Patients' satisfaction with the reconstructive options provided to them measured 18 months after mastectomy surgery for breast cancer

INTRODUCTION

Mastectomy patients' satisfaction with reconstructive options has not been examined.

METHODS

A national study measured 18-month satisfaction with reconstructive options and collected case-mix and reconstructive offer and uptake data on breast cancer patients having mastectomy with or without immediate reconstruction (IR) in England between January 2008 and March 2009. Multivariable logistic regression examined the relationship between satisfaction, age, IR offer and uptake, and clinical suitability.

RESULTS

Of 4796 patients, 1889 were not offered IR, 1489 declined an offer and 1418 underwent it. Women not offered IR were more likely older, obese or smokers and had higher ASA grades, ECOG scores, tumour burdens and adjuvant chemotherapy and radiotherapy likelihoods (9% of lowest suitability group offered IR; 81% in highest suitability group). 83.7% were satisfied with their reconstructive options, varying significantly by IR offer and uptake (76.1% for those not offered IR; 85.8% for those who declined IR; 91.7% following IR). Older women and women deemed more suitable for IR were more often satisfied (p-values <0.001).

CONCLUSIONS

Satisfaction varied by offer and uptake status, age and suitability score. Clinicians should target equity for women deemed unsuitable by exploring their needs and desired outcomes, standardising operative fitness assessments and utilising shared decision-making aids.

Measuring the patient perspective on latissimus dorsi donor site outcomes following breast reconstruction

BACKGROUND

There is little evidence about the long-term donor site outcome of latissimus dorsi breast reconstruction and no patient-reported outcome measures designed specifically for the procedure.

METHODS

A prospective cohort of breast cancer patients having latissimus dorsi reconstruction after a mastectomy was recruited from 270 hospitals in the United Kingdom. An 18-month follow up questionnaire containing two novel scales was sent to consenting patients. The prevalence of aesthetic and functional morbidity at the donor site was described. The two new scales were refined using the Rasch measurement model and subsequently validated.

RESULTS

1,096 women completed the new scales. 78% of patients reported that no back appearance issues had bothered them "most of the time" or "all of the time" in the past two weeks. The equivalent figure for functional morbidity was 60%. Four items were eliminated following initial psychometric testing. This produced an 8-item Back Appearance scale and an 11-item Back and Shoulder Function scale. Both scales showed adequate fit to the Rasch measurement model. Higher levels of aesthetic and functional bother were observed for completely autologous procedures versus those where latissimus dorsi reconstruction was used to cover an implant (p <0.05). Higher levels of aesthetic bother were observed in women who had suffered a perioperative complication at the donor site (p = 0.003).

CONCLUSION

These results can inform patients of the morbidity associated with latissimus dorsi reconstruction. The new scales can be used to compare groups undergoing different variations of the procedure and to monitor individual patients.

The association between complications and quality of life after mastectomy and breast reconstruction for breast cancer

BACKGROUND

Medical treatment for breast cancer is associated with substantial toxicity and patient burden. There is less known about the impact of surgical complications. Understanding this impact could provide important information for patients when they are considering surgical options.

METHODS

Between 2008 and 2009, the UK National Mastectomy and Breast Reconstruction Audit recorded surgical complications for a prospective cohort of 17,844 women treated for breast cancer at 270 hospitals; 6405 of these women were surveyed about their quality of life 18 months after surgery. Breast appearance, emotional well-being, and physical well-being were quantified on 0- to 100-point scales. Linear multiple regression models, controlling for a range of baseline prognostic factors, were used to compare the scores of patients who had complications with the scores of those who did not.

RESULTS

The overall complication rate was 10.2%. Complications were associated with little or no impairment in women undergoing mastectomy without reconstruction or with delayed reconstruction. The association was much larger for flap-related complications suffered during immediate reconstruction. The breast-appearance scores (adjusted mean difference, -23.8; 95% confidence interval [CI], -31.0 to -16.6) and emotional well-being scores (adjusted mean difference, -14.0; 95% CI, -22.0 to -6.0) of these patients were much lower than those of any other patient group. Implant-related complications were not associated with a lower quality of life in any surgical group.

