Patient Reported Satisfaction and Quality of Life in Post-Mastectomy Radiated Patients: A Comparison between Delayed and Delayed Immediate Autologous Breast Reconstruction in a Predominantly Minority Patient Population
George Kamel, MD, Heather Erhard, MD, David Greenspun, MD, Teresa Benacquista, MD, Evan S. Garfein, MD, Katie E. Weichman, MD.
Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA.
Background: Breast reconstruction serves as an integral component in the care of patients with breast cancer, with higher rates of reported satisfaction in patients undergoing autologous based breast reconstruction. Delayed immediate autologous breast reconstruction consists of immediate post mastectomy tissue expander placement, followed by radiation therapy and subsequent autologous reconstruction. The decision between delayed versus delayed immediate autologous breast reconstruction in patients anticipating post mastectomy radiotherapy is challenging and remains to be elucidated. With this in mind, the purpose of this investigation was to evaluate the effects of delayed versus delayed immediate autologous breast reconstruction in patients undergoing post mastectomy radiotherapy on patient reported outcomes and quality of life in predominantly minority patients.
Methods: After IRB approval was obtained, a retrospective review of all patients who underwent autologous based breast reconstruction at Montefiore Medical Center from January of 2009 to December of 2016 was conducted. Patients who underwent post mastectomy radiotherapy were included for analysis. Patients were divided into two cohorts: those undergoing delayed and delayed immediate autologous breast reconstruction. Patients were mailed a BREAST-Q survey for response. Additionally, the demographic information, complications, and need for revisionary procedures were analyzed in comparison. BREAST Q satisfaction was then analyzed using Q-Score software (Perth, Australia).
Results: 56 patients met the inclusion criteria: 37.5 percent (n=21) of patients underwent delayed autologous breast reconstruction and 62.5 percent (n=35) underwent delayed immediate autologous breast reconstruction. 87.5 percent (n=49) of the patients were identified as minority. Patients in each cohort were similar in BMI, mean mastectomy specimen weight, indication for surgery and smoking status. All patients received post mastectomy radiotherapy. Patients undergoing delayed immediate autologous breast reconstruction were more likely to have bilateral reconstruction (34.3 percent (n=12) versus 9.5 percent (n=2), p=0.04), and were more likely to have major mastectomy flap necrosis (17.0 percent (n=8) versus 0.0 percent (n=0), p= 0.02). Furthermore, 14.9 percent (n=7) of patients undergoing delayed immediate autologous breast reconstruction required removal of their tissue expanders. Of those patients undergoing delayed autologous breast reconstruction, 28.6% (n=6) responded to the BREAST-Q survey, whereas 40.0% (n=14) of patients with delayed immediate autologous breast reconstruction were responders. BREAST-Q responses showed similar satisfaction with their breasts, overall outcome, chest wall physical well-being, sexual well-being, and psychosocial well-being in both groups.
Conclusions: Delayed autologous breast reconstruction yields similar satisfaction with breasts, overall outcome, chest wall physical well-being, sexual well-being, and psychosocial well-being as compared to delayed immediate autologous based reconstruction. However, patients who undergo delayed immediate autologous breast reconstruction have higher rates of major mastectomy necrosis and subsequent removal of their tissue expanders. This information will be important in preoperative patient discussions and counseling.
Delayed versus Delayed Immediate (DI) Outcomes
| Delayed (n=21) | DI (n= 35) | Test | p-value | |
| Patients | 21 | 35 | n/a | n/a |
| Breasts | 23 | 47 | n/a | n/a |
| Laterality Unilateral Bilateral | 19 (90.5) 2 (9.5) | 23 (65.7) 12 (34.3) | Chi Squared | 0.04 |
| Age | 50 (10.5) | 46 (9.9) | T-test | 0.09 |
| BMI (kg/m2) | 30.0 (4.6) | 31.0 (3.8) | T-test | 0.13 |
| Average mastectomy weight (grams) | 1066 (853) | 853 (425) | T-test | 0.16 |
| Average Flap weight (grams) | 922 (216) | 876 (245) | T-test | 0.28 |
| Adjuvant radiation | 21 (100) | 35 (100) | Fishers Exact | 1.0 |
| Neoadjuvant chemotherapy | 16 (76.2) | 31 (88.6) | Fishers Exact | 0.27 |
| Adjuvant chemotherapy | 1 (4.8) | 1 (2.9) | Fishers Exact | 1.0 |
| Indications Prophylactic Therapeutic | 2 (8.7) 21 (91.3) | 11 (23.4) 36 (76.6) | Chi Squared | 0.14 |
| Flap Type DIEP MS0 TRAM MS1 TRAM | 10 (43.5) 12 (52.2) 1 (4.3) | 15 (31.9) 28 (59.6) 4 (8.5) | Chi Squared | 0.58 |
| Race White Hispanic Black Multiracial | 2 (9.5) 4 (19.1) 3 (14.3) 12 (57.1) | 5 (14.3) 10 (28.6) 13 (37.1) 7 (20.0) | Chi Squared | 0.04 |
Delayed versus Delayed Immediate (DI) Complications
| Delayed (n=21) | DI (n= 35) | Test | p-value | |
| Hematoma | 1 (4.3) | 1 (2.1) | Fishers Exact | 1.0 |
| Seroma | 1 (4.3) | 0 (0.0) | Fishers Exact | 0.33 |
| Donor Site Wound Infection | 3 (14.3) | 8 (22.9) | Fishers Exact | 0.51 |
| Reconstructive Failure | 0 (0.0) | 1 (2.1) | Fishers Exact | 1.0 |
| Vessel Thrombosis Arterial Venous | 0 (0.0) 1(4.3) | 3 (6.4) 1 (2.1) | Fishers Exact | 0.4 |
| Mastectomy Skin flap necrosis Minor Major | 2 (8.7) 0 (0.0) | 0 (0.0) 8 (17.0) | Fishers Exact | 0.02 |
| Fat Necrosis | 0 (0.0) | 5 (10.6) | Fishers Exact | 0.16 |
| TE Explant | n/a | 7 (14.9) |
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