Although recent data have been published regarding trends surrounding mastectomy with reconstruction for breast cancer, little data exist about predictors of immediate vs delayed reconstruction and the prevalence of reconstruction where it is traditionally contraindicated, such as inflammatory breast cancer and stage IV disease.
Allison A. Aggon, DO, Elin R. Sigurdson, MD, PhD, Eric Chang, MD, Brian L. Egleston, PhD, Sameer Patel, MD, Marcia Boraas, MD, Neal S. Topham, Richard J. Bleicher, MD; Fox Chase Cancer Center
Background: Although recent data have been published regarding trends surrounding mastectomy with reconstruction for breast cancer, little data exist about predictors of immediate vs delayed reconstruction and the prevalence of reconstruction where it is traditionally contraindicated, such as inflammatory breast cancer and stage IV disease.
Methods: Surveillance, Epidemiology, and End Results (SEER)-Medicare data were reviewed for women ≥ 66 years old and diagnosed between 1992 and 2005 with stage 0 through IV breast cancer. Immediate reconstruction was defined by claims dated the same day as their mastectomy, while delayed reconstruction was defined as reconstruction performed up to 36 months after that date. Postmastectomy radiotherapy was reviewed by searching for radiotherapy claims up to 1 year after mastectomy.
Results: Of the 50,843 women who underwent mastectomy, 5.8% had reconstruction, increasing from 3.2% to 7.3% (P < .0001) during the study period, with a maximum patient age of 99 years. There were 4.3% of the 783 having inflammatory breast cancer and 2.9% of the 1,241 patients with metastatic disease who underwent reconstruction. Implants, autologous tissue flaps (ATFs), the combination, and unspecified reconstruction types occurred in 57.2%, 20.4%, 17.0%, and 5.2%, respectively, with radiotherapy performed in 14.9%, 37.3%, 14.6%, and 51.0% of those respective groups. Postmastectomy radiotherapy was also performed in 23% of immediate and 14.9% of delayed reconstruction cases. Among all patients having reconstruction, 79% underwent immediate reconstruction and 21% had delayed reconstruction, with a median delay of 8.5 months. From 1998 to 2005, immediate reconstruction increased from 2.6% to 5.8%, while delayed reconstruction plateaued at ~1.4% in this period. The likelihood of having any reconstruction declined with increasing comorbidities (trend P < .0001). Delayed-reconstruction patients had greater comorbidities than those who had immediate reconstruction (trend P = .04). ATF patients had greater comorbidities than implant patients (P = .0003). Variables associated with delayed reconstruction (vs immediate) were SEER region (P < .0001), higher stage (P < .0001), postoperative radiotherapy (P < .0001), diagnosis year (P < .037), and comorbidity index (P = .037). Age, marital status, race, and histology were not predictive.
Conclusion: A small minority of patients have reconstruction when it is traditionally considered contraindicated. Radiotherapy was used more frequently in patients having immediate than delayed reconstruction, with ATF reconstruction used to a greater degree than implants in both immediate and delayed reconstruction groups. Although immediate reconstruction is on the rise, its use in Medicare patients remains low. Further efforts to educate clinicians and patients about eligibility for immediate reconstruction, even in those over 65 years of age, may be worthwhile.