Rates Of Immediate Breast Reconstruction Research Articles

Immediate Breast Reconstruction After Mastectomy for Cancer Among US Military Health System Beneficiaries.

In the Military Health System (MHS), women with breast cancer may undergo surgical treatment in military hospitals (direct care) or in the civilian setting via the insurance benefit (private sector care). We conducted this study to determine immediate breast reconstruction rates among women undergoing mastectomy for cancer in the MHS by setting of care. Using the linked Department of Defense's Central Cancer Registry and MHS Data Repository, the Department of Defense's medical claims database, we identified adult women who underwent mastectomy for breast cancer from 1998 to 2014. Patients were then subgrouped by setting of care (direct vs private sector care). The primary outcome was the rate and type of immediate breast reconstruction. Regression models were constructed to determine factors associated with receipt of immediate breast reconstruction. The final sample included 3251 women who underwent mastectomy for cancer in the direct (67.0%) or private sector care (32.6%) settings. The overall rate of immediate breast reconstruction was 29.9% with an upward trend noted throughout the study (P < 0.001). Overall, implant-based reconstruction (81.4%) was more common than tissue-based reconstruction (18.6%). Compared with direct care, the immediate breast reconstruction rate was significantly higher in the private sector care setting (49.3% vs 20.5%, P < 0.001) despite accounting for differences in clinical characteristics (adjusted odds ratio = 4.51, 95% confidence interval [3.72-5.46]). Immediate breast reconstruction in the direct care setting lags that in the civilian community during the study time period. Further research is needed to ascertain current immediate reconstruction rates and understand factors contributing to any differences in rates between care settings.

Is immediate breast reconstruction surgery safe for elderly women? Assessment of postoperative complications in women aged 70 years and older

IntroductionThe rate of immediate breast reconstruction (IBR) in elderly women (EW) is lower than in younger patients because of concerns related to postoperative complications (POC) and their consequences. ObjectiveWe assessed POC 30 days after IBR, readmissions rate within 30 days, and the time to start adjuvant therapy in EW aged ≥ 70 years. Materials and MethodsWe conducted an observational, retrospective, single-center study between January 2014 and May 2022 at the University Cancer Institute of Toulouse-Oncopole (IUCT-O), including patients over 70 years old treated with mastectomy and IBR. Patients’ characteristics, medical treatments with the time between therapies and POC were recorded. ResultsA total of 125 women aged 70 to 84 years old were included in our study. The rate of IBR was 13.7 %. The rate of major POC was 17.6 % (n = 22), including 9.8 % (n = 11) implant removal. There was significantly more skin necrosis in patients with a history of homolateral radiotherapy (p = 0.016) but less hematoma (p = 0.004). Overweight or obese EW tending to have more than one surgical POC (p = 0.019). EW with nipple-areola complex (NAC) conservation had significantly more skin necrosis (p = 0.01). The median time for initiation of adjuvant chemotherapy (ACT) and hormonal therapy was 5.7 [1.6–11.9] and 4.3 [1.6–78.9] weeks respectively. The median time to initiate adjuvant radiotherapy (ART) when preceded by ACT or not, was 9.2 [5.1–22] and 21.1 [16.9–21.4] weeks respectively. ConclusionOur study confirms that IBR in women aged ≥ 70 years is safe and does not delay adjuvant therapies.

Racial Disparities in Immediate Breast Reconstruction after Mastectomy: A Systematic Review and Meta-Analysis

Background: In the past few decades, there has been a gradual increase in breast reconstruction post mastectomy; however, there exists a conflict about whether race has an influence on reconstruction rates. Methods: We conducted an electronic search from MEDLINE and Cochrane CENTRAL from their inception to September 2022. Primary outcome was disparity in rates of Immediate Breast Reconstruction (IBR) in racial minorities. Odds ratios were pooled using a random-effects model. All statistical analyses were performed on the Review Manager. Quality of included studies was assessed using the Joanna Briggs Institute critical appraisal checklist. Results: Twenty studies ( n = 1 840 671) were identified. The pooled analysis of all the studies showed that subjects in racial minorities were significantly less likely to receive IBR as compared to White subjects (OR = 0.62, [95% confidence interval: 0.57-0.68; P &lt; .01, I2 = 97%]. Subgroup analyses revealed that Asian subjects were the least likely to undergo IBR among different minorities (OR = 0.43). Conclusion: There exists a significant disparity in rates of IBR in different racial minorities as compared to White subjects. Future studies are warranted to assess factors contributing to such disparities in provision of healthcare.

Impact of Safety-Net Hospital Status on Immediate Reconstruction Following Mastectomy: A Contemporary National Analysis.

Immediate breast reconstruction (IBR) following mastectomy has been shown to improve quality of life and partially mitigate the adverse psychological impacts associated with the procedure. The present study examined hospital-based and patient-level disparities in utilization and outcomes of IBR following mastectomy. All female adult hospitalizations with a diagnosis of breast cancer undergoing mastectomy were identified in the 2016 to 2020 National Inpatient Sample. Safety-net hospitals (SNH) were defined as those in the top quartile of all Medicaid or self-pay admissions. Patients who underwent mastectomy at SNH comprised the SNH cohort (others: Non-SNH). Multivariable models were developed to examine the impact of SNH status and patient factors on rates of IBR. Of an estimated 127,740 hospitalizations, 28,330 (22.2%) were treated at SNH. The proportion of patients receiving IBR increased from 46.7% in 2016 to 51.7% in 2020 (nptrend<.001). Compared to others, SNH were younger (57.9 ± 13.5 vs 58.3 ± 13.5years) and less commonly White (45.6 vs 69.9%) (all P < .001). Additionally, SNH were more likely to receive unilateral mastectomy (67.1 vs 55.2%) but less frequently underwent IBR (37.7 vs 51.5%) (all P < .001). After adjustment, Black and Asian race, SNH, and bilateral mastectomy were associated with decreased odds of IBR. Increasing IBR hospital volume did not eliminate the observed racial disparity at non-SNH or SNH. There are disparities in rates of IBR following mastectomy attributable to SNH status. Future work is needed to ensure all patients have access to reconstructive care irrespective of payer status or the hospital at which they receive care.

Ten-year trend analysis of breast cancer, oncoplastic, and reconstructive breast surgery in a single institution (2010-2019), what has not changed?

There has been a UK national directive to ensure that patients are offered reconstructive surgical options. We aimed to assess any change in oncoplastic practice over a 10-year period. The surgical management of 7019 breast cancers was retrospectively assessed at Nightingale Breast Centre, Manchester University UK, from 2010 to 2019. The procedures were categorised into breast conservative surgery (BCS) and mastectomy ± immediate reconstruction. The data were analysed using inclusion and exclusion criteria. The overall rates of BCS and mastectomy were 60.1% and 39.9% respectively. No statistically significant change in the overall rates of BCS or mastectomy was observed over the last decade (p = 0.08). The rate of simple wide local excision (WLE) decreased from 98.7% to 89.3% (p < 0.001), whilst the rate of therapeutic mammoplasty (TM) increased from 1.3% to 8% (p < 0.01). The rate of chest wall perforator flaps (CWPF) changed from zero to account for 2.7% of all BCS by 2019. The overall rate of immediate breast reconstruction (IBR) did not significantly change over the study period, but it consistently remained above the national average of 27%. The rate of implant-based IBR increased from 61.3% to 76.5% (p = 0.012), whilst the rate of Latissimus Dorsi (LD) reconstruction decreased from 26.7% to 5.1% (p < 0.05). Additionally, the rate of nipple-sparing mastectomy significantly increased from 5.2% to 24%. No significant changes in the overall rates of BCS was observed, the rates of advanced breast conservation techniques, nipple-sparing mastectomy, and implant-based IBR all have increased, whilst the use of LD reconstruction decreased.

Rising age-specific rates of immediate breast reconstruction after mastectomy: Report from an Italian Breast Unit.

Immediate breast reconstruction (IBR) represents a fundamental part in the management of patients receiving mastectomy. In recent years, there has been an increasing trend in the use of IBR in all age groups. The study aims were to evaluate the age-specific trend of IBR, and to discuss its effects in work organization at an Italian Breast Unit. We searched for women diagnosed with breast cancer between 2010 and 2019, focusing on IBR rates in patients who received mastectomy. Age-specific trends were assessed using the Cochrane-Armitage test. Differences in operative times and hospital stay between women undergoing mastectomy + IBR (Ma + IBR) or mastectomy alone (Ma) were evaluated by Student's t test or χ2 test. Among 1915 patients, 62.4% underwent breast conserving surgery (BCS), and 37.6% mastectomy. Overall, rates of Ma + IBR increased from 32% in 2010 to 58% in 2019 (p < 0.001). Although rates of IBR rose in all age groups, the trend was significantly increased among patients aged 50-59 (p < 0.001), 60-69 (p < 0.0001), and 70-79 (p < 0.05). Rates of Ma + IBR have increased over years, especially among older women. Ma + IBR resulted in longer operative times and hospital stay than Ma alone. These findings imply that, in the near future, resources should be implemented to improve and strengthen the surgical activity of Breast Units, to support the increasing use of IBR in women of all age groups.

