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Controversy has surrounded the areas of postmastectomy radiotherapy (PMRT), use and timing of chemotherapy, and outcomes in patients who want immediate breast reconstruction (IBR) after mastectomy. To address these issues, investigators conducted two retrospective studies involving radiotherapy or chemotherapy in mastectomy patients who underwent IBR.
In the first study, 100 of 302 mastectomy patients received PMRT; surgical complications occurred in 44% of those who had undergone IBR and in 7% who had not (P<0.001). PMRT independently foretold the risk for complications (odds ratio, 3.3; P<0.001). Implant removal was required in 31% of patients who underwent PMRT and in 6% of patients who did not (P=0.005). The authors did not provide a breakdown by initial breast cancer stage in the 131 patients who underwent IBR.
In the second study, researchers focused on the potential effects of chemotherapy on IBR outcomes in 163 patients. Of these, 57 received neoadjuvant chemotherapy, 41 received postoperative chemotherapy, and the remainder did not require systemic therapy. Overall, 31% of patients had complications requiring operative management; this rate did not differ whether they received neoadjuvant, adjuvant, or no chemotherapy (P=0.79). Among patients whose reconstructive surgery involved tissue expanders and implants, complications rates also were similar among groups (P=0.70). Thus, neither the inclusion of chemotherapy nor the timing of its administration significantly affected risk for surgical complications following IBR.
Christante D et al. Using complications associated with postmastectomy radiation and immediate breast reconstruction to improve surgical decision making. Arch Surg 2010 Sep; 145:873.
Warren Peled A et al. Impact of chemotherapy on postoperative complications after mastectomy and immediate breast reconstruction. Arch Surg 2010 Sep; 145:880.
Beatty JD. Start by decreasing unnecessary postmastectomy irradiation. Arch Surg 2010 Sep; 145:878.
Giuliano AE. Chemotherapy and breast reconstruction. Arch Surg 2010 Sep; 145:885.
Comment
Mounting evidence shows that PMRT after IBR leads to unacceptably high complication rates. During the last decade, use of PMRT for patients with early-stage breast cancer has increased, based mostly on data from trials conducted 25 to 50 years ago. Unquestionably, radiotherapy after mastectomy is effective at lowering risk for locoregional recurrence (LRR) and is indicated in breast cancer patients with >4 positive nodes and LRR risk >15%. However, the need for PMRT in early-stage breast cancer patients has been debated for decades, particularly because advances in all treatment modalities have been substantial (JW Oncol Hematol Jun 22 2010). For most women with early-stage breast cancer, PMRT provides little benefit; in the first study, the number of patients who received PMRT seems higher than would be expected for U.S. practice. As an editorialist suggests, more-selective use of PMRT is preferable to delaying or withholding the well-known psychological benefits of IBR.
Chemotherapy will be recommended for most women with primary tumors >1 cm; therefore, the potential negative effects of chemotherapy on IBR outcomes must be recognized. Of note, the second study shows that rates of these untoward consequences are not related to the timing of chemotherapy (i.e., neoadjuvant or adjuvant), nor, indeed, to whether the patient receives chemotherapy at all. Both studies are timely and essential because they emphasize the complexities faced by both patients and their caregivers regarding multidisciplinary cancer care and the potential complications associated with breast reconstruction.