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Broadening Indications for Immediate Implant-Based Breast Reconstruction
Claudia R. Albornoz, MD, MSc, Gina Farias-Eisner, BA, Joseph J. Disa, MD, Babak J. Mehrara, MD, Colleen M. McCarthy, MD MS, Andrea L. Pusic, MD MHS, Peter G. Cordeiro, MD, Evan Matros, MD MMSc.
Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
Over the past 10 years there has been a 200% increase in the number of implant-based breast reconstructions performed within the US while the number of autologous reconstructions is unchanged. The rise in implant use may reflect: 1) increased patient or physician preference for implants, and/or 2) expanding indications for implants in patients previously denied breast reconstruction because of unfavorable clinical characteristics. The aim of the current study is to measure implant use over time in patients previously considered poor reconstructive candidates.
Analysis of the prospectively collected breast disease management team database at Memorial Sloan-Kettering Cancer Center was performed. All patients who underwent a total mastectomy during the years 2001-2012, with or without reconstruction, served as the cohort. A literature review was performed to identify commonly cited relative contraindications for breast reconstruction. These included: age greater than 60 years, BMI>30, comorbidities (diabetes, cardiovascular disease, COPD), smoking, stage III or IV breast cancer, prior radiotherapy, post-mastectomy radiotherapy, and chemotherapy. Trends in use of implant reconstruction among patients with unfavorable clinical characteristics were analyzed with Poisson regression. To understand reconstructive trends within the specific group, rates for each unfavorable characteristic were adjusted by 100 total mastectomies performed for patients with that specific feature. An incidence rate ratio (IRR) greater than 1.0 with a p-value <0.05 was considered a significant rate increase
A total of 9,543 patients underwent total mastectomies during the study period. The immediate reconstruction rate increased from 49.9 in 2001 to 77.6 per 100 total mastectomies in 2012 (IRR 1.04, p<0.01). While autologous reconstruction rates were unchanged during this period, implant reconstruction rates increased from 43.9 to 71.8 per 100 total mastectomies (IRR 1.05, p<0.01). From 2001-2012 there was a significant increase in implant use for patients with any of the following features: age greater than 60 years, BMI>30, diabetes, cardiovascular disease, smoking, COPD, Stage III or IV breast cancer, prior radiotherapy, post-mastectomy radiotherapy, and chemotherapy (Figure 1). Rates of autologous tissue use were unchanged in every group except for an increase in patients with BMI>30 (IRR 1.17, p<0.01). Overall, reconstructive rates in patients with any adverse clinical characteristic increased from 45.7 to 72.7 per 100 total mastectomies (IRR 1.04, p<0.01) (Figure 2).
Broadening indications has lead to increasing immediate breast reconstruction rates in high-risk patients at a major academic medical center. The majority of patients with unfavorable clinical characteristics undergo immediate implant-based reconstruction, relative to autologous tissue, as an efficient less invasive means of recreating the breast mound. Moving forward, the long-term safety and reliability of implant use in this patient group needs to be determined.
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