Regional Implicit Racial Bias and Rates of Breast Reconstruction, Complications, and Cost Among US Patients With Breast Cancer

Racial disparities influencing breast reconstruction have been well-researched; however, the role of implicit racial bias remains unknown. An analysis of the disparities in care for patients with breast cancer may serve as a policy target to increase the access and quality of care for underserved populations. To identify whether variations in implicit racial bias by region are associated with the differences in rates of immediate breast reconstruction, complications, and cost for White patients and patients from minoritized racial and ethnic groups. This cohort study used data from the National Inpatient Sample (NIS) from 2009 to 2019. Adult female patients with a diagnosis of or genetic predisposition for breast cancer receiving immediate breast reconstruction at the time of mastectomy were included. Patients receiving both autologous free flap and implant-based reconstruction were included in this analysis. US Census Bureau data were extracted to compare rates of reconstruction proportionately. The Implicit Association Test (IAT) was used to classify whether implicit bias was associated with the primary outcome variables. Data were analyzed from April to November 2022. IAT score by US Census Bureau geographic region. Variables of interest included demographic data, rate of reconstruction, complications (reconstruction-specific and systemic), inpatient cost, and IAT score by region. Spearman correlation was used to determine associations between implicit racial bias and the reconstruction utilization rate for White patients and patients from minoritized racial and ethnic groups. Two-sample t tests were used to analyze differences in utilization, complications, and cost between the 2 groups. A total of 52 115 patients were included in our sample: 38 487 were identified as White (mean [SD] age, 52.0 [0.7] years) and 13 628 were identified as minoritized race and ethnicity (American Indian, Asian, Black, and Hispanic patients and patients with another race or ethnicity; mean [SD] age, 49.7 [10.5] years). Implicit bias was not associated with disparities in breast reconstruction rates, complications, or cost. Nonetheless, the White-to-minoritized race and ethnicity utilization ratio differed among the regions studied. Specifically, the reconstruction ratio for White patients to patients with minoritized race and ethnicity was highest for the East South Central Division, which includes Alabama, Kentucky, Mississippi, and Tennessee (2.17), and lowest for the West South Central Division, which includes Arkansas, Louisiana, Oklahoma, and Texas (0.75). In this cohort study of patients with breast cancer, regional variation of implicit bias was not associated with differences in breast reconstruction utilization, complications, or cost. Regional disparities in utilization among racial and ethnic groups suggest that collaboration from individual institutions and national organizations is needed to develop robust data collection systems. Such systems could provide surgeons with a comparative view of their care. Additionally, collaboration with high-volume breast centers may help patients in low-resource settings receive the desired reconstruction for their breast cancer care, helping improve the utilization rate and quality of care.

Extended dermal sling for implant-based immediate prepectoral breast reconstruction in large ptotic breasts without using a mesh in early breast cancer

Background The rate of immediate breast reconstruction after mastectomy for early breast cancer has recently increased owing to the technological advancements in tissue expanders and implant designs, acellular dermal matrices, and fat grafting. The use of an extended dermal sling to cover the implant in patients with large ptotic breast allows prepectoral breast reconstruction, avoiding the complications and pitfalls of pectoralis muscle elevation and evading the use of the acellular dermal matrices with its high cost and being a foreign material. Patients and methods A total of 22 patients underwent mastectomy through a Wise pattern incision. The de-epithelialized extended dermal sling was used to create a prepectoral pocket for the implant and sutured to the pectoralis fascia. Results The median BMI was 31.5 kg/m2 (range, 28–39). The median distance between the areola and the inframammary fold was 20.3 cm (range, 18–26). A total of 13 patients had permanent implant and nipple graft, whereas nine patients had a tissue expander. The average implant size was 375 ml (range, 325–450). Three patients developed seroma around the implant. One patient had mild erythema and two patients had delayed wound healing. Two patients developed partial nipple necrosis. One patient experienced infection and wound dehiscence mainly at the T-junction, and the vertical limb, which was managed by a re-do surgery, removal of the implant, and insertion of a tissue expander. The average follow-up was 14 months (range, 8–24). Conclusion Extended dermal sling is a safe, reliable, and effective option for immediate prepectoral breast reconstruction after mastectomy for patients with early breast cancer who have a large ptotic breast. It has a great advantage of being an autologous tissue with minimal complications and good esthetic results.

