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Neoadjuvant Chemotherapy is Associated with Decreased Morbidity amongst 77,958 Patients Undergoing Mastectomy-only and Immediate Tissue Expander Reconstruction
Nicholas B. Abt, BS1, José M. Flores, MPH2, Pablo A. Baltodano, MD1, Karim A. Sarhane, MD, MSc1, Lyonell Kone, MHS1, Francis M. Abreu, BS2, Carisa Cooney, MPH1, Martin A. Makary, MD, MPH1, Gedge D. Rosson, MD1, Anne Tong, MD1.
1Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2Johns Hopkins School of Public Health, Baltimore, MD, USA.
PURPOSE: Neoadjuvant chemotherapy is being increasingly utilized in breast cancer patients and there are limited evidence-based data related to its independent effects on morbidity after mastectomy and immediate reconstruction. Our objective was to determine the impact of neoadjuvant chemotherapy on 30-day postoperative morbidity in women undergoing mastectomy with or without immediate reconstruction.
METHODS: We analyzed data from all females undergoing mastectomy with or without immediate reconstruction from 2005-2011 in the American College of Surgeons National Surgical Quality Improvement Program databases. Patients having underwent neoadjuvant chemotherapy were compared to controls and multivariable regression was used to evaluate 30-day postoperative overall morbidity following mastectomy with or without immediate breast reconstruction. Morbidity included events affecting: cardiac, respiratory, neurological, urinary, venous thromboembolism, wound, and prosthesis/flap failure complications.
RESULTS: 85,851 patients were analyzed; 7,893 patients were excluded due to missing exposure data. The mastectomy-only population included 66,593 (77.57%) patients with 2,876 (4.32%) receiving neoadjuvant chemotherapy. The immediate breast reconstruction population included 19,258 (22.43%) patients with 820 (4.26%) receiving neoadjuvant chemotherapy. We present unadjusted and adjusted odds ratios (OR). Following univariate analysis, neoadjuvant chemotherapy was associated with a lower overall morbidity in the mastectomy-only group (OR_unadjusted=0.80; 95% Confidence Interval [CI]: 0.71-0.91) but had no significant effect in the immediate breast reconstruction group (OR_unadjusted=0.98; CI:0.79-1.23). This observation persisted after extensive adjustment for confounding demonstrating that neoadjuvant chemotherapy independently was associated with lower overall morbidity in the mastectomy-only group (OR_adjusted=0.67; CI:0.53-0.87) and immediate tissue expander reconstruction subgroup (OR_adjusted=0.43; CI:0.36-0.91).
CONCLUSION: Our study supports the safety profile of neoadjuvant chemotherapy in women undergoing mastectomy and immediate breast reconstruction. Additionally, neoadjuvant chemotherapy does not increase postoperative morbidity in implant and flap breast reconstruction while being protective within the mastectomy-only and tissue expander reconstruction setting. We recommend patients receiving neoadjuvant chemotherapy and electing for immediate reconstruction undergo a tissue expander reconstruction due to decreased overall morbidity. The mechanisms behind the protective association of neoadjuvant chemotherapy remain unknown and the mechanisms warrant further investigation.
Logistic models for 30-day postoperative overall morbidity.
|Univariable analysis Odds Ratio||Univariable analysis 95% Confidence Interval||Multivariable analysis Odds Ratio||Multivariable analysis 95% Confidence Interval|
|No neoadjuvant chemotherapy||Referent||-||Referent||-|
|Neoadjuvant chemotherapy followed by mastectomy||0.80||0.71-0.91||0.67||0.53-0.87|
|Neoadjuvant chemotherapy followed by immediate breast reconstruction||0.98||0.79-1.23||0.79||0.44-1.42|
|Neoadjuvant chemotherapy followed by tissue expander reconstruction||0.81||0.60-1.09||0.43||0.21-0.89|
|Neoadjuvant chemotherapy followed by implant reconstruction||1.20||0.64-2.24||1.21||0.27-5.30|
|Neoadjuvant chemotherapy followed by flap reconