORTC QoL Breast Cancer-specific version (QLQ-BR23)). All patients will be followed up to 24 months after operations. All data will be prospectively collected using an app software. Data will be analysed using SPSS and Stata software.

ETHICS AND DISSEMINATION

This study follows the Helsinki Declaration. All patients will be asked to sign an informed consent before enrolment. The results of this study will be presented at national and international meetings and published in a scientific peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04030845; Pre-results.

The Performance of Patient-Worn Actigraphy Devices to Measure Recovery after Breast Reconstruction

Annually, over 250,000 women are diagnosed with breast cancer with over one-third undergoing mastectomy and contemplating reconstruction. Surgical breast reconstructive options vary in post-operative recovery, yet with a paucity of objective data to inform women of their expected recovery after flap or implant-based reconstruction. As a result, patient decision-making is based primarily on surgeon preference and subjective data regarding perceived invasiveness of surgical options. This study aims to identify recovery outcomes of interest to breast cancer patients and to determine the feasibility of objectively measuring patient recovery after mastectomy and reconstruction using patient-worn actigraphy devices.

PROMs in post-mastectomy care: Patient self-reports (BREAST-Q™) as a powerful instrument to personalize medical services

One of the goals of immediate breast reconstruction (IBR) is to satisfy the patient's outcome. Recent studies therefore tended to focus on the patient's perception of the care and on the impact on quality of life using patients-reported-outcome-measures (PROMs), able to measure the health status directly without the clinician's interposition. We present a preliminary prospective study on 333 patients who underwent mastectomy with IBR in a two-year period, in a single Italian centre, using a dedicated PROMs, the BREAST-Q™, to determine the patient's satisfaction. We studied two groups of IBR: Group A (two-step with tissue-expander) and Group B (one-step: prosthesis/mesh) and conducted a pre- and post-operative comparison for each group to evaluate score-gain over time, and a group-score comparison to determine whether differences were significant between reconstruction types. Two-hundred-and-nine were actually enrolled and 132 completed all the questionnaires. The response rate was 62.8% and the compliance rate (completion of all the questionnaires) was 63.1%. In both groups all the analyzed domains worsened comparing the pre and post-operative period; the differences were statistically significant only for physical and sexual-wellbeing. In the comparison between the two groups, none of the detected differences reached the statistical significance. According to our experience, we can state that PROMs could improve the health concept redefining the variables to be monitored even if data is still insufficient to draw any definitive conclusion. PROMs can help surgeons and patients decide the most appropriate surgery for a particular patient-profile and to identify those who require further support.

Measuring Patient-Reported Outcomes: Key Metrics in Reconstructive Surgery

Satisfaction and improved quality of life are among the most important outcomes for patients undergoing plastic and reconstructive surgery for a variety of diseases and conditions. Patient-reported outcome measures (PROMs) are essential tools for evaluating the benefits of newly developed surgical techniques. Modern PROMs are being developed with new psychometric approaches, such as Rasch Measurement Theory, and their measurement properties (validity, reliability, responsiveness) are rigorously tested. These advances have resulted in the availability of PROMs that provide clinically meaningful data and effectively measure functional as well as psychosocial outcomes. This article guides the reader through the steps of creating a PROM and highlights the potential research and clinical uses of such instruments. Limitations of PROMs and anticipated future directions in this field are discussed.

Optimal assessment tools in assessing breast surgery: patient reported outcome measures (PROMs) vs. objective measures

Improving the health-related quality of life (HRQoL) of patients is the fundamental aim of aesthetic breast surgery and its importance is increasingly recognised in breast cancer-related surgery. There has been growing acceptance of the value of assessing physical, psychological and social well-being through patient reported outcome measures (PROMs). It is important to consider the role of PROMs in relation to objective measures to ensure that the optimal assessment tools are selected when assessing outcomes in breast surgery. A narrative review was conducted of published articles identified on Ovid Medline by searching the terms: patient reported outcome measures, quality of life (QoL), functional outcomes, aesthetic outcomes, complications and breast surgery. Reference lists were also examined to find relevant articles not detected through the search. Survival and mortality are outcomes of immense importance in breast surgery that are not suitable for assessment through PROMs and should be measured objectively. Post-operative complication rates and markers of their severity are most appropriately assessed using objective measures, however, patients may provide valuable insights into the impact complications have on their QoL. All current assessment tools for assessing aesthetic outcome have inherent limitations, and thus it is likely that both subjective and objective measures are required to comprehensively assess aesthetic outcomes in breast surgery. Physical dysfunction can be assessed objectively, however, PROMs may better evaluate physical well-being, reflecting the real-life implications of a change in function. Psychological and social well-being is irrefutably personal in nature and best assessed through PROMs. There is no one optimal assessment tool for assessing breast surgery outcomes. Utilising a combination of PROMs and objective measures is necessary to accurately and comprehensively evaluate the impact and effectiveness of surgical breast interventions.