Patient-reported outcomes for immediate breast reconstruction with mastectomy among breast cancer patients in Pakistan

Introduction: The rate of immediate breast reconstruction (IBR) with mastectomy is less than 1% in Pakistan. It is important to assess the change in the quality of life in women undergoing mastectomy with IBR in a developing country where resources are limited, and patients are not accustomed to reconstructive procedures. This study aimed to evaluate the effect of IBR with mastectomy in the Pakistani patient population.

Disparities in Access to Postmastectomy Breast Reconstruction: Does Living in a Specific ZIP Code Determine the Patient's Reconstructive Journey?

Postmastectomy breast reconstruction (BR) has been shown to provide long-term quality of life and psychosocial benefits. Despite the policies initiated to improve access to BR, its delivery continues to be inequitable, suggesting that barriers to access have not been fully identified and/or addressed. The purpose of this study was to assess the influence of geographic location, socioeconomic status, and race in access to immediate BR (IBR). An institutional review board-approved observational study was conducted. All patients who underwent breast cancer surgery from 2014 to 2019 were queried from our institutional Breast Cancer Registry. A geographical analysis was conducted using demographic characteristics and patient's ZIP codes. Euclidean distance from patient home ZIP code to UPMC Magee Women's Hospital was calculated, and χ2, Student t test, Mann-Whitney, and Kruskal-Wallis tests was used to evaluate differences between groups, as appropriate. Statistical significance was set at P < 0.05. Overall, 5835 patients underwent breast cancer surgery. A total of 56.7% underwent lumpectomy or segmental mastectomy, and 43.3% underwent modified, total, or radical mastectomy. From the latter group, 33.5% patients pursued BR at the time of mastectomy: 28.6% autologous, 48.1% implant-based, 19.4% a combination of autologous and implant-based, and 3.9% unspecified reconstruction. Rates of IBR varied among races: White or European (34.1%), Black or African American (27.7%), and other races (17.8%), P = 0.022. However, no difference was found between type of BR among races (P = 0.38). Moreover, patients who underwent IBR were significantly younger than those who did not pursue reconstruction (P < 0.0001). Patients who underwent reconstruction resided in ZIP codes that had approximately US $2000 more annual income, a higher percentage of White population (8% vs 11% non-White) and lower percentage of Black or African American population (1.8% vs 2.9%) than the patients who did not undergo reconstruction. While the use of postmastectomy BR has been steadily rising in the United States, racial and socioeconomic status disparities persist. Further efforts are needed to reduce this gap and expand the benefits of IBR to the entire population without distinction.

Exploring breast surgeons’ reasons for women not undergoing immediate breast reconstruction

IntroductionFactors influencing breast reconstruction rates in Canada are complex and multi-factorial, ranging from patient-related to systemic considerations. For plastic surgeons, rates of immediate breast reconstruction (IBR) hinge on referral patterns from general surgeons performing breast cancer surgery and informed discussions with patients about their goals and risk tolerance. We seek to understand the reasons Alberta patients are not receiving IBR as reported by general surgeons. MethodsThe Synoptec™ database is a synoptic operative report designed by Cancer Surgery Alberta™ and utilized by 95% of Alberta breast cancer surgeons. Within this report are mandatory questions regarding if a patient is receiving IBR and, if not, why. A retrospective review of this database was performed for all patients undergoing surgical treatment of breast cancer over two years. All statistical comparisons were made using chi-squared test for categorical variables with a p-value of 0.05 considered significant. ResultsOf 6253 patients undergoing breast cancer surgery, 2649 underwent mastectomy and 615 mastectomy patients received IBR. The most commonly reported reasons patients did not undergo IBR were patient preference (55%), high likelihood of postoperative radiation therapy (20%), and high risk due to patient co-morbidities (12%). Resource limitations (2%) and a lack of an IBR discussion (3%) was rarely cited as reasons for no IBR. ConclusionsThere are many reconstructive options following mastectomy in breast cancer survivors. This study provides a unique look into general surgeon reported reasons patients are not receiving IBR and demonstrates the need for further probing into the thought-process behind these reported reasons from both a surgeon and patient perspective.

