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A Comparison of Postoperative Complications Between Immediate Breast Reconstruction and Mastectomy Alone: Impact on Chemotherapy Initiation
Toni Zhong, MD, David McCready, MD, FRCS(C), Stefan Hofer, MD, PhD, FRCS(C).
University Health Network, Toronto, ON, Canada.
Purpose: Since the role for postmastectomy chemotherapy has been expanding, there is increased concern that the routine use of immediate breast reconstruction (IBR) may delay the initiation of adjuvant chemotherapy. The purpose of this study, therefore, is to perform an institutional audit and compare postoperative complication rates between IBR and mastectomy alone, as well evaluate the timing of chemotherapy initiation.
Methods: A retrospective review was conducted of all consecutive patients who underwent mastectomy alone or with IBR from May 2007 through June 2010 at University Health Network, Toronto, Canada. The primary outcome evaluated was complications within the first three postoperative months. The secondary endpoint evaluated was delay in adjuvant chemotherapy which was defined as greater than 12 weeks between mastectomy and time to start chemotherapy.
Results: A total of 432 patients were identified, 174 had mastectomy plus IBR and 258 patients had mastectomy alone. There were significant differences between the two groups with patients in the mastectomy group being significantly older and more likely to be a smoker (p<0.01) compared to the IBR group. Patients having IBR were more likely to have had previous lumpectomy and radiation to the breast (P<0.0001). All mastectomy alone procedures were unilateral while 53% of IBR procedures were bilateral (P<0.0001). In the IBR group, 37% used tissue expander, 57% used microsurgical transfer techniques, and 6% used latissimus dorsi with tissue expanders.
Overall, the proportion of patients who had a complication was significantly greater in the IBR than mastectomy alone group (26% vs. 17%, p=0.02). Multivariate analysis revealed that after controlling for the effect of the other covariates, IBR was not a significant predictor (p=0.64) of complications. Laterality was the only independent predictor of increased complications (OR for bilateral vs. unilateral = 2.2, p=0.04). In addition, a confirmatory analysis was performed using the propensity score that was determined using age, BMI, previous radiation and lumpectomy status, smoking, and presence of co-morbidity. Propensity score analysis confirmed that laterality was a significant predictor of increased complications (p=0.04) but the inclusion of IBR with mastectomy was not (p=0.51).
Of the 147 patients who received adjuvant chemotherapy, the median time from mastectomy to start of chemotherapy was 6.7 weeks in the mastectomy alone group compared to 8.4 weeks in the IBR group (p=0.02). However, interestingly, the 12 patients in the entire cohort who were found to have had a delay in start of chemotherapy beyond 12 weeks were all in the mastectomy alone group.
Conclusions: This is the largest series to compare postoperative complication rates between mastectomy alone and IBR. It revealed that although complication rates were found to be significantly higher following IBR, this was most likely explained by the significantly higher proportion of bilateral procedures in the IBR group compared to the mastectomy group, rather than by the IBR procedure itself. More importantly, the performance of IBR did not result in a delay in the start of chemotherapy compared to mastectomy alone.
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