Should Immediate Autologous Breast Reconstruction Be Considered in Women Who Require Postmastectomy Radiation Therapy? A Prospective Analysis of Outcomes

Abstract

Background In women who require post-mastectomy radiation therapy, immediate autologous breast reconstruction is often discouraged. We aim to prospectively evaluate postoperative morbidity and satisfaction reported by women undergoing delayed or immediate autologous breast reconstruction in the setting of post-mastectomy radiation therapy. Methods Patients enrolled in the Mastectomy Reconstruction Outcomes Consortium Study, who received post-mastectomy radiotherapy and had immediate or delayed free abdominal-based autologous breast reconstruction were identified. Postoperative complications at one and two years after reconstruction were assessed. Patient reported outcomes were evaluated using the BREAST-Q questionnaire preoperatively, at one and two-years postoperatively. Bivariate analyses and mixed-effects regression models were used to compare outcomes. Results A total of 175 patients met our inclusion criteria. Immediate reconstructions were performed in 108 patients and delayed reconstructions in 67 patients. 93.5% of the immediate reconstructions were performed at a single center. Overall complication rates were similar based on reconstructive timing (25.9% immediate and 26.9% delayed at one year; p=0.54). Patients with delayed reconstruction reported significantly lower pre-reconstruction scores (p<0.0001) for satisfaction with breast, psychosocial and sexual well-being than did patients with immediate reconstruction. At one and two years postoperatively, both groups of patients reported comparable levels of satisfaction in assessed BREAST-Q domains. Conclusions From this prospective cohort, immediate autologous breast reconstruction in the setting of post-mastectomy radiation therapy appears to be a safe option that may be considered in select patients and centers. Breast aesthetics and quality of life, evaluated from the patient’s perspective, were not compromised by flap exposure to radiation therapy.

A systematic review of factors affecting quality of life after postmastectomy breast reconstruction in women with breast cancer

“…Autologous reconstruction was also related to higher levels of psychosocial and sexual well‐being, compared with implant‐based procedures . The integration of postreconstruction radiation has also been suggested since the overall quality of life, evaluated from the patient's perspective, does not seem to be compromised . However, the assessment of surgical‐related variables is no longer sufficient to understand the multidimensional construct of quality of life which refers to a combination of physical, psychological, social, and spiritual domains .…”

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

“…A total of 697 studies were identified. Of these, 12 studies (including 1756 patients) evaluated adjuvant radiotherapy (350 patients), neoadjuvant radiotherapy (723) and no radiotherapy (683) ( Fig . ).…”

“…There were three prospective study designs and nine that were retrospective, but no RCTs. There were two multicentre (1 prospective and 1 retrospective) and ten single‐centre studies (2 prospective and 8 retrospective) ( Table ). Study quality (GRADE) was low in eight studies and moderate in the other four, with an overall high risk of bias.…”

“…There were two multicentre (1 prospective and 1 retrospective) and ten single‐centre studies (2 prospective and 8 retrospective) ( Table ). Study quality (GRADE) was low in eight studies and moderate in the other four, with an overall high risk of bias. A summary of baseline characteristics, including numbers of centres, country of origin, dates, patient numbers, breast cancer pathology and adjuvant medical treatments in comparative adjuvant and neoadjuvant radiotherapy groups, including non‐comparative studies, is provided in Table S1 (supporting information).…”

“…The third study evaluated serial QOL outcomes, concluding a significant impact of PMRT on QOL domains (BREAST‐Q) at 1 and 2 years, despite the absence of a control group (no radiotherapy). Moreover, clinical significance was defined as P = 0·05, which may not account for multiple variables ( Table S2 , supporting information). Highly significant abdominal adverse effects in a small patient group (108 patients) may be unrelated to PMRT, but rather an indication of donor site morbidity.…”