Racial Disparity in Immediate Breast Reconstruction; a Gap That is not Closing.

Background: Immediate breast reconstruction (IBR) is offered as part of the standard-of-care to females undergoing mastectomy. Racial disparity in IBR has been previously reported with a longstanding call for its elimination, though unknown if this goal is achieved. The aim of this study was to examine the current association between race and IBR and to investigate whether racial disparity is diminishing. Methods: Data was extracted from the National Cancer Database (NCDB) from 2004 to 2016. All variables in the database were controlled so that the comparison would be made solely between Black and White females. We also analyzed the trend in racial disparity to see if there has been a change from 2004 to 2016 after several calls for healthcare equality. Results: After propensity score matching, 69,084 White females were compared to 69,084 Black females. There was a statistically significant difference between the rate of IBR and race (23,386 [33.9%] in White females vs 20,850 [30.2%] in Black females, P-value < .001). Despite a twofold increase in the rate of IBR in both White and Black females, a persistent gap of about 4% was observed over the study period, which translates to more than 2,500 Black females not receiving IBR. Conclusions: Using the NCDB database, a racial disparity was identified for IBR between White and Black females from 2004 and 2016. Unfortunately, the gap between the groups remained constant over this 13-year period.

Changes in Korean National Healthcare Insurance Policy and Breast Cancer Surgery Trend in Korea

BackgroundSince April 2015, the Korean National Health Insurance (NHI) has reimbursed breast cancer patients, approximately 50% of the cost of the breast reconstruction (BR) procedure. We aimed to investigate NHI reimbursement policy influence on the rate of immediate BR (IBR) following total mastectomy (TM).MethodsWe retrospectively analyzed breast cancer data between April 2011 and June 2016. We divided patients who underwent IBR following TM for primary breast cancer into “uninsured” and “insured” groups using their NHI statuses at the time of surgery. Univariate analyses determined the insurance influence on the decision to undergo IBR.ResultsOf 2,897 breast cancer patients, fewer uninsured patients (n = 625) underwent IBR compared with those insured (n = 325) (30.0% vs. 39.8%, P < 0.001). Uninsured patients were younger than those insured (median age [range], 43 [38–48] vs. 45 [40–50] years; P < 0.001). Pathologic breast cancer stage did not differ between the groups (P = 0.383). More insured patients underwent neoadjuvant chemotherapy (P = 0.011), adjuvant radiotherapy (P < 0.001), and IBR with tissue expander insertion (P = 0.005) compared with those uninsured.ConclusionIBR rate in patients undergoing TM increased after NHI reimbursement.

Early Postoperative Complications From National Surgical Quality Improvement Program: A Closer Examination of Timing and Technique of Breast Reconstruction.

BackgroundDespite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality.Study DesignThe NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications.ResultsOf 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01).ConclusionsImmediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.

Regret and Quality of Life After Mastectomy With or Without Reconstruction

BackgroundMastectomy represents a deep burden for women with breast cancer. Very little is known about the psychological consequences over time and the quality of life (QoL) of women so treated, with or without breast reconstruction (BR). Patients and MethodsA total of 709 patients underwent mastectomy with or without BR between 2002 and 2012 at one institution. Among 468 surviving patients, a 60-query QoL questionnaire on personal issues including some European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire items was presented either by email, letter, or telephone interview. ResultsOf those questioned, 328 patients participated, whereas 140 (30%) declined the invitation or were unavailable. The median age was 63 years (range, 30-93 years). Stage I or II of disease was recorded in 73% of patients. Immediate BR was performed in 168 (51%) of 328 patients. Of the remaining patients, only 7 (4%) of 160 proceeded to delayed BR. Younger women had significantly worse Emotional Functioning and Social Functioning (SF) scores (P < .001), independently of tumor stage, and immediate BR improved that (P = .02). SF score was also worsened by chemotherapy (P = .03). Cognitive Functioning score was independent of age, BR, stage, or adjuvant therapies. Body Image and Sexual Functioning scores improved with BR (P < .03), and age was a strong co-variable (P < .001). On multivariate analysis, immediate BR was correlated with age and preoperative plastic surgery consultation. Some 68 (21%) of 328 patients regretted their decision or were disappointed with their choice regarding BR. ConclusionsYounger patients with breast cancer report a worse impact on their Emotional Functioning and SF scores after mastectomy, both of which are improved by BR. Reconstructing the breast at the time of mastectomy has a significant impact on Body Image and Sexual Functioning scores. A preoperative plastic surgeon consultation improves the rate of immediate BR, whereas delayed reconstruction is rarely adopted. Some 20% of patients are disappointed in or regret their decision regarding BR. We need to improve our management in consideration of these findings.

