Complications and thromboembolic events associated with tamoxifen therapy in patients with breast cancer undergoing microvascular breast reconstruction: a systematic review and meta-analysis

Abstract

Purpose Tamoxifen therapy is integral in the treatment of patients with hormone receptor-positive breast cancer. However, there is an association between tamoxifen and thromboembolic events. Flap and systemic thromboembolic events have devastating consequences in microvascular breast reconstruction. Currently, there is conflicting data on the association between tamoxifen therapy and thromboembolic complications for patients undergoing microvascular breast reconstruction. The objective of this study is to determine if perioperative tamoxifen therapy modifies the risk of complications and thromboembolic events for patients with breast cancer undergoing microvascular breast reconstruction. Methods A comprehensive literature search was performed across 6 databases from January 2003 to February 2016. Pooled estimates and relative risk (RR) were calculated using a random-effects model, confounding was examined with meta-regression, and risk of bias was evaluated. Primary outcomes were thrombotic flap complications and total flap loss. Study quality was assessed using Downs and Black criteria. Results Of 95 studies reviewed, 4 studies comprising 1700 patients and 2245 procedures were included for analysis. Compared to non-recipients, patients on tamoxifen were at increased risk of developing thrombotic flap complications (pooled RR: 1.5; 95% CI: 1.14–1.98) and total flap loss (pooled RR: 3.35; 95% CI: 0.95–11.91). There was no significant heterogeneity present in either outcome and no evidence of publication bias. Conclusions Perioperative tamoxifen therapy may increase the risk of thrombotic flap complications and flap loss for patients with breast cancer undergoing microvascular reconstruction. These findings further the ability of providers to make evidence-based recommendations in the perioperative management of patients with breast cancer.

Interdisciplinary Treatment of Breast Cancer After Mastectomy With Autologous Breast Reconstruction Using Abdominal Free Flaps in a University Teaching Hospital—A Standardized and Safe Procedure

“…Although other risk factors, such as radiotherapy or obesity, are discussed in the literature, we could not prove an influence of previous radiation therapy or a BMI of >30 kg/m 2 on vesselassociated complications (32)(33)(34)(35). Furthermore, flap failure was not associated with venous thrombosis underlining the superiority of venous coupler systems compared to handsewn anastomoses (23,30,36).…”

Microvascular breast reconstruction and thromboembolic events in patients on hormone therapy: Audit of practice from a tertiary referral centre

“…Results of previous studies have been conflicting, and there is no consensus on the timing for the suspension of hormone treatment prior to reconstructive surgery. [11][12][13][14][15][16][17][18] The increasing adoption of extended endocrine treatments and the increasing number of patients undergoing reconstructive surgery provide an imperative to determine the balance of benefits and risks of perioperative hormonal therapy in the reconstructive setting, particularly when microvascular techniques are employed. 6 , 8 This retrospective study of 233 patients has revealed neither an increased risk of flap complications nor thromboembolic events in patients receiving hormone therapy (either tamoxifen or AIs), within one month prior to breast reconstruction.…”

“…12 , 14 , 15 , 17 , 18 The current study was prompted by an analysis of four studies by Parikh et al involving 1700 patients and 2245 procedures. 13 These authors concluded that breast cancer patients receiving perioperative tamoxifen therapy, as compared to those who were not, have an increased risk of thrombotic flap complications (including total flap loss) following microvascular breast reconstruction. 13 Results from the present, albeit much smaller, study do not support these findings.…”

“…9 Although hormone therapy is an independent risk factor for thromboembolic events, studies linking the usage of perioperative tamoxifen or AIs with thrombotic flap complications are conflicting. [10][11][12][13][14][15] Patients undergoing breast reconstruction with free tissue transfer techniques are intrinsically susceptible to thrombotic events due to prolonged operating time, reduced postoperative mobility and the duration of hospital stay. Moreover, cancer surgery itself is associated with the doubling of risk for deep vein thrombosis (DVT) and trebled risk of fatal pulmonary embolism (PE).…”

A specific controlled ovarian stimulation (COS) protocol for fertility preservation in women with breast cancer undergoing neoadjuvant chemotherapy

“…Being so, the random start COS prevents the delay to start chemotherapy, and the concomitant use of letrozole and tamoxifen may help to make the procedure safer. It is known that there is an association between tamoxifen therapy and thromboembolic events [ 31 ]. Furthermore, considering the possibility of venous thromboembolism as a paraneoplasic syndrome, we propose the prophylactic administration of enoxaparin in order to prevent this complication.…”