BackgroundReconstructive alternatives should be discussed with women facing mastectomy for breast cancer. These include immediate and delayed reconstruction, which both have inherent advantages and disadvantages. Immediate reconstruction rates vary considerably in Swedish healthcare regions, and the aim of the study was to analyse reasons for this disparity.MethodsAll women who underwent mastectomy for primary breast cancer in Sweden in 2013 were included. Tumour data were retrieved from the Swedish National Breast Cancer Registry and from questionnaires regarding patient information and involvement in preoperative decision‐making sent to women who were still alive in 2015.ResultsOf 2929 women who had undergone 2996 mastectomies, 2906 were still alive. The questionnaire response rate was 76·3 per cent. Immediate reconstruction rates varied regionally, between 3·0 and 26·4 per cent. Tumour characteristics impacted on reconstruction rates but did not explain regional differences. Patient participation in decision‐making, availability of plastic surgery services and patient information, however, were independent predictors of immediate breast reconstruction, and varied significantly between regions. Even in younger patients with low‐risk tumours, rates of patient information ranged between 34·3 and 83·3 per cent.ConclusionSignificant regional differences in immediate reconstruction rates were not explained by differences in tumour characteristics, but by disparities in patient information, availability of plastic surgery services and involvement in decision‐making.

Background Immediate breast reconstruction (IBR) rates in breast cancer differ between healthcare regions in Sweden. This is not explained by regional differences in patient age distribution or tumour characteristics, but by differences in patient‐reported information and patient involvement in the decision‐making process. As socioeconomic status may play a significant role in surgical decision‐making, its potential associations with IBR rates were analysed. Methods Women who had undergone therapeutic mastectomy for primary breast cancer in Sweden in 2013 were included in the analysis. Tumour and treatment data were retrieved from the Swedish National Breast Cancer Register, and socioeconomic background data from the Central Bureau of Statistics Sweden. Postal questionnaires regarding information about reconstruction and perceived involvement in the preoperative decision‐making process had been sent out in a previous survey. Results In addition to regional differences, lower tumour and nodal category, independent factors increasing the likelihood of having IBR for the 3131 women in the study were living without a registered partner, having current employment and high income per household. Patient‐reported perceived preoperative information (odds ratio (OR) 12·73, 95 per cent c.i. 6·03 to 26·89) and the feeling of being involved in the decision‐making process (OR 2·56, 1·14 to 5·76) remained strong independent predictors of IBR despite adjustment for socioeconomic factors. Importantly, responders to the survey represented a relatively young and wealthy population with a lower tumour burden. Conclusion Several socioeconomic factors independently influence IBR rates; however, patient‐reported information and involvement in the surgical decision‐making process remain independent predictors for the likelihood of having IBR.

Background Radiotherapy (RT) is a risk factor for impaired outcomes after implant-based immediate breast reconstruction (IBR). Large studies including long-term follow-up are relatively scarce. The purpose of this analysis was to assess long-term effects of RT in implant-based IBR, distinguishing between implant removal because of postoperative complications versus patient preference. Methods This population-based cohort study included all patients with breast cancer who underwent implant-based IBR in Stockholm between 2005 and 2015. Data were collected through national registers and medical charts. The main endpoint was implant removal owing to postoperative complications (wound breakdown, infection, bleeding) or patient preference (dissatisfaction, pain, capsular contracture), with or without conversion to autologous reconstruction. Results Some 1749 implant-based IBRs in 1687 women were included. Median follow-up was 72 (range 1–198) months. Reconstructions were divided according to receipt of RT: No RT (n = 856, 48.9 per cent), adjuvant RT (n = 749, 42.8 per cent), and previous RT (n = 144, 8.2 per cent). Implant removal occurred after 266 reconstructions (15.2 per cent); 68 (7.9 per cent) in the no RT, 158 (21.1 per cent) in the adjuvant RT, and 40 (27.8 per cent) in the previous RT group. Implant removal was because of postoperative complications in 152 instances (57.1 per cent) and was most common in the first 3 years. This was especially observed in the previous RT group, where 15 of 23 implant removals occurred during the first 6 months. Implant removal owing to patient preference (114 of 266, 42.9 per cent) became more common with increasing follow-up. Conclusion Implant removal after implant-based IBR is significantly associated with RT. The reason for implant removal shifts over time from postoperative complications to patient preference.

