A Claims-Based Study of Baseline Comorbidities as a Predictive Factor for Complications After Breast Reconstruction in Geriatric Cancer Patients
Hope Xu, BA1, Jenny Lin, MD, MPH2, Keith Sigel, MD, PhD2, Peter J. Taub, MD2.
1Icahn School of Medicine at Mount Sinai, New York City, NY, USA, 2Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Background: Given the prevalence of breast cancer in geriatric women and their growing interest in breast reconstruction, a strong understanding of factors that influence surgical outcomes is crucial. Elderly patients are often anecdotally considered poor candidates for surgery due to comorbidity burden and frailty; however, the relationship between complications and comorbidity burden has yet to be thoroughly examined in a large population. The purpose of this study was to analyze specific medical comorbidities as a predictive factor for complications following breast reconstruction in geriatric cancer patients.
Methods: A longitudinal, retrospective cohort study was conducted using the Surveillance, Epidemiology and End Results registry linked to Medicare claims. A cohort of women age 66+ years diagnosed with primary breast cancer between 2000-2011 who underwent mastectomy was identified. Mastectomy, reconstruction, comorbidities as delineated by the Elixhauser Comorbidity Index, and complications were identified using ICD-9 and CPT codes between 2000-2014. Weighted Elixhauser scores were calculated to estimate burden across thirty-one comorbidities. Primary predictors were comorbidities. Secondary predictors were sociodemographic and tumor data. Univariate analyses and multivariate logistic regression models were fit to analyze for differences in the primary outcome— complications within 30 days of reconstruction.
Results: A total of 63,696 women underwent mastectomy, and 4,962 women (7.80%) received primary reconstruction by implant (70.8%) or autologous (29.2%) procedures before 2014. Of these women, none suffered 30-day mortality and 1,255 (25.3%) had 30-day complications, consisting of 473 seromas, 173 hematomas, 901 infections, 398 wound healing complications, and 50 graft failures. In univariate analyses, women who developed complications were more likely to have autologous reconstruction (p<0.0001), lower income quartile (p=0.0430), positive lymph node status (p=0.0043), higher AJCC stage (p=0.0002), greater comorbidity burden (mean weighted Elixhauser score 1.69 vs. 1.30, p=0.0069), and a history of cardiac arrhythmia, hypertension, neurological disorders, chronic pulmonary disease, diabetes, obesity, and/or depression. A predictive multivariate model demonstrated increased odds of complications in patients with a baseline comorbidity of uncomplicated diabetes (OR=1.318) and chronic pulmonary disease (OR=1.356), after controlling for covariates. Autologous reconstruction (OR=1.543) and AJCC stage (OR=1.168) were also associated with increased odds of complications.
Conclusions: Among older women, only diabetes and chronic pulmonary disease were significant predictors of complications after reconstruction. Importantly, overall comorbidity burden was only associated without controlling for other predictors, and age itself was not at all associated with complications. Elderly women desiring reconstruction should not be considered inherently poor candidates before careful evaluation of their specific comorbidity profiles.
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