Immediate Breast Reconstruction After Mastectomy Does Not Delay Adjuvant Therapy

By Will Boggs MD

April 22, 2019

NEW YORK (Reuters Health) - Immediate breast reconstruction after mastectomy for breast cancer does not delay initiation of adjuvant therapy, according to results from the iBRA-2 study.

"Immediate reconstruction does not appear to delay treatment, but major complications following implant-based or free-flap reconstruction are significantly higher than following mastectomy only, and if patients experience a complication, this may result in treatment delays," Dr. Shelley Potter from Bristol Medical School and North Bristol NHS Trust in the U.K. told Reuters Health by email.

Delays of more than 90 days in the delivery of adjuvant chemotherapy have been associated with worse survival, but evidence regarding the impact of immediate breast reconstruction (IBR) on the timing of adjuvant therapy is inconsistent.

Dr. Potter and colleagues from 76 centers investigated whether IBR influences the time to delivery of adjuvant therapy, compared with mastectomy alone, in their prospective study of 2,540 women, 1,008 (39.7%) of whom underwent IBR.

Overall, 929 patients (36.6%) experienced at least one postoperative complication, and 221 patients (8.7%) experienced major complications requiring readmission to hospital or further surgery.

Undergoing bilateral surgery and free-flap reconstruction were independent risk factors for postoperative complications; implant-based and free-flap reconstruction were the strongest predictors for major complications, the researchers report in the British Journal of Cancer, online March 29.

There were no differences between the treatment groups in median time to chemotherapy or radiotherapy or in the proportions of patients experiencing treatment delays (>90 days for chemotherapy; greater than eight weeks for radiotherapy).

In multivariable analyses, free-flap reconstruction, major complications, and obesity were associated with longer time to chemotherapy, and major complications and smoking were associated with longer time to adjuvant radiotherapy.

There were increasing trends of time to first adjuvant therapy, time to chemotherapy, and time to radiotherapy according to whether women had no, minor, or major complications.

Women experiencing complications were also significantly more likely to experience significant treatment delays for chemotherapy and radiotherapy, compared with women whose procedures were uncomplicated.

"The high rate of complications in all patient groups was disappointing and highlights a need for improvement to improve outcomes for patients," Dr. Potter said.

"Careful patient selection and fully informed shared decision-making with accurate communication of risks is vital for patients considering immediate breast reconstruction when adjuvant treatment is likely to be needed," she said.

Dr. Sharon S. Lum, medical director of Loma Linda University School of Medicine's Breast Health Center, in California, told Reuters Health by email, "Overall, the study is reassuring that there are no clinically significant delays in time from definitive surgery to initiation of adjuvant chemo- or radiation therapy, regardless of whether a woman undergoes IBR or which type of IBR is performed. Clinicians are doing a good job of selecting appropriate patients for IBR, but need to remain vigilant about getting postop patients to timely adjuvant care."

"There are opportunities for improvement to get patients to recommended radiation, as 60% of patients needing radiation started after the recommended 8-week postop period," she said. "Clinical pathways/enhanced recovery after surgery (ERAS) protocols associated with decreased complication rates should be studied."

SOURCE: https://bit.ly/2GnVQP2

Br J Cancer 2019.

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