Purpose Breast cancer treatment is reported to be influenced by socioeconomic status (SES). Few reports, however, stem from national, equality-based health care systems. The aim of this study was to analyse associations between SES, rates of breast-conserving surgery (BCS), patient-reported preoperative information and perceived involvement in Sweden. Methods All women operated for primary breast cancer in Sweden in 2013 were included. Tumour and treatment data as well as socioeconomic data were retrieved from national registers. Postal questionnaires regarding preoperative information about breast-conserving options and perceived involvement in the decision-making process had previously been sent to all women receiving mastectomy. Results Of 7735 women, 4604 (59.5%) received BCS. In addition to regional differences, independent predictors of BCS were being in the middle or higher age groups, having small tumours without clinically involved nodes, being born in Europe outside Sweden, having a higher education than primary school and an intermediate or high income per household. Women with smaller, clinically node-negative tumours felt more often involved in the surgical decision and informed about breast-conserving options (both p < 0.001). In addition, women who perceived that BCS was discussed as an alternative to mastectomy were more often in a partnership (p < 0.001), not born in Sweden (p = 0.035) and had an employment (p = 0.031). Conclusion Socioeconomic factors are associated with surgical treatment even in a national health care system that is expected to offer all women the same standard of care. This should be taken into account and adapted to in preoperative counselling on surgical options in breast cancer.

Background Current evidence for the effects of radiotherapy (RT) on implant-based immediate breast reconstruction (IBR) is limited by short follow-up and lack of patient-reported outcomes (PROs). It is central to integrate long-term comprehensive outcome data into the preoperative decision-making process. The aim of the present study was to determine long-term surgical outcomes and PROs in relation to RT after implant-based IBR. Methods This was a longitudinal cohort study of PRO data obtained in surveys conducted in 2012 and 2020 using the BREAST-Q questionnaire. All women undergoing therapeutic mastectomy and implant-based IBR between 1 January 2007 and 31 December 2011 at four breast centres in Stockholm, Sweden, were identified. The endpoint was implant removal owing to surgical complications or patient preference. Results Median follow-up was 120 (range 1–171) months. After 754 IBRs in 729 women, implant removal occurred in 128 (17 per cent): 34 of 386 (8.8 per cent) in the no-RT group, 20 of 64 (31.3 per cent) in the group with previous RT, and 74 of 304 (24.3 per cent) in the postoperative RT group (P &lt; 0.001). Implant removal was because of surgical complications in 60 instances (7.9 per cent), and patient preference in 68 (9.0 per cent). The BREAST-Q response rate was 72.2 per cent. Women with previous RT scored lower than those without RT on all scales, apart from psychosocial well-being. Women with postoperative RT scored lower only on physical well-being. No scores in the two RT groups had deteriorated between the survey time points, whereas satisfaction with breasts and overall outcome had decreased in the no-RT group. Conclusion Although RT was significantly associated with higher implant removal rates, PROs remained stable over 8 years despite irradiation.

Purpose The aim of the current study was to evaluate risk factors and timing of revision surgery following immediate implant-based breast reconstruction (IBR). Methods This retrospective cohort included women with a previous therapeutic mastectomy and implant-based IBR who had undergone implant revision surgery between 2005 and 2015. Data were collected by medical chart review and registered in the Stockholm Breast Reconstruction Database. The primary endpoint was implant removal due to surgical complications, i.e. implant failure. Results The cohort consisted of 475 women with 707 revisions in 542 breasts. Overall, 33 implants were removed due to complications. The implant failure rate (4.7%) was lower without RT (2.4%) compared to RT administered after mastectomy (7.5%) and prior to IBR (6.5%) (p = 0.007). While post-mastectomy RT (OR 3.39, 95% CI 1.53–7.53), smoking (OR 3.90, 95% CI 1.76–8.65) and diabetes (OR 5.40, 95% CI 1.05–27.85) were confirmed as risk factors, time from completion of RT (> 9 months, 6–9 months, < 6 months) was not (OR 3.17, 95% CI 0.78–12.80, and OR 0.74, 95% CI 0.20–2.71). Additional risk factors were a previous axillary clearance (OR 4.91, 95% CI 2.09–11.53) and a history of a post-IBR infection (OR 15.52, 95% CI 4.15–58.01, and OR 12.93, 95% CI 3.04–55.12, for oral and intravenous antibiotics, respectively). Conclusions Previous axillary clearance and a history of post-IBR infection emerged as novel risk factors for implant failure after revision surgery. While known risk factors were confirmed, time elapsed from RT completion to revision surgery did not influence the outcome in this analysis.

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