CONCLUSIONS

There is a strong case for prospectively collecting flap-complication rates at the surgeon and surgical unit level and for allowing patients to access these data when they make choices about their breast cancer surgery. Cancer 2017;123:3460-7. © 2017 American Cancer Society.

Association between age and access to immediate breast reconstruction in women undergoing mastectomy for breast cancer

BACKGROUND

National guidelines state that patients with breast cancer undergoing mastectomy in England should be offered immediate breast reconstruction (IR), unless precluded by their fitness for surgery or the need for adjuvant therapies.

METHODS

A national study investigated factors that influenced clinicians' decision to offer IR, and collected data on case mix, operative procedures and reconstructive decision-making among women with breast cancer having a mastectomy with or without IR in the English National Health Service between 1 January 2008 and 31 March 2009. Multivariable logistic regression was used to examine the relationship between whether or not women were offered IR and their characteristics (tumour burden, functional status, planned radiotherapy, planned chemotherapy, perioperative fitness, obesity, smoking status and age).

RESULTS

Of 13 225 women, 6458 (48·8 per cent) were offered IR. Among factors the guidelines highlighted as relevant to decision-making, the three most strongly associated with the likelihood of an offer were tumour burden, planned radiotherapy and performance status. Depending on the combination of their values, the probability of an IR offer ranged from 7·4 to 85·1 per cent. A regression model that included all available factors discriminated well between whether or not women were offered IR (c-statistic 0·773), but revealed that increasing age was associated with a fall in the probability of an IR offer beyond that expected from older patients' tumour and co-morbidity characteristics.

CONCLUSION

Clinicians are broadly following guidance on the offer of IR, except with respect to patients' age.

Socioeconomic deprivation and inpatient complication rates following mastectomy and breast reconstruction surgery

BACKGROUND

Socioeconomic deprivation is known to influence the presentation of patients with breast cancer and their subsequent treatments, but its relationship with surgical outcomes has not been investigated. A national prospective cohort study was undertaken to examine the effect of deprivation on the outcomes of mastectomy with or without immediate breast reconstruction.

METHODS

Data were collected on patient case mix, operative procedures and inpatient complications following mastectomy with or without immediate breast reconstruction in the English National Health Service between 1 January 2008 and 31 March 2009. Multivariable logistic regression was used to examine the relationship between patients' level of (regional) deprivation and the likelihood of local (mastectomy site, flap, flap donor and implant) and distant or systemic complications, after adjusting for potential confounding factors.

RESULTS

Of 13,689 patients who had a mastectomy, 2849 (20.8 per cent) underwent immediate reconstruction. In total, 1819 women (13.3 per cent) experienced inpatient complications. The proportion with complications increased from 11.2 per cent among the least deprived quintile (Q1) to 16.1 per cent in the most deprived (Q5). Complication rates were higher among smokers, the obese and those with poorer performance status, but were not affected by age, tumour type or Nottingham Prognostic Index. Adjustment for patient-related factors only marginally reduced the association between deprivation and complication incidence, to 11.4 per cent in Q1 and 15.4 per cent in Q5. Further adjustment for length of hospital stay, hospital case volume and immediate reconstruction rate had minimal effect.

CONCLUSION

Rates of postoperative complications after mastectomy and breast reconstruction surgery were higher among women from more deprived backgrounds.

Findings of a national comparative audit of mastectomy and breast reconstruction surgery in England

OBJECTIVES

This paper summarises the findings of a national audit of mastectomy and breast reconstruction surgery carried out in England. It describes patterns of treatment, and the clinical and patient-reported quality of life outcomes associated with these types of procedure.

DESIGN

Prospective cohort study.

SETTING

All 150 National Health Service hospital groups (NHS trusts) in England that provided mastectomy or breast reconstruction surgery, along with six NHS trusts in Wales and Scotland and 114 independent hospitals.

PARTICIPANTS

Women aged 16 years and over undergoing mastectomy with or without immediate breast reconstruction, or primary delayed breast reconstruction, between 1st January 2008 and 31st March 2009.

MAIN OUTCOME MEASURES

Reconstructive utilisation, post-operative complications and sequelae, and patient-reported satisfaction and quality of life.