Quality of life after oncoplastic breast-conserving surgery: a systematic review

BACKGROUND

Oncoplastic breast-conserving surgery (OBCS) has gained increasing attention as a treatment option for early breast cancer patients, aiming to achieve the best possible breast symmetry with concomitant oncological safety. This paper aims to systematically review the current literature on patient quality of life (QoL) after OBCS compared with QoL after breast-conserving surgery (BCS) alone.

METHODS

MEDLINE via Ovid, CINAHL via EBSCO and PsycINFO via OvidSP were searched to retrieve all relevant studies. The reference lists of identified eligible studies were manually examined to search for additional eligible studies. The methodological quality of the included studies was assessed using the Critical Appraisal Skills Programme.

RESULTS

A total of six articles met the inclusion criteria. Most of the studies used validated patient-reported outcome measures for assessing QoL with good response rates. However, only one study was of sufficiently good quality to provide good evidence (P < 0.05) in favour of OBCS, while the remainder were of low to moderate quality with differences in outcomes that were not statistically significant.

CONCLUSION

The review found that the current evidence base is limited and not adequate enough to support or to reject the assumption that OBCS is associated with improved QoL when compared with QoL post-BCS. However, the majority of studies show that OBCS is associated with a trend towards better patient QoL. The impact of OBCS on patient QoL needs to be more adequately investigated. Large prospective cohort studies to assess the impact of OBCS on QoL compared with QoL post-BCS are strongly recommended.

Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives

The management of postoperative pain is of critical importance for women undergoing breast reconstruction after surgical treatment for breast cancer. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Multimodal analgesia pain management strategies with nonopioid analgesics have improved the value of surgical care in patients undergoing various operations but have only recently been reported in reconstructive breast surgery. Regional anesthesia techniques, with paravertebral blocks (PVBs) and transversus abdominis plane (TAP) blocks, and enhanced recovery after surgery (ERAS) pathways have been increasingly utilized in opioid-sparing multimodal analgesia protocols for women undergoing breast reconstruction. The objectives of this review are to 1) comprehensively review regional anesthesia techniques in breast reconstruction, 2) outline important components of ERAS protocols in breast reconstruction, and 3) provide evidence-based recommendations regarding each intervention included in these protocols. The authors searched across six databases to identify relevant articles. For each perioperative intervention included in the ERAS protocols, the literature was exhaustively reviewed and evidence-based recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation system methodology. This study provides a comprehensive evidence-based review of interventions to optimize perioperative care and postoperative pain control in breast reconstruction. Incorporating evidence-based interventions into future ERAS protocols is essential to ensure high value care in breast reconstruction.

BREAST-Q Measurement of the Patient Perspective in Oncoplastic Breast Surgery: A Systematic Review

Background

Since BREAST-Q was developed in 2009, it has been widely used by clinicians and researchers to capture information regarding health-related quality of life (HRQoL) and patient satisfaction related to breast surgery. Yet clinical guidelines regarding the use of BREAST-Q for assessment of success of surgery in women with breast cancer remain limited. To maximize the benefits of using BREAST-Q to inform clinical decision making, this systematic review aimed to identify and appraise current evidence on patient-reported outcomes (PROs) assessed by BREAST-Q associated with breast oncoplastic surgery.

Methods

A detailed search strategy was implemented and electronic databases searched include PubMed, MEDLINE, CINAHL, and PsycINFO. Review was limited to peer-reviewed studies published in English from 2009 to January 2018. Any interventional and observational studies that used BREAST-Q to assess PROs in the assessment of breast oncoplastic surgery were included.

Results

Fifty-four peer-reviewed articles met inclusion criteria. Fifty-three studies were observational, 1 study was interventional. Current comparative studies using BREAST-Q indicated that abdominal flap, buttock flap, or thigh flap reconstruction offered highest satisfaction with breast; contralateral prophylactic mastectomy with immediate reconstruction offered higher levels of satisfaction with breast, but poor postsurgical physical well-being. Silicone implant and no radiation therapy offered higher level satisfaction and HRQoL.

Conclusions

Current evidence showed that BREAST-Q can effectively measure patient's satisfaction and HRQoL in relation to different type of breast oncoplastic surgeries. BREAST-Q captured meaningful and reliable information from the patients' perspective and may be useful for clinical decision making.

