Bilateral Mastectomy: Doubling Down on Complications?

Abstract

Complications after breast cancer surgery can result in increased hospitalization, additional surgical and medical interventions, increased costs, and delays in initiating recommended adjuvant treatment. Moreover, complications may lead to long-term emotional distress and patient dissatisfaction. Thus, accurate information regarding the risk, severity, and timing of postoperative complications must be clearly presented to breast cancer patients. In the accompanying study by Silva and colleagues, the authors used the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) to compare the rates of postoperative complications between unilateral and bilateral mastectomy among patients who underwent immediate reconstruction. 1 The authors reported that bilateral mastectomy was associated with longer hospital stays and higher transfusion rates than unilateral mastectomy. Also, bilateral mastectomy with implant reconstruction was associated with a modestly increased reoperation rate. Surprisingly, surgical site infections, prosthesis failure, and medical complications occurred at similar rates between unilateral and bilateral mastectomy. For implant-reconstructed patients, the overall complication rate was 8.8 % after unilateral mastectomy and 10.1 % after bilateral mastectomy. The rates of surgical site complications were 4.2 and 4.6 %, respectively.Determining the rates of postoperative complications after breast cancer surgery can be a frustrating endeavor. Published studies vary widely in regards to the definition, inclusion, and severity of postoperative complications. In addition, the length of follow-up from different studies ranges from a few weeks to a few years. As a result, the published rates of postoperative complications after breast surgery vary dramatically from study to study. Even the results from different studies using the same database seem incongruent. For example, Silva and colleagues report the 30-day surgical site complication rate after bilateral mastectomy and implant-based reconstruction as only 4.6 %. In a very similar study also using NSQIP, Osman and colleagues report the 30-day surgical site complication rate after bilateral mastectomy without reconstruction as 5.8 %.2 Is the surgical site complication rate really lower for mastectomy after implant-based reconstruction as compared with mastectomy without reconstruction? Also, in the report by Osman and colleagues, the risk of postoperative complications was almost double after bilateral mastectomy as compared to unilateral mastectomy.The 30-day outcomes reported by Silva and colleagues likely substantially underestimate the overall postoperative complication rates after bilateral mastectomy and reconstruction. In a multicenter study from the Cancer Research Network, Barton and colleagues determined the complication rates after bilateral mastectomy. 3 In their patient cohort, 69.1 % underwent implant reconstruction, and almost two-thirds of the women undergoing bilateral mastectomy had at least one complication.3 ...

Impact of COVID-19 Disease in Early Breast Cancer Management: A Summary of the Current Evidence

“…Regarding patients with contralateral prophylactic mastectomy in unilateral BC indication, although there are still limited data on this subject, historically, these cases have a more extended hospital stay than to breast-conserving surgery or unilateral mastectomy and have more postsurgery visits and higher rates of hospitalization. 77 This potential increase in patient exposure could lead to a greater risk of infection by COVID-19 disease. 25 The expert panel suggested that a contralateral prophylactic mastectomy is not recommended during this period, and conservative breast surgery or even unilateral mastectomy should be carried out instead.…”

“…BCS is associated with lower rates of hospital stay and visits after surgery and hospitalization than mastectomy 77 : a study with patients undergoing nipple-sparing mastectomy had total complication rates of 47% and reoperations around 9%. 78 Regarding the use of oncoplastic surgery, complication rates also tend to be higher than in BCS.…”

Implant-sparing Mastectomy: An Alternative for Women Undergoing Mastectomy With Retropectoral Implants

“…Complication rates for skin-sparing mastectomy range from 6% to 42%, and have been found to be as high as 69.1% if including patients undergoing bilateral mastectomy with immediate reconstruction. 10,11 Differences in complication rates also vary by the data source used, with the National Surgical Quality Improvement Program often reporting complication rates for breast surgery that are lower than those reported in retrospective institutional reviews or claims-based data. [11][12][13][14][15] We report an overall complication rate of 15.7% per ISM, generally in line with the accepted ranges in the literature and also in line with a contemporary institutional cohort complication rate of 20.7%.…”

“…10,11 Differences in complication rates also vary by the data source used, with the National Surgical Quality Improvement Program often reporting complication rates for breast surgery that are lower than those reported in retrospective institutional reviews or claims-based data. [11][12][13][14][15] We report an overall complication rate of 15.7% per ISM, generally in line with the accepted ranges in the literature and also in line with a contemporary institutional cohort complication rate of 20.7%. The skin necrosis rate of 8.2% in the ISM cohort was also similar to that of the mastectomy with reconstruction cohort of 7.4% and is consistent with a reported rate of 13% for patients undergoing mastectomy with immediate reconstruction by Petersen et al 10 The infection rate of 0.8% in the ISM cohort was lower than the 5.9% in the mastectomy with reconstruction cohort.…”

Impact of COVID-19 in early breast cancer management: a summary of the current evidence

“…Regarding patients with contralateral prophylactic mastectomy in unilateral breast cancer indication, although there is still limited data on this subject, historically these cases have a longer hospital stay compared to breast-conserving surgery or unilateral mastectomy, and also have more post-surgery visits and higher rates of hospitalization 57 . This potential increase in patient exposure could lead to a greater risk of infection by COVID-19 25 .…”