RESULTS

Overall, 21% of the 16,485 women who had mastectomy underwent immediate reconstruction. However, the proportion varied between regions from 9% to 43% (p < 0.001). Levels of patient satisfaction with information, choice and the quality of care were high. The proportion of women who experienced local complications was 10.30% (95% CI 9.78-10.84) for mastectomy surgery, ranged from 11.02% (9.31-12.92) to 18.24% (14.80-22.10) for different immediate reconstructive procedures, and from 5.00% (2.76-8.25) to 19.86% (16.21-23.94) for types of delayed reconstruction. Breast appearance and overall well-being scores reported 18 months after surgery were higher among women having immediate breast reconstruction compared to mastectomy only. Postoperative outcomes were similar across providers..

CONCLUSIONS

The Audit found women were highly satisfied with their peri-operative care, with hospital providers achieving similar outcomes. English providers should examine how to reduce the variation in rates of immediate reconstruction.

Reoperation rates after breast conserving surgery for breast cancer among women in England: retrospective study of hospital episode statistics

OBJECTIVES

To examine whether rate of reoperation after breast conserving surgery is associated with patients' characteristics and investigate whether reoperation rates vary among English NHS trusts.

DESIGN

Cohort study using patient level data from hospital episode statistics.

SETTING

English NHS trusts.

PARTICIPANTS

Adult women who had breast conserving surgery between 1 April 2005 and 31 March 2008.

MAIN OUTCOME MEASURE

Reoperation rates after primary breast conserving surgery within 3 months, adjusted using logistic regression for tumour type, age, comorbidity, and socioeconomic deprivation. Tumours were grouped by whether a carcinoma in situ component was coded at the time of the primary breast conserving surgery.

RESULTS

55,297 women had primary breast conserving surgery in 156 NHS trusts during the three year period. 11,032 (20.0%, 95% confidence interval 19.6% to 20.3%) women had at least one reoperation. 10,212 (18.5%, 18.2% to 18.8%) had one reoperation only; of these, 5943 (10.7%, 10.5% to 11.0%) had another breast conserving procedure and 4269 (7.7%, 7.5% to 7.9%) had a mastectomy. Of the 45,793 women with isolated invasive disease, 8229 (18.0%) had at least one reoperation. In comparison, 2803 (29.5%) of the 9504 women with carcinoma in situ had at least one reoperation (adjusted odds ratio 1.9, 95% confidence interval 1.8 to 2.0). Substantial differences were found in the adjusted reoperation rates among the NHS trusts (10th and 90th centiles 12.2% and 30.2%).

CONCLUSION

One in five women who had breast conserving surgery in England had a reoperation. Reoperation was nearly twice as likely when the tumour had a carcinoma in situ component coded. Women should be informed of this reoperation risk when deciding on the type of surgical treatment of their breast cancer.

Regional variation in use of immediate breast reconstruction after mastectomy for breast cancer in England

AIMS

English national guidelines recommend that breast reconstruction is made available to women with breast cancer undergoing mastectomy. We examined the use of immediate reconstruction (IR) across English Cancer Networks, who are responsible for the regional organisation of cancer services and ensuring equitable access to treatment.

METHODS

We analysed Hospital Episodes Statistics data for all women with breast cancer who underwent mastectomy in the English NHS between April 2006 and February 2009. IR rates were calculated for the 30 Networks. Multivariable logistic regression was used to adjust the rates for patient age, comorbidity, ethnicity and socioeconomic deprivation.

RESULTS

Of 44 837 mastectomy patients, 7375 (16.5%) underwent IR. The IR rate was highest in women under 50 years (32.7%) and lowest in women aged 70 years or over (1.5%), and was lower in women with more comorbidities. Unadjusted IR rates varied from 8.4% to 31.9% among the 30 Networks (p<0.001). Adjusting for their patient characteristics did not appreciably reduce Network-level variation, with adjusted IR rates still ranging from 8.0% to 29.4% (p<0.001). The risk-model also suggested that non-white women and those from more deprived areas were less likely to undergo immediate reconstruction.

CONCLUSIONS

There is substantial regional variation in immediate reconstruction use in England that is not explained by the characteristics of the local patient population. English Cancer Networks should act to reduce this variation. They should also examine why rates of reconstruction differ between particular patient groups.

