Does response to neo-adjuvant chemotherapy impact breast reconstruction?

Abstract

Neo-adjuvant chemotherapy (NAC) is administered in breast cancer treatment for downstaging of disease. Here, we determined the impact of response to NAC on breast reconstruction uptake. A prospective NAC and mastectomy database with or without reconstruction were reviewed with IRB approval. Univariable analyses were conducted using Kruskal-Wallis or Fisher's exact tests. Multivariable logistic regression was used to adjust for potential confounders. We identified 271 patients with unilateral breast cancer receiving NAC and either unilateral or bilateral mastectomy from 9/2013 to 5/2016. Seventy patients (25.8%) had a pCR to NAC. One hundred and seventy-five patients (64.6%) had immediate reconstruction (IR), and 96 had no IR. On univariable analysis, younger age (P < .001), lower T-stage at presentation (P < .001), bilateral versus unilateral mastectomy (P<.001) and HR-negative tumor subtype (P = .006) were significantly associated with higher IR rates. On multivariable analysis, pCR (P = .792) and tumor subtype (P = 0.061) were not significantly associated with IR; T-stage was significantly associated with IR (P < .001), such that patients with T4 tumors at presentation had lower odds of IR (OR 0.10, 95% CI 0.02-0.50), even when accounting for response to NAC. One hundred and seventy-three patients (63.8%) received adjuvant radiation therapy; this was associated with lower IR frequency (P = .048) but was not associated with reconstruction type (tissue expander versus autologous, P = 1.0) among 175 patients who had IR. In patients who have mastectomy after NAC, IR is influenced by age, T-stage at presentation, and choice of bilateral mastectomy, but not by response to NAC. A subset of patients who are young, with earlier T-stage and pCR, is more likely to proceed with bilateral mastectomy.

Immediate Breast Reconstruction After Neoadjuvant Chemotherapy

“…During this study, we examined factors influencing the type of IR surgery after NAC. Our findings indicated that younger age and earlier tumor and nodal stages at presentation were correlated with IR after NAC, which was consistent with the findings of some previous studies 15 . Because the pathological tumor stage was significantly associated with IR, and because the pathological nodal stage and total pCR were not, we speculated that the response of the primary site after NAC was more important to the choice of IR than that of the axillary nodes.…”

“…Because the pathological tumor stage was significantly associated with IR, and because the pathological nodal stage and total pCR were not, we speculated that the response of the primary site after NAC was more important to the choice of IR than that of the axillary nodes. During a study of patients treated at Memorial Sloan Kettering Cancer Center, Cassidy et al revealed that neither conversion from clinically node-positive to clinically node-negative nor pCR was associated with increased rates of IR 15 …”

“…During a study of patients treated at Memorial Sloan Kettering Cancer Center, Cassidy et al revealed that neither conversion from clinically node-positive to clinically node-negative nor pCR was associated with increased rates of IR. 15 Determining the most appropriate type of IR surgery for patients who have undergone NAC is a complicated process that is influenced to some extent by the preferences of both the surgeon and patient. Almost half of the patients in our study chose ATR, which has been considered the gold standard approach by many plastic surgeons because the reconstructed breasts are softer, easier to shape based on individual characteristics, and appear more natural when the contralateral breast is used as the reference.…”

“…During a study of patients treated at Memorial Sloan Kettering Cancer Center, Cassidy et al revealed that neither conversion from clinically node-positive to clinically node-negative nor pCR was associated with increased rates of IR. 15 …”