Breast Reconstruction After Mastectomy: Now or Later?
MONDAY Sept. 20, 2010 -- Two new studies may help breast cancer patients and their doctors make treatment decisions involving immediate breast reconstruction after mastectomy.
One study finds that about half of women who need radiation therapy after having had a mastectomy with immediate reconstruction develop complications that require additional surgery. Another study finds that chemotherapy does not affect complication rates after mastectomy and immediate reconstruction.
Both reports are published in the September issue of the Archives of Surgery.
The growing trend toward immediate reconstruction "has turned into a runaway train," said researcher Dr. Rodney Pommier, professor of surgery at Knight Cancer Institute, Oregon Health & Science University in Portland. Some women, he said, would be better off delaying it.
Pommier and his colleagues evaluated 302 women who had mastectomies; of these, 152 had reconstruction, including 131 immediately, and 100 had radiation after the mastectomy.
Among those 100 who needed radiation, complications occurred in 44 percent of those who had immediate reconstruction, but only in 7 percent of those who did not have immediate reconstruction.
Both scenarios -- having radiation after mastectomy and having reconstruction done immediately -- strongly predicted the risk of complications, Pommier's team found. Radiation tripled the risk, and immediate reconstruction increased the risk eightfold.
Implants had to be removed in 31 percent of patients who had radiation after mastectomy, compared to just 6 percent of those who did not have to have radiation, the researchers reported.
"We were surprised that one in three lost implants," he said. His team was also surprised at the complication rates overall. "I think it was known that complication rates [among those who need radiation] are fairly high, but I don't think they have been quantified," he noted.
The results, Pommier said, have changed his thinking. He now suggests that having a biopsy of the sentinel lymph node (the first to receive drainage from a tumor) before deciding whether to have immediate reconstruction would be wise. "If the sentinel node is negative, there is a low probability they would get radiation," he explained.
This biopsy is typically done at the start of the mastectomy, he said. But it can be done as a 30-minute outpatient procedure before the mastectomy is scheduled and before the reconstruction decision is made. In determining who will need radiation after mastectomy, doctors consider biopsy results as well as other factors, such as tumor size.
In the second study, researchers from the University of California, San Francisco, found that chemotherapy, either before or after the mastectomy and immediate reconstruction, had no bearing on complications and the need for more procedures.
Overall, 31 percent of 163 patients studied (some of whom received chemo, and some who did not) had a complication that required a return trip to the operating room. But the rate didn't differ based on whether the woman received chemo before surgery, after, or not at all.
The two new studies are putting some numbers behind what doctors have observed in patients, said Dr. Joanne Mortimer, director of the women's cancer program at City of Hope Comprehensive Cancer Center in Duarte, Calif., who reviewed the findings.
"I think they actually put in writing what physicians have appreciated clinically," she said.
While immediate reconstruction can help a woman cope psychologically, Mortimer said, sometimes it is not best in the long run if a woman needs radiation.
For more on breast reconstruction after mastectomy, visit the American Cancer Society.
Posted: September 2010