Determinants influencing immediate breast reconstruction in an Australian tertiary public hospital.

In Australia, the rate of immediate breast reconstruction (IBR) following breast cancer surgery is highly variable. This study aimed to identify the rate of IBR within an Australian public tertiary breast oncology referral centre and analyse the tumour and demographic factors that impact upon IBR uptake. A retrospective cohort study of 288 admissions of women requiring mastectomy between January 2012 and March 2015 was performed. Data collected included demographic data, tumour pathology, operative details and neoadjuvant therapy. Demographic data included a Socioeconomic Index for Area score, based on individual residential postcode, country of birth and need for an interpreter. Our study demonstrated an IBR rate of 41.3% and included a wide variety of reconstructions. Factors that increased the IBR rate included younger age and negative lymph node status. Our patient population was ethnically and linguistically diverse, with over 50 different countries of birth represented and with 53 patients requiring interpreters in 19 different languages. Our analysis shows that the requirement for an interpreter is negatively correlated with having an IBR. Our research demonstrates a high rate of IBR that includes a wide range of autologous and alloplastic reconstructions. Our study represents a unique opportunity to identify socioeconomic barriers that influence patient choice for reconstruction following mastectomy. This can lead to improved health care provision for our patients. This is particularly important in tertiary services with a strong multicultural and multi-linguistic population.

Trends in immediate breast reconstruction and radiation after mastectomy: A population study.

In the last decade, there has been an increase in women undergoing immediate breast reconstruction (IBR) at the time of mastectomy. Recent literature suggests a shift in practice: Surgeons are becoming more comfortable with IBR in the setting of possible postoperative adjuvant radiotherapy, despite the known complications. This study sought to investigate, at a population level, the patient and surgeon characteristics associated with the use of IBR and which of these factors were predictive of adjuvant radiotherapy. This retrospective population-based cohort study included all adult women who underwent mastectomy in the province of Ontario from 2007 to 2014. The Canadian Institute for Health Information (CIHI) administrative data base was used to generate patient demographic and clinical data. The Ontario Health Insurance Plan (OHIP) data base was used to elicit surgeon characteristics including clinical experience and volume of practice dedicated to breast surgery. Outcome variables included reconstruction concurrent with mastectomy, alloplastic vs autologous reconstruction, and use of radiation. A total of 25861 patients underwent mastectomy and 2972 had IBR (11.5%). The rate of IBR after mastectomy increased over time from 7.2% in 2007 to 17.2% in 2014 (P<.001). There was also an increase in the proportion of patients with IBR who received radiation over the time period, from 19.4% in 2007 to 28.2% in 2014 (P=.003). In the first regression analysis, IBR was associated with younger patient age, residing in closer proximity to cancer clinics, absence of malignant breast disease (ie, prophylactic mastectomy), having a younger surgeon performing the mastectomy, and receiving care at a teaching hospital. A second analysis showed that patient variables predictive of radiation after IBR were a younger age and a more advanced cancer stage and no variables specific to surgeon or institution were predictive of radiation in patients with IBR. A significant increase in the rate of IBR as well as the use of radiation occurred over the 7-year study period. Multiple patient and surgeon factors were associated with IBR. Variables associated with radiation in IBR were harder to predict. Given the increase in the use of radiation in IBR, further research is needed to look at long-term outcomes in these patients at the population level.

Patterns of immediate breast reconstruction in New South Wales, Australia: a population-based study.