Women gain weight and fat mass despite lipectomy at abdominoplasty and breast reduction

OBJECTIVES

In animal models, fat removal results in compensatory weight gain. No study has reported measurement of weight following lipectomy in humans. We have examined changes in weight in patients who underwent lipectomy.

METHODS

In a retrospective analysis, 16 patients who had abdominoplasty and 17 patients who underwent bilateral breast reduction were compared with 16 patients who had carpal tunnel syndrome release. Following this, a prospective study was carried out on 7 subjects awaiting abdominoplasty and 12 subjects awaiting bilateral breast reduction surgery.

RESULTS

In the retrospective study, all three patient groups gained weight following surgery. The abdominoplasty group was heavier before surgery and showed greatest weight gain but there was no statistically significant difference in weight gain between the groups. In the prospective study, the abdominoplasty group had a mean fat removal of 1.77 kg and breast reduction group had a mean of 3.22 kg. Eighteen months following surgery the abdominoplasty group showed a significant mean increase in body weight (mean increase: 4.82 kg) and body mass index (BMI) (mean increase: 1.66 kg/m(2)). In the bilateral breast reduction group, there was a non-significant mean gain in weight (mean increase: 0.67 kg) and BMI (mean increase: 0.21 kg/m(2)).

CONCLUSIONS

Patients undergoing lipectomy during abdominoplasty and bilateral breast reduction will gain weight in the long term. This weight gain probably reflects the expected gain in weight without surgery as a similar finding is observed in patients who have undergone surgery without lipectomy. These results highlight the limitation of lipectomy as a weight control measure.

Keratinocytes suppress TRP-1 expression and reduce cell number of co-cultured melanocytes - implications for grafting of patients with vitiligo

A pilot study for grafting of patients with vitiligo using cultured epithelial autografts containing melanocytes gave disappointing clinical results, with pigmentation achieved in only one out of five patients. Irrespective of the fate of melanocytes grafted back onto the patients, we experienced problems in identifying melanocytes within these well-integrated keratinocyte sheets. This led us to explore the fate of these cells within these sheets in vitro and to seek to improve their number and function within the sheets. We report that the introduction of a fibroblast feeder layer can improve melanocyte number within melanocyte/keratinocyte co-cultures initially, but at very high keratinocyte density, there is a marked loss of melanocytes (as detected by staining for S100). Additionally, we found that keratinocytes not only down-regulate melanocyte number, but also pigmentary function; thus, it was possible to identify melanocytes that were S100 positive but tyrosinase-related protein-1 (TRP-1) negative in confluent well-integrated keratinocyte sheets. In summary, our data suggest that keratinocytes at high density initially suppress melanocyte pigmentation (as evidenced by a lack of TRP-1 expression) and then cause a physical loss of melanocytes. The introduction of a fibroblast feeder layer can help maintain melanocyte number while keratinocytes are subconfluent, but fails to oppose the inhibitory influence of the keratinocytes on melanocyte TRP-1 expression.

A goniometric glove for clinical hand assessment. Construction, calibration and validation

The construction of a goniometric glove is described. Each of the sensors in the glove was calibrated over a custom built metal hand using blocks of known angles as angular references. The digital data output from each sensor of the glove were converted into angular displacements at each joint. The glove was validated for consistency of measurement and accuracy over a custom built metal jig and in the human hand. The accuracy of the glove was found to be within the limits of traditional goniometry. It is proposed that goniometric gloves could be useful in the assessment of hand function.

A new method for the assessment of suturing ability

A new method for the formal assessment of surgical ability in simple wound closure is presented. Suture tension and accuracy of placement are measured indirectly in a standardized rig using Lyofoam as a skin substitute. This method has been used to assess a group of seven junior hospital doctors before and after instruction in a workshop setting. Formal instruction reduced suture tension by an average of 30.3% for the group as a whole (P < 0.01). Standard deviation in inter-suture distance was reduced by an average of 39.4% (P < 0.05), suggesting increased accuracy of suture placement following teaching. On the basis of this study, it appears that those involved in suturing wounds would benefit from postgraduate instruction in workshop setting early in their career.

