Breast reconstruction (academic analysis)
In preparation for my consult with plastic surgery this week, I’ve been doing some reading on patient satisfaction after breast reconstruction. I began by asking the medical information officers at Bay Area Cancer Connections for a link to a few articles. From there, the academic in me took over, and I search and read a variety of articles regarding post reconstruction patient satisfaction.
First off, I should start by pointing out an important blog post written by Nancy on why post-cancer breast reconstruction is not a boob job. When looking at patient satisfaction, I focused on post-cancer reconstruction which is a lot more complex than cosmetic reconstruction.
I should also point out the my literature review focused on autologous reconstruction, in particular on DIEP flat reconstruction – as this is what I currently believe I’m most interested in. I’ll have a better sense after the consult, as I don’t yet know that I’m a candidate (although I think I am).
- Autologous reconstruction is reconstruction that involves the patients own tissue (e.g. DIEP flap, TRAM flap).
- Prophylactic mastectomy (PMX) is the removal of the healthy breast to reduce the likelihood of re-occurrence of breast cancer. PMX is also performed on women who after unilateral mastectomy dislike the lack of symmetry.
In my literature review, some interesting things emerged:
- In a great general article on breast reconstruction Serletti et al (2011) indicate that “studies suggest that generic counseling increases the likelihood of choosing prophylactic mastectomy, despite the fact that BRCA accounts for only 5 to 10 percent of all breast cancers” (Serletti et al, 2011, p.124e). In other words, seeing a generic counsellor likely increases prophylactic mastectomy. Now, given that you typically are referred to a genetic counsellor if you have a family history and/or are diagnosed under 45 years of age, I’m not completely surprised by this.
- The biggest factor in determining timing for reconstruction should be whether or not radiation therapy is required, as “several studies have identified postreconstruction radiation therapy as an independent risk factor for volume loss, fat necrosis, and poor cosmetics” (Serletti et al, 2011, p.129e). That being said, women are generally happier (sooner) with immediate reconstruction. That is, Zhong et al, 2012 highlight that post-surgery happiness is the same, however, the time post-mastectomy pre-reconstruction women are less happy. However, the reason for delayed reconstruction is usually cancer treatment, so I’m not surprised they would be less happy!
- The rates of implant-based surgeries in the US has dramatically increased (as compared to autologous reconstructions option) (Albornoz et al, 2013) despite literature that indicates that patients longer term satisfaction is greater with autologous reconstruction (Yuch et al, 2010). This in part may be attributed to the increased surgeon compensation rates, but also the availability of operating room time. Autologous surgeries take significantly more time to perform and the hourly rate of compensation by insurance companies in the US is lower than for implant-based surgeries (Albornoz et al, 2013) . One of the studies I read said that university hospitals did not show this same increase in implant surgeries – highlighting the economic reason for the increase (I can’t find the reference now).
- “The strongest predictors of implant reconstruction were procedures performed after 2002, Medicare recipients, bilateral mastectomy defects, and patients operated on in the West and Midwest regions” (Albornoz et al, 2013, p.21).
- “It is now mandatory for partitioners caring for women with breast cancer to inform them about reconstruction” (Albornoz et al, 2013, p.20).
- “Studies suggest the increase in bilateral mastectomies is attributable not to the changing incidence of bilateral breast cancer but rather to the growing use of contralateral prophylactic mastectomy” (Albornoz et al, 2013, p.21-22).
- In a Canadian study that looked at patient outcomes after autologous reconstruction patients scores on breast, sexual well being, and psychosocial well being improved after surgery (measured at 3-weeks and 3-months). The only negative finding was that at 3-months patients scored lower on abdominal well-being – that is, even after 3-months patients felt a decrease in their abdominal health. Note that the surgeries in question were predominantly DIEP flap which did not involve muscle from the donor site (Zhong et al, 2012).
