乌鸦传媒

Opting for implant-based or autologous breast reconstruction should be a shared decision, with patient preference taken into account, according to two new studies using data from the Mastectomy Reconstruction Outcomes Consortium (MROC).

At 2 years post-mastectomy, patients reported better quality of life and breast satisfaction with autologous reconstruction, but complication rates were higher compared with those who underwent implant-based reconstruction, researchers reported in JAMA Surgery.

In the , which looked at long-term patient-reported outcomes (PROs) using the BREAST-Q survey, patients who received autologous reconstruction reported greater satisfaction with their breasts (difference 7.94, 95% CI 5.68-10.20, P<0.001), sexual well-being (difference 5.53, 95% CI 2.95-8.11, P<0.001), and psychosocial well-being (difference 3.27, 95% CI 1.25-5.29, P=0.002) compared with those who underwent implant reconstruction, Andrea L. Pusic, MD, MHS, of Brigham and Women's Hospital in Boston, and colleagues found.

But the found that rates of any complication ranged from 35.8% to 73.9% among patients who underwent common autologous reconstruction techniques compared with 26.6% and 31.3% for those who underwent expander-implant (EI) and direct-to-implant (DTI) procedures, respectively, reported Edwin G. Wilkins, MD, MS, of the University of Michigan Health System in Ann Arbor, and colleagues.

"This information should not be used in any way to say, 'This is the right operation for any specific woman,'" said Pusic, in an that accompanied the studies. "What's right for every woman is to really understand expected outcomes, both in terms of complications and expected quality of life."

"Every time I go to the clinic and talk to new breast reconstruction patients I'm referencing MROC -- and not just for those two variables, but across the board," said Wilkins in the interview, who noted that the point of MROC was to improve physician and surgeon decision-making in finding the best option for the patient. "This enables us to have a much more evidence-based data-driven discussion."

At 2 years post-mastectomy, odds of complications were higher in patients who received any of several common autologous construction techniques compared with those who received the EI technique:

• Superficial inferior epigastric artery (SIEA) flap: OR 4.71, 95%CI 2.32-9.54, P<0.001
• Free transverse rectus abdominis myocutaneous (fTRAM) flap: OR 2.05, 95% CI 1.24-3.40, P=0.005
• Pedicled transverse rectus abdominis myocutaneous (pTRAM) flap: OR 1.91, 95% CI 1.10-3.31, P=0.02
• Deep inferior epigastric perforator (DIEP) flap: OR 1.97, 95% CI 1.41-2.76, P<0.001
• Latissimus dorsi (LD) flap: OR 1.87, 95% CI 1.03-3.40, P=0.04

Compared with EI techniques, all flap procedures (except LD) were significantly associated with higher odds of re-operative complications (fTRAM, OR 3.02; DIEP, OR 2.76; SIEA, OR 2.62; pTRAM, OR 2.48). Infections were also more frequent in patients who received autologous reconstructions (except for with DIEP flap).

But Wilkins noted that "contrary to flap-based techniques, where most of the complications occur early if they're going to occur, implant complications often occur late -- even decades down the road."

Failure rates were higher with DTI and EI procedures (7.1% compared with 2.8% or less with flap methods).

A regression analysis found that older age was significantly associated with higher complication rates (OR 1.02, 95% CI 1.01-1.03, P=0.004). As was higher BMI: any complications (OR 1.05, 95% CI 1.05-1.10), re-operative complications (OR 1.04, 95% CI 1.02-1.07), and wound infection (OR 1.07, 95% CI 1.05-1.10, P<0.001 for all).

"Different patient characteristics help us to predict how a woman can expect her quality of life, her satisfaction with her breast, to be postoperatively," said Pusic, who noted that one of the priorities of the study was to be able to provide this data to women as they're making their preoperative decisions.

In a that accompanied the studies, Kenneth L. Fan, MD, and David H. Song, MD, MBA, both of MedStar Georgetown University Hospital in Washington, DC, wrote: "These studies are vital in shared decision-making, assuming that patients are candidates for both autologous and prosthetic breast reconstruction. It is critical that we inform patients of the published rates of complications."

Fan and Song described autologous reconstruction as "doing all the work upfront," highlighting that the lifetime of implants is limited and that patients will have to return to the operating room after a decade.

"Much evidence of superior long-term satisfaction and improved quality of life after autologous breast reconstruction exists, which translates to long-term cost-effectiveness to society," they added.

But despite this, autologous breast reconstruction rates have not improved, and implant-based techniques have become the most common method since 2002. "This trend correlates with reimbursement rates, which have declined for autologous breast reconstruction but have remained steady for implant-based reconstruction to more than a 300% to 1,000% disparity per operating room hour," said Fan and Song.

MROC was a multicenter study (11 sites across the country with 57 different surgeons) that examined outcomes for 2,343 patients who were prospectively followed from February 2012 to July 2015 after breast reconstruction surgery. Mean patient age was 48.1 years for those who had implant-based reconstruction and 51.6 for those who had flap-based reconstructions.

"We saw variations -- not so much in patient-reported outcomes, but in complication rates -- across different sites, all of whom are considered top-notch sites," said Wilkins. "It highlights the need for multicenter studies if we're really going to evaluate these operations as far as how they work in real life."

In all, 1,490 opted for implant and 523 chose autologous tissue reconstruction. Complications occurred in 771 patients (32.9%) overall, with 453 (19.3%) having re-operative complications. Additionally, 126 reconstructions (5.4%) failed.

Of these, 2,013 met the inclusion criteria for the PRO data. Using the BREAST-Q survey, four domains were evaluated: breast satisfaction, and physical, psychosocial, and sexual well-being. While these domains were improved with autologous reconstruction, these quality-of-life benefits may come with added abdominal morbidity at the donor site, the authors noted.