Breast reconstruction using patient’s own tissues yield higher satisfaction rates

New insights for patient decision-making, suggests study in plastic and reconstructive surgery

For women who have undergone mastectomy, breast reconstruction using the patient’s own tissues, rather than implants, provides higher satisfaction scores, reports a study in Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS).

But the findings may at least partly reflect differences in the characteristics of women choosing different options for breast reconstruction, according to the study by plastic surgeon Dr. Yassir Eltahir and colleagues of University Medical Center Groningen, the Netherlands.

Higher Satisfaction Score with Autologous Breast Reconstruction

The researchers used the recently developed “BREAST-Q” questionnaire to analyze patient satisfaction and quality of life after breast reconstruction. The BREAST-Q was designed to gauge these important outcomes from the patient’s point of view.

The study included BREAST-Q surveys completed by 92 women who had breast reconstruction between 2006 and 2010. Forty-seven women underwent autologous reconstruction, with the patient’s own tissues–generally “donor” flaps from the abdomen–used to create the new breast. The remaining 45 women underwent alloplastic reconstruction, using implants.

The results suggested that women choosing reconstruction with their own tissues were more satisfied with the results. Scores for satisfaction with the reconstructed breasts averaged about 75 (on a 100-point scale) after autologous reconstruction versus 65.5 for implant-based reconstruction.

Overall patient satisfaction scores were also higher with autologous reconstruction: about 82 versus 74.5. Scores for various aspects of quality of life–including psychosocial, sexual, and physical well-being–were not significantly different between groups.

Significant Differences in Patient Characteristics

The researchers also noted some important differences between the two groups of patients. Women choosing autologous reconstruction were older: 51 versus 44 years. Autologous reconstruction was performed on a delayed basis, an average of 21 months after mastectomy; whereas implant-based reconstruction was usually performed immediately.

Women receiving implant reconstruction were also more likely to undergo reconstruction of both breasts. Many of these women underwent preventive double mastectomy because of high genetic risk of breast cancer.

Women undergoing autologous reconstruction were more likely to receive radiation therapy, had a higher average body weight, and were less educated. Complication rates were similar between groups, although the autologous reconstruction group had a higher rate of secondary corrective surgeries.

Women have several options for breast reconstruction after mastectomy, in terms of the type of reconstruction and immediate versus delayed reconstruction. Studies comparing the outcomes of autologous versus implant-based reconstruction have reported conflicting results. The new study, using the validated BREAST-Q questionnaire, suggests higher patient satisfaction rates for women undergoing reconstruction using their own tissues.

But the findings may reflect differences in patient characteristics between groups. For example, younger women undergoing immediate implant reconstruction may have higher expectations, compared to women who have waited several months for delayed autologous reconstruction. The researchers plan further studies to evaluate some of the questions raised by their preliminary results.

Meanwhile, Dr. Eltahir and coauthors emphasize that both methods of breast reconstruction provided good outcomes, with similar scores for quality of life. “The study found no ideal breast reconstruction suitable for all patients,” the researchers write. “However, it may inform patients and medical teams in making decisions about breast reconstruction.

Eltahir et al. Which breast is the best? Successful autologous or alloplastic breast reconstruction: Patient-reported quality-of-life outcome. Plast Reconstr Surg. 2015;135(1):43-50. doi: 10.1097/PRS.0000000000000804 [Article]

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Unfounded fear prompts young breast cancer patients to remove healthy breasts

Despite evidence that contralateral prophylactic mastectomy (CPM) does not improve survival rates, an increasing number of young women with breast cancer elect to remove their healthy breast to avoid recurrence and improve survival.

Researchers surveyed 123 women aged 40 or younger without known bilateral breast cancer who reported having bilateral mastectomy. The purpose of the survey was to better understand how women approach the decision to have CPM. The survey included questions about the women’s health history, reason for choosing CPM, and knowledge and perceptions about breast cancer.

Most of the women (n = 97) had stage I or stage II breast cancer and 60 percent of tumors were estrogen receptor-positive. Almost all (98 percent) of the women surveyed indicated that desires to decrease their risk for contralateral breast cancer (CBC) prompted their decision to remove the healthy breast. Although 94 percent of the women surveyed said they chose bilateral mastectomy to increase survival, only 18 percent reported thinking that CPM improved survival rates.

Almost all of the women surveyed overestimated the actual risk of CBC. While physicians were identified as the most important sources of information about breast cancer, only one-third of the women cited a desire to follow a physician’s recommendations as an extremely or very important factor in their decision.

The authors suggest that this survey underscores a need for better risk communication strategies that help patients make decisions based on evidence.

Rosenberg et al., (2013). Perceptions, Knowledge, and Satisfaction With Contralateral Prophylactic Mastectomy Among Young Women With Breast Cancer. A Cross-sectional Survey. Ann. Intern. Med.159: 373-381. doi:10.7326/0003-4819-159-6-201309170-00003 [Article]

Is growing MRI use leading to more invasive breast cancer surgery?

Heavy use of magnetic resonance imaging (MRI) may be leading to unnecessary breast removal in older women with breast cancer, according to a study by Yale School of Medicine researchers in the current issue of Breast Cancer Research and Treatment.

“These data are concerning because the long-term benefits associated with bilateral mastectomy for older women with breast cancer are unclear,” said the study’s lead author Cary Gross. M.D., associate professor of internal medicine at Yale School of Medicine and director of the Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale Cancer Center.

“Patient concern about recurrence and survival must be balanced with the increased risk for complications associated with more aggressive cancer surgery, particularly when there is no proven benefit of the more aggressive option,” Gross added.

The research team tracked the use of breast MRI and surgical care of 72,461 female Medicare beneficiaries age 67-94 who were diagnosed with breast cancer during 2000 to 2009.

The team found a considerable increase in the use of preoperative breast MRI over the study period from 1% in 2000-2001 to 25% in 2008-2009. The researchers also found that women who received an MRI were more likely to subsequently undergo more aggressive surgical treatment. In women who received mastectomy, 12.5% of those who had MRI received bilateral mastectomy, while only 4.1% of those who did not have MRI had bilateral mastectomy.

The study also revealed that women undergoing MRI were more likely to have a contralateral prophylactic mastectomy (surgery to remove both breasts when cancer was only found in one breast). Among women who underwent mastectomy, 6.9% of women who had an MRI underwent contralateral prophylactic mastectomy, compared to 1.8% in women who did not have an MRI.

“There has been no randomized controlled clinical trial demonstrating improved outcomes for women who undergo preoperative breast MRI at any age,” said Brigid Killelea, M.D., assistant professor of surgery at Yale School of Medicine, and first author on the study. “Breast conserving therapy, when feasible, remains the preferred approach for women with early stage breast cancer.”

Killelea et al., (2013). Trends and clinical implications of preoperative breast MRI in Medicare beneficiaries with breast cancer. Breast Cancer Res. Treat., EPub Ahead of Print, doi:10.1007/s10549-013-2656-1 [Abstract]