- Both Zhong et al (2012) and Yueh et al (2010) indicate that women undergoing DIEP surgery travelled further for treatment. This is likely because it requires specially trained surgeons (surgeons trained in microsurgery) and as a result the surgery is only available in major centers (more commonly offered in academic settings – in part also because surgeons are not compensates as much for autologous surgery as they are for implant surgery).
- Institutions that do more flap surgery have better flap surgery outcomes (significantly). Specifically, “in centers with a high volume of microsurgical procedures and experienced surgeons, the number of total flap losses tends to be low, an dis consistent with our flap loss rate of 1.8% in the DIEP flap group” (Momoh et al, 2012, p.22). I’ve seen numbers as high at 10% for flap loss rate.
- Patients who have reconstruction have increased body image afterwards (Gopie et el, 2014) – not a comparative study – so doesn’t say anything about body image of patients who don’t have reconstruction – does breast cancer create a more positive body image regardless of type of post mastectomy surgery choice?
- In Canada the barriers to immediate reconstruction for flap surgeries include availability of operating rooms and experienced surgeons. Socioeconomics play a role in whether Canadians get access to immediate flap reconstruction. Women travel to special centers to access immediate flap reconstruction (Zhong et al, 2014).
- With abdominal flap reconstruction, patients are not necessarily satisfied with the abdominal outcomes. This highlights the need to better set patient expectations regarding not just the breast outcomes but also the abdominal surgery outcomes (Niddam et al, 2014).
- In looking at a large insurance claims database, Jagsi et al (2014) note that 76% of patients who underwent bilateral mastectomy opted for reconstruction. They also note that those who underwent radio therapy were less likely to undergo reconstruction. That being said, I wonder if the radiotherapy numbers include lumpectomies (which they would), such that reconstruction is less likely to be necessary.
- In a study looking at risk factors associated with blood transfusions and DIEP surgery, Fischer et al (2014) looked at neo-adjuvant chemotherapy but did not indicate that it was a risk factor. Those who have blood transfusions are more likely to have complications (no mention of causality in the study – so it could also be said that those who have complications are more likely to have blood transfusions). One thing that is useful to look at if you are having the longer bilateral mastectomy with reconstruction surgery is giving your own blood in advance of the surgery, so that you can have it available for transfusion. I’m not sure if this is even possible when you have neo-adjuvant chemo.
- Lundberg et al (2014) reviewed the literature and provided a view that DIEP surgery is only cost effective in patients who have been treated with radiotherapy (and are therefore not candidates for implants). They point out that the studies done so far use “bad science” (I don’t agree – this article reads as somewhat biased itself). They do say that if you are a smoker, you should stop smoking 4-weeks before DIEP flat surgery in order to significantly reduce complications. They also point out the BMI over 30 is a risk factor. What is interesting here is that you need to have enough body fat to have enough fat at the donor site, but too much fat reduces the likelihood of successful outcome. It will be interesting to see what the plastics folks say for me.
- Lundberg et al (2014) recommend “angiography … preoperatively to find out if the flap has perforators and can provide the anatomical prerequisites for the operation to be successful” (p. 108)
- Those undergoing nipple sparing surgeries are more likely (>88%) to have immediate reconstruction (Albornoz et al, 2013).
- Serletti et al (2011) highlight that many patients “begin by saying they do not want implant reconstruction” (p.125e).
One of the challenges with using literature to help inform your decision is that it is all based upon the past. As was highlighted by Lundbert et al. (2014), the techniques and tools (e.g. implants) used today are not the same as those used 5 and 10 years ago. As a result, the studies involving longer term outcomes are not truly representative. In many ways the surgery will be a gamble – the decision may be based upon the best information available at the time, but there is always the random chance variable that we just don’t know. In many ways, my surgery choice needs to be in part based upon my gut feel – the same as my decision for neo-adjuvant chemotherapy. I have to choose based upon what ‘feels’ right for me, after collecting all the evidence I can.