BackgroundThe rate of immediate breast reconstruction (IBR) following mastectomy for breast cancer in Australia is low and varies between regions. To date, no previous Australian studies have examined IBR rates between all hospitals within a particular jurisdiction, despite hospitals being an important known contributor to variation in IBR rates in other countries.MethodsWe used cross‐classified random‐effects logistic regression models to examine the inter‐hospital variation in IBR rates by using data on 7961 women who underwent therapeutic mastectomy procedures in New South Wales (NSW) between January 2012 and June 2015. We derived IBR rates by patient‐, residential neighbourhood‐ and hospital‐related factors and investigated the underlying drivers for the variation in IBR.ResultsWe estimated the mean IBR rate across all hospitals performing mastectomy to be 17.1% (95% Bayesian credible interval (CrI) 12.1–23.1%) and observed wide inter‐hospital variation in IBR (variance 4.337, CrI 2.634–6.889). Older women, those born in Asian countries (odds ratio (OR) 0.5, CrI 0.4–0.6), residing in neighbourhoods with lower socioeconomic status (OR 0.7, CrI 0.5–0.8 for the most disadvantaged), and who underwent surgery in public hospitals (OR 0.4, CrI 0.1–1.0) were significantly less likely to have IBR. Women residing in non‐metropolitan areas and attending non‐metropolitan hospitals were significantly less likely to undergo IBR than their metropolitan counterparts attending metropolitan hospitals.ConclusionWide inter‐hospital variation raises concerns about potential inequities in access to IBR services and unmet demand in certain areas of NSW. Explaining the underlying drivers for IBR variation is the first step in identifying policy solutions to redress the issue.

Increases in Postmastectomy Reconstruction in New York State Are Not Related to Changes in State Law.

Postmastectomy reconstruction remains underused. In 2011, new legislation in New York State mandated discussion of reconstructive options before mastectomy. This study assesses the impact of this policy on immediate breast reconstruction rates. The Statewide Planning and Research Cooperative System database was queried to identify women undergoing mastectomy from January of 2005 to October of 2015 and follow them for at least 1 year postoperatively to determine the incidence and timing of reconstruction. Demographic and socioeconomic characteristics were collected. Chi-square test and multivariable logistic regression were used to compare periods before (2005 to 2010) and after (2011 to 2015) the legislative change. Of 52,837 records, there were 24,340 patients (46 percent) who underwent immediate breast reconstruction. The incidence of immediate breast reconstruction increased over the study period, most significantly in 2008 to 2009. Rates of immediate breast reconstruction continued to increase, although at a slower rate, after 2011 compared with before 2011 across all subgroups. Both implant and autologous reconstructive techniques increased over time. Implant-based reconstruction increased steadily, whereas autologous reconstruction increased most significantly between 2008 and 2009. Despite an overall increase in immediate breast reconstruction, there was an overall lack of effect on post-2011 reconstructive rates attributable to the legislative changes. Reconstructive rates have increased significantly in New York State over the past decade, and these changes appear to be largely independent of the 2011 New York State Breast Reconstruction Act. There are likely nonlegislative drivers of breast reconstruction use.

Post-mastectomy immediate breast reconstruction is oncologically safe in well-selected T4 locally advanced breast cancer: a large population-based study and matched case-control analysis.

Although it is well accepted that the survival outcome is most probably unaffected by immediate breast reconstruction (IBR) for T1-T3 tumors, the safety of IBR in T4 locally advanced breast cancer (LABC) remains unclear. By using data from the Surveillance, Epidemiology, and End Results (SEER) database, the trend of IBR for female T4 LABC patients undergoing mastectomy, chemotherapy and radiotherapy was explored. The predictors of IBR in T4 LABC were evaluated by multivariate logistic regression. The survival outcomes were compared by means of Cox hazards models adjusting for known clinicopathological variables and stratifying on the T stage and contralateral prophylactic mastectomy (CPM). Altogether 714 cases underwent IBR between 1998 and 2015. The IBR cohort had a lower percentage of cases with T4d disease whereas higher percentage with CPM. The IBR rate was 10.1% and increased from 4.1% in 1998 to 17.7% in 2015. Since 2009, the rate of implant-based IBR exceeded that of the autologous tissue method. An age less than 45years (OR 2.930, 95% CI 2.299-3.735) and CPM (OR 2.758, 95% CI 2.306-3.299) were the strongest predictors of IBR. In the 1:2 matched case-control analysis, IBR was not an independent prognostic factor for breast cancer specific-survival (BCSS) (HR 0.893, p = 0.236, 95% CI 0.741-1.077) and overall survival (OS) (HR 0.886, p = 0.183, 95% CI 0.741-1.059). BCSS and OS were similar among patients undergoing IBR whether they underwent CPM or not and whether they were inflammatory breast cancer (IBC) or not. IBR is oncologically safe in well-selected T4 LABC.