An anatomic review of the delay phenomenon: I. Experimental studies

A number of experiments were conducted to study the anatomic changes in a flap following a surgical delay using the Doppler probe to add precision to the technique. After scanning the integument of a series of anesthetized animals with the probe, each was sacrificed; a total-body arterial injection was performed with a lead oxide mixture, the integument and deep tissues were radiographed separately, and the results were correlated and compared with our previous human studies. The dog was selected from the range of animals examined, and the arterial networks of a number of skin and muscle flaps were studied with and without a surgical delay. The study included the use of a tissue expander. Results revealed that an adjacent cutaneous perforator could be captured with safety on the artery at the base of an undelayed flap; that the survival length of that flap was related to the distance between perforators; that the necrosis line of the flap usually appeared in the zone of choke vessels connecting adjacent territories; that a surgical delay results in a dilatation of existing vessels with maximal effect in the zone of choke arteries; that the most effective delay was obtained by elevating the flap in stages from the base, leaving detachment of the tip until last; that tissue expansion is a form of surgical delay, with particular emphasis on vessel hypertrophy; and that similar changes occur when a muscle is delayed. The clinical applications of this investigation are presented in Part II of this anatomic review of the delay phenomenon.

An anatomic review of the delay phenomenon: II. Clinical applications

This paper applies the anatomic concepts and data obtained from our animal experimental studies of the delay phenomenon to a series of clinical cases. Similar clinical results were obtained to those seen in Part I of our study when skin flaps were raised with and without a delay, when a tissue expander was used, and when the delay technique was extended to musculocutaneous flaps. In each instance, the cutaneous perforators were identified with the Doppler probe to facilitate the delay of specific vessels rather than dividing those at random. Intraoperative arteriograms and venograms reveal that the choke arteries dilate and the anatomically unfavorable valved vein segments become regurgitant. The end result is the observation that at least one additional anatomic vascular territory can be added to the length of a flap with safety following a surgical delay.

The venous territories (venosomes) of the human body: experimental study and clinical implications

The venous architecture of the integument and the underlying deep tissues was studied in six total-body human fresh cadavers and a series of isolated regional studies of the limbs and torso. A radiopaque lead oxide mixture was injected, and the integument and deep tissues were dissected and radiographed. The sites of the venous perforators were plotted and traced to their underlying parent veins that accompany the source (segmental) arteries. A series of cross-sectional studies were made in one subject to illustrate the course of the perforators between the integument and the deep tissues. The veins were dissected under magnification to identify the site and orientation of the valves. Results revealed a large number of valveless (oscillating) veins within the integument and deep tissues that link adjacent valved venous territories and allow equilibration of flow and pressure throughout the tissue. Where choke arteries define the arterial territories, they are matched by boundaries of oscillating veins in the venous studies. The venous architecture is a continuous network of arcades that follow the connective-tissue framework of the body. The veins converge from mobile to fixed areas, and they "hitchhike" with nerves. The venous drainage mirrors the arterial supply in the deep tissues and in most areas of the integument in the head, neck, and torso. In the limbs, the stellate pattern of the venous perforators is modified by longitudinal channels in the subdermal network. However, when an island flap is raised, these longitudinal channels are disconnected, and once again the arterial and venous patterns match. Our venous studies add strength to the angiosome concept. Where source arteries supply a composite block of tissue, we have demonstrated radiologically and by microdissection that the branches of these arteries are accompanied by veins that drain in the opposite direction and return to the same locus. Hence each angiosome consists of matching arteriosomes and venosomes. The clinical implications of these results are discussed with particular reference to the design of flaps, the delay phenomenon, venous free flaps, the pathogenesis of flap necrosis, the "muscle pump," varicose veins, and venous ulceration.

An atraumatic technique for harvesting cancellous bone for secondary alveolar bone grafting in cleft palate

Secondary alveolar bone grafting in cleft palate patients has been popularised by the Oslo group. Harvesting of the bone graft has been carried out by techniques developed initially for cranio-facial surgery. This paper describes a more refined technique applicable to the requirements of alveolar bone grafting. The Craig bone biopsy set is used to trephine cores of autogenous particulate marrow and cancellous bone from the iliac bone. The method was tested in a cadaver and then applied in 10 clinical cases. The aesthetic and functional results of this technique proved to be superior to the conventional approach.