Breast Reconstruction Decisions Should Be Personalized, Informed By Most Current Data

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Many, but not all, women who have mastectomy to treat breast cancer go on to have one or both breasts reconstructed. There are many ways to reconstruct a breast. Tissue from the back, belly, buttocks, or other part of the body can be used to create a new breast. Doctors call this autologous reconstruction. Saline or silicone gel implants are another option. In some cases, an implant is added after autologous reconstruction.

Breast reconstruction can be done at different times, depending on what works best for a woman’s individual situation. When breast reconstruction is done at the same time as mastectomy surgery, it’s called immediate reconstruction. As soon as the breast is removed by the breast cancer surgeons, the plastic surgeon reconstructs the breast.

Results from two studies suggest that decisions about the type of reconstruction to have need to be personalized to each woman’s unique situation and informed by the most current information on long-term outcomes, satisfaction, and complication rates.

Both studies used information from the Mastectomy Reconstruction Outcomes Consortium, a study designed to evaluate breast reconstruction from a patient’s point of view, compiling information on postoperative pain, psychosocial well-being, physical functioning, fatigue, and patient satisfaction.

The studies both were published online on June 20, 2018 by JAMA Surgery. Read the abstracts of:

In the first study, 1,217 women who had immediate breast reconstruction after mastectomy at 11 centers across North America between 2012 and 2015 completed surveys on outcomes and satisfaction before reconstruction and 2 years after the surgery.

Compared to women who had implant reconstruction, the results showed that women who had autologous reconstruction said they had:

  • greater satisfaction with their breasts
  • better psychosocial well-being
  • better sexual well-being

The second study included 2,343 women who had breast reconstruction between 2012 and 2015 at 11 centers across North America:

  • 65.1% had expander-implant reconstruction
  • 4.8% had direct-to-implant reconstruction
  • 3.6% had pedicled TRAM flap reconstruction
  • 4.1% had free TRAM flap reconstruction
  • 16.6% had DIEP flap reconstruction
  • 3.0% had latissimus dorsi flap reconstruction
  • 2.8% had SIEA flap reconstruction

All the women had at least 2 years of follow-up. The researchers looked at the women’s medical records to see how many had complications after breast reconstruction surgery, such as infection or breakdown of transplanted tissue.

Overall, 32.9% of the women had complications after reconstruction surgery. Women who had any type of autologous reconstruction had a higher risk of developing a postsurgical complication compared to women who had implant reconstruction.

Complication rates ranged from 35.8% to 73.9% among women who had autologous reconstruction, compared with rates of 26.6% for women who had expander-implant reconstruction and 31.3% for women who had direct-to-implant reconstruction.

The researchers also found that women who were older and women who had higher body mass index (BMI) were more likely to have complications after reconstruction surgery.

“This information should not be used in any way to say, ‘This is the right operation for any specific woman,’” said Andrea Pusic, M.D., chief of plastic and reconstructive surgery at Brigham Health and senior author of the study, in an audio interview that was published with the studies. “What’s right for every woman is to really understand the expected outcomes, both in terms of complications and expected quality of life. Different patient characteristics help us to predict how a woman can expect her quality of life, her satisfaction with her breast, to be postoperatively.”

Dr. Pusic also said that one of the priorities of the study was to be able to provide this information to women as they're making decisions about reconstruction.

In a commentary piece that was published at the same time as the studies, Kenneth Fan, M.D. and David Song, M.D., both of the department of plastic and reconstructive surgery at MedStar Georgetown University Hospital, wrote, “These studies are vital in shared decision making, assuming that patients are candidates for both autologous and prosthetic breast reconstruction. It is critical that we inform patients of the published rates of complications. The time frame for reoperation is inevitable with implant-based breast reconstruction, whereas we have found after autologous breast reconstruction, rates of immediate revision are higher, but delayed revision is rare.”

Deciding whether to have a breast reconstructed after surgery to remove breast cancer is a very personal choice. If you’ve been diagnosed with breast cancer and are planning your surgery, you may decide not to have reconstruction, but it can be helpful to consider all your options.

Here are some questions you might want to think about as you're making your decision about breast reconstruction:

  • Is it important to you to have a permanent breast shape? Some women prefer to wear a prosthesis instead of having reconstruction.
  • Is it important to you that your breasts look balanced when wearing a bra and bathing suits? Though you'll be able to see the difference between the rebuilt breast and your other breast when you're naked, reconstruction usually looks very natural when you're wearing a bra or bathing suit.
  • In your unique situation, will breast reconstruction involve several surgeries over a long period of time? For many women, the answer is yes.
  • Will your insurance pay for all the reconstruction procedures? Find out what your insurance company will cover.
  • Did you have a lumpectomy that gave your breast a very different shape than it originally had? If you had a large portion of tissue removed, you might want to have reconstruction to restore a more balanced look.
  • Do you have any other medical conditions that might affect your ability to heal after surgery? If you have diabetes, circulatory problems, or a bleeding disorder, it may take your body longer to heal from reconstruction surgery than someone who doesn't have these conditions.
  • Do you have a condition that might give you a distorted image of your body? If you've been diagnosed with anorexia or bulimia, you may have a hard time accepting how your body looks in general, which may make it hard to accept how your reconstructed breast looks.

There are advantages and disadvantages to both implant reconstruction and autologous reconstruction. Implant reconstruction is considered easier up front, but usually requires another surgery after 10 or more years. Autologous reconstruction is a more involved surgery, with higher rates of complications and a longer recovery time, but offers better patient satisfaction. You will need to decide what is right for you and your unique situation.

For more information, including types of reconstruction, the timing of reconstruction, and questions to ask your breast surgeon and plastic surgeon, visit the Breastcancer.org Breast Reconstruction section.

To discuss with others facing reconstruction decisions, join the Breastcancer.org Discussion Board forum Breast Reconstruction.


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