Met and Unmet Expectations for Breast Reconstruction in Early Posttreatment Breast Cancer Survivors

The purpose of this study was to evaluate the prevalence of met and unmet expectations after breast reconstruction among breast cancer survivors following mastectomy. A secondary objective was to examine reasons women report their experiences of reconstructive surgery were better or worse than expected. As part of a larger study of breast cancer survivors, participants completed self-administered questionnaires within 8 months of diagnosis and at 6, 12, and 18 months later. At the 18-month follow-up, women who had breast reconstruction were asked whether their reconstruction was better, the same, or worse than expected. The sample consisted of 130 survivors (mean age = 48.5 years) who had breast reconstruction following mastectomy and completed the 18-month follow-up, 42% of whom reported their reconstruction was worse than expected and only 25% reported it was better. Most frequently reported reasons for reconstruction being worse than expected were related to appearance of the reconstructed breast and pain. A high percentage of patients with breast cancer undergoing breast reconstruction following mastectomy reported the results as worse than expected, with the primary reasons for dissatisfaction related to the feel and appearance of the reconstructed breast. Patients with breast cancer considering breast reconstruction need better preoperative education or understanding about what to expect from reconstruction.

Acellular Dermal Matrix in Immediate Expander/Implant Breast Reconstruction: A Multicenter Assessment of Risks and Benefits

BACKGROUND

Acellular dermal matrix has gained widespread acceptance in immediate expander/implant reconstruction because of perceived benefits, including improved expansion dynamics and superior aesthetic results. Although previous investigators have evaluated its risks, few studies have assessed the impact of acellular dermal matrix on other outcomes, including patient-reported measures.

METHODS

The Mastectomy Reconstruction Outcomes Consortium Study used a prospective cohort design to evaluate patients undergoing postmastectomy reconstruction from 10 centers and 58 participating surgeons between 2012 and 2015. The analysis focused on women undergoing immediate tissue expander reconstruction following mastectomies for cancer treatment or prophylaxis. Medical records and patient-reported outcome data, using the BREAST-Q and Numeric Pain Rating Scale instruments, were reviewed. Bivariate analyses and mixed-effects regression models were applied.

RESULTS

A total of 1297 patients were evaluated, including 655 (50.5 percent) with acellular dermal matrix and 642 (49.5 percent) without acellular dermal matrix. Controlling for demographic and clinical covariates, no significant differences were seen between acellular dermal matrix and non-acellular dermal matrix cohorts in overall complications (OR, 1.21; p = 0.263), major complications (OR, 1.43; p = 0.052), wound infections (OR, 1.49; p = 0.118), or reconstructive failures (OR, 1.55; p = 0.089) at 2 years after reconstruction. There were also no significant differences between the cohorts in the time to expander/implant exchange (p = 0.78). No significant differences were observed in patient-reported outcome scores, including satisfaction with breasts, psychosocial well-being, sexual well-being, physical well-being, and postoperative pain.

CONCLUSIONS

In this multicenter, prospective analysis, the authors found no significant acellular dermal matrix effects on complications, time to exchange, or patient-reported outcome in immediate expander/implant breast reconstruction. Further studies are needed to develop criteria for more selective use of acellular dermal matrix in these patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P &lt; 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

Tissue expansion for breast reconstruction: Methods and techniques

OBJECTIVE

In this work, the authors review recent data on the different methods and techniques of TE/implant-based reconstruction to determine the complication profiles and the advantages and disadvantages of the different techniques. This information will be valuable for surgeons performing breast reconstructions.

MATERIALS AND METHODS

A thorough literature review was conducted by the authors concerning the current strategy of tissue expander (TE)/implant-based breast reconstruction following breast cancer surgery.

RESULTS

Loss of the breast can strongly affect a woman's personal and social life while breast reconstruction reduces the sense of mutilation felt by women after a mastectomy, and provides psychosocial as well as aesthetic benefits. TE/implant-based reconstruction is the most common breast reconstructive strategy, constituting almost 65% of all breast reconstructions in the US. Although numerous studies have been published on various aspects of alloplastic breast reconstructions, most studies are single-center observations. No evidence-based guidelines are available as yet. Conventional TE/implant-based reconstruction can be performed as a two-stage procedure either in the immediate or delayed setting. Moreover, the adjunctive use of acellular dermal matrix further broadened the alloplastic breast reconstruction indication and also enhanced aesthetic outcomes.

CONCLUSIONS

TE/implant-based reconstruction has proved to be a safe, cost-effective, and reliable technique that can be performed in women with various comorbidities. Short operative time, fast recovery, and absence of donor site morbidity are other advantages over autologous breast reconstruction.

Surgical Determinants of Patient-Reported Outcomes following Postmastectomy Reconstruction in Women with Breast Cancer

BACKGROUND

This national prospective cohort study compared the patient-reported outcomes of breast cancer patients undergoing postmastectomy autologous reconstruction to those who had breast implants, in terms of aesthetic appearance; levels of psychological, physical, and sexual well-being; and overall satisfaction.

