Neoadjuvant Chemotherapy and Short-term Morbidity in Patients Undergoing Mastectomy With and Without Breast Reconstruction

Abstract

IMPORTANCE Neoadjuvant chemotherapy (NC) is increasingly being used in patients with breast cancer, and evidence-based reports related to its independent effects on morbidity after mastectomy with immediate breast reconstruction are limited. OBJECTIVE To determine the effect of NC on 30-day postoperative morbidity in women undergoing mastectomy with or without immediate breast reconstruction. DESIGN, SETTING, AND PARTICIPANTS All women undergoing mastectomy with or without immediate breast reconstruction from January 1, 2005, through December 31, 2011, at university and private hospitals internationally were analyzed using the American College of Surgeons National Surgical Quality Improvement Program 2005-2011 databases. Patients who received NC were compared with those without a history of NC to estimate the relative odds of 30-day postoperative overall, systemic, and surgical site morbidity using model-wise multivariable logistic regression. EXPOSURE Neoadjuvant chemotherapy. MAIN OUTCOMES AND MEASURES Thirty-day postoperative morbidity (overall, systemic, and surgical site). RESULTS Of 85 851 women, 66 593 (77.6%) underwent mastectomy without breast reconstruction, with 2876 (4.3%) receiving NC; 7893 patients were excluded because of missing exposure data. The immediate breast reconstruction population included 19 258 patients (22.4%), with 820 (4.3%) receiving NC. After univariable analysis, NC was associated with a 20% lower odds of overall morbidity in the group undergoing mastectomy without breast reconstruction (odds ratio [OR], 0.80; 95% CI, 0.71-0.91) but had no significant effect in the immediate breast reconstruction group (OR, 0.98; 95% CI, 0.79-1.23). After adjustment for confounding, NC was independently associated with lower overall morbidity in the group undergoing mastectomy without breast reconstruction (OR, 0.61; 95% CI, 0.51-0.73) and the immediate tissue expander reconstruction subgroup (OR, 0.49; 95% CI, 0.30-0.84). Neoadjuvant chemotherapy was associated with decreased odds of systemic morbidity in 4 different populations: complete sample (OR, 0.59; 95% CI, 0.49-0.71), mastectomy without breast reconstruction (OR, 0.59; 95% CI, 0.48-0.72), any immediate breast reconstruction (OR, 0.57; 95% CI, 0.37-0.88), and the tissue expander subgroup (OR, 0.41; 95% CI, 0.23-0.72). CONCLUSIONS AND RELEVANCE Our study supports the safety of NC in women undergoing mastectomy with or without immediate breast reconstruction. Neoadjuvant chemotherapy is associated with lower overall morbidity in the patients undergoing mastectomy without breast reconstruction and in those undergoing tissue expander breast reconstruction. In addition, the odds of systemic morbidity were decreased in patients undergoing mastectomy with and without immediate breast reconstruction. The mechanisms behind the protective association of NC remain unknown and warrant further investigation.

Surgical site infection in immediate breast reconstruction: Does chemotherapy timing make a difference?

“…Previous studies have demonstrated that IBR (both autologous and alloplastic based reconstruction) has a favorable complication profile even in the setting of chemotherapy. [16][17][18][19][20] In one study of 163 patients, with 66% undergoing expander/implant reconstruction, the authors found no statistically significant differences in infection or postoperative wound complications comparing patients who received neoadjuvant and adjuvant chemotherapy. However, they did find the adjuvant treatment group to have the highest rate of infectious complications (44%).…”

“…20 A large database study including 19 258 IBR patients deemed neoadjuvant chemotherapy safe in both tissue expander and autologous breast reconstruction. However, the authors combined all complication types into "postoperative morbidity" and so the impact on infection could not be assessed; in addition they only included neoadjuvant chemotherapy 30 days before the operation, as was pre-defined by the AmericanCollege of Surgeons-National Surgical Quality Improvement Program variable 19. A proposed mechanism for the lack of significance found in overall morbidity with the introduction of neoadjuvant chemotherapy was discussed by Abt et al19 in which the authors hypothesized that the use of neoadjuvant chemotherapy decreases the tumor size, reducing operation time, and hence the reduction in operation time could lead to decreased overall morbidity.Given that limited studies discuss the impact of neoadjuvant chemotherapy as it relates to autologous reconstruction, and the one significantly powered study by Abt et al 8 grouped all complications together, our next aim was to sub-group by reconstructive type.…”

Surgical issues in patients with breast cancer receiving neoadjuvant chemotherapy

“…For example, in a study including 3,696 patients with breast cancer who underwent NACT followed by mastectomy with or without immediate breast reconstruction, no increase in 30-day morbidity was observed compared to more than 60,000 women who underwent initial surgery. 38 …”

Determinants of short and long term outcomes in patients undergoing immediate breast reconstruction following neoadjuvant chemotherapy

“…There have been a limited number of studies evaluating complication rates in patients undergoing NAC followed by SSM or NSM with IR, with conflicting results demonstrated. [21][22][23][24][25][26][27] Several studies have demonstrated no increased risk in patients having immediate reconstruction following NAC. 21,[24][25][26][27] On the other hand, others have reported very high complication rates in this setting.…”

“…[21][22][23][24][25][26][27] Several studies have demonstrated no increased risk in patients having immediate reconstruction following NAC. 21,[24][25][26][27] On the other hand, others have reported very high complication rates in this setting. 22,23 In A strength of this study is that we report on a large wellcharacterized patient group with longitudinal review of both shortterm as well as long-term complications and oncologic outcomes.…”