In looking at the literature I am most concerned about studies regarding the cost/benefit analysis of the different reconstruction types. There is a significant trend towards implant based reconstruction. This can be attributed to the change in technology being used (a new type of silicon implant was approved in 2006), but also because it requires less time in surgery, and it therefore easier to schedule. In addition, the autologous surgeries require specially trained plastic surgeons – which means women need to travel to major centers in order to have this type of surgery (makes me glad that I’m being treated at Stanford!). My concern is that the cost/benefit studies will be used by insurance companies to deny women specific types of surgery. Although the Women’s Health and Cancer Right Act of 1998 requires that insurance companies cover reconstruction, I’m not sure how comprehensive that coverage is and whether insurance companies can limit it to types of reconstruction?
OK, I have a few more articles to read, but I’m not getting much new information – which means I’m reaching saturation on this particular literature review.
If you want a copy of a particular article and don’t have access, send me an email.
Albornoz, C. R., Bach, P. B., Mehrara, B. J., Disa, J. J., Pusic, A. L., McCarthy, C. M., . . . Matros, E. (2013). A paradigm shift in U.S. Breast reconstruction: increasing implant rates. Plast Reconstr Surg, 131(1), 15-23. doi:10.1097/PRS.0b013e3182729cde
Gopie, J. P., ter Kuile, M. M., Timman, R., Mureau, M. A., & Tibben, A. (2014). Impact of delayed implant and DIEP flap breast reconstruction on body image and sexual satisfaction: a prospective follow-up study. Psychooncology, 23(1), 100-107. doi:10.1002/pon.3377
Jagsi, R., Jiang, J., Momoh, A. O., Alderman, A., Giordano, S. H., Buchholz, T. A., . . . Smith, B. D. (2014). Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States. J Clin Oncol, 32(9), 919-926. doi:10.1200/JCO.2013.52.2284
Lundberg, J., Thorarinsson, A., Karlsson, P., Ringberg, A., Frisell, J., Hatschek, T., . . . Elander, A. (2014). When is the deep inferior epigastric artery flap indicated for breast reconstruction in patients not treated with radiotherapy? Ann Plast Surg, 73(1), 105-113. doi:10.1097/SAP.0b013e31826cafd0
Momoh, A. O., Colakoglu, S., Westvik, T. S., Curtis, M. S., Yueh, J. H., de Blacam, C., . . . Lee, B. T. (2012). Analysis of complications and patient satisfaction in pedicled transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flap breast reconstruction. Ann Plast Surg, 69(1), 19-23. doi:10.1097/SAP.0b013e318221b578
Niddam, J., Bosc, R., Lange, F., Chader, H., Hersant, B., Bigorie, V., . . . Meningaud, J. P. (2014). DIEP flap for breast reconstruction: retrospective evaluation of patient satisfaction on abdominal results. J Plast Reconstr Aesthet Surg, 67(6), 789-796. doi:10.1016/j.bjps.2014.02.008
Serletti, J. M., Fosnot, J., Nelson, J. A., Disa, J. J., & Bucky, L. P. (2011). Breast reconstruction after breast cancer. Plast Reconstr Surg, 127(6), 124e-135e. doi:10.1097/PRS.0b013e318213a2e6
Yueh, J. H., Slavin, S. A., Adesiyun, T., Nyame, T. T., Gautam, S., Morris, D. J., . . . Lee, B. T. (2010). Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg, 125(6), 1585-1595. doi:10.1097/PRS.0b013e3181cb6351
Zhong, T., Fernandes, K. A., Saskin, R., Sutradhar, R., Platt, J., Beber, B. A., . . . Baxter, N. N. (2014). Barriers to immediate breast reconstruction in the Canadian universal health care system. J Clin Oncol, 32(20), 2133-2141. doi:10.1200/JCO.2013.53.0774
Zhong, T., McCarthy, C., Min, S., Zhang, J., Beber, B., Pusic, A. L., & Hofer, S. O. (2012). Patient satisfaction and health-related quality of life after autologous tissue breast reconstruction: a prospective analysis of early postoperative outcomes. Cancer, 118(6), 1701-1709. doi:10.1002/cncr.26417