METHODS

Of 5063 women who underwent immediate reconstruction (n = 3349) or delayed reconstruction (n = 1714) between January 1, 2008, and March 31, 2009, in England, 2923 women who gave informed consent were sent validated, procedure-specific, 18-month follow-up questionnaires. Outcome scale scores ranged from 0 (poor) to 100 (excellent); multiple linear regression was used to adjust scores for patient and treatment characteristics.

RESULTS

Two thousand two hundred eighty-nine women (78 percent) returned completed questionnaires (immediate reconstruction, n = 1528; delayed reconstruction, n = 761). For immediate reconstruction, mean overall satisfaction scores for the various techniques ranged from 67 to 85 (median, 67 to 93). For delayed reconstruction, mean overall satisfaction scores ranged from 70 to 85 (median, 75 to 100). For both groups, similar gradients were observed for the other outcome scales across techniques. Reconstruction using patients' own tissues tended to have higher mean adjusted scores compared with those techniques using implants alone (p < 0.0001 for aesthetic appearance, psychological well-being, sexual well-being, and satisfaction with outcomes for immediate and delayed reconstruction groups).

CONCLUSIONS

Women who underwent autologous reconstruction tended to report greater satisfaction than those who underwent implant reconstruction. These results can inform patients of the anticipated outcomes of their selected surgery, but further research is required to confirm whether autologous reconstruction is superior in general.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Quality of life after mastectomy with or without immediate breast reconstruction

BACKGROUND

Mastectomy with immediate breast reconstruction (IBR) is a surgical strategy in breast cancer when breast-conserving surgery is not an option. There is a lack of evidence showing an advantage of mastectomy plus IBR over mastectomy alone on health-related quality of life (QoL).

METHODS

A large prospective multicentre survey, STIC-RMI (support of innovative and expensive techniques - immediate breast reconstruction), was undertaken to study the changes in QoL in patients treated by mastectomy with or without IBR. Patients were recruited between 2007 and 2009. European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-BR23 instruments were used to assess QoL before operation, and at 6 and 12 months after surgery. A propensity score was used to compare QoL between mastectomy alone and mastectomy plus IBR, with limited bias.

RESULTS

A total of 595 patients were included from 22 French academic hospitals, of whom 407 (68·4 per cent) underwent IBR. One-year data were available for 71·1 per cent of patients. Factors associated with IBR were age, histological tumour type, palpable nodes and an attempt at breast-conserving surgery. At inclusion, QoL was significantly better in the IBR group (P < 0·001) and there was no significant change in either group during 1 year compared with baseline. Results for the QLQ-BR23 functional dimension varied according to propensity score quartiles; IBR had no influence in the lowest quartile. In the upper quartiles, QoL increased slightly over the year among patients who had IBR, whereas it decreased among those who had mastectomy alone (P = 0·037). Satisfaction with the cosmetic outcome strongly influenced QoL, especially in upper quartiles (P < 0·001). However, an unsatisfactory outcome after IBR was still considered a better condition than simple mastectomy.

CONCLUSION

The QoL benefit provided by IBR depends on patients' life status at inclusion; young active women with an in situ tumour are more likely to preserve their QoL after IBR.

Complications and thromboembolic events associated with tamoxifen therapy in patients with breast cancer undergoing microvascular breast reconstruction: a systematic review and meta-analysis

PURPOSE

Tamoxifen therapy is integral in the treatment of patients with hormone receptor-positive breast cancer. However, there is an association between tamoxifen and thromboembolic events. Flap and systemic thromboembolic events have devastating consequences in microvascular breast reconstruction. Currently, there are conflicting data on the association between tamoxifen therapy and thromboembolic complications for patients undergoing microvascular breast reconstruction. The objective of this study is to determine if perioperative tamoxifen therapy modifies the risk of complications and thromboembolic events for patients with breast cancer undergoing microvascular breast reconstruction.

METHODS

A comprehensive literature search was performed across six databases from January 2003 to February 2016. Pooled estimates and relative risk (RR) were calculated using a random-effects model, confounding was examined with meta-regression, and risk of bias was evaluated. Primary outcomes were thrombotic flap complications and total flap loss. Study quality was assessed using Downs and Black criteria.

RESULTS

Of 95 studies reviewed, 4 studies comprising 1700 patients and 2245 procedures were included for analysis. Compared to non-recipients, patients on tamoxifen were at increased risk of developing thrombotic flap complications (pooled RR 1.5; 95% CI 1.14-1.98) and total flap loss (pooled RR 3.35; 95% CI 0.95-11.91). There was no significant heterogeneity present in either outcome and no evidence of publication bias.

CONCLUSIONS

Perioperative tamoxifen therapy may increase the risk of thrombotic flap complications and flap loss for patients with breast cancer undergoing microvascular reconstruction. These findings further the ability of providers to make evidence-based recommendations in the perioperative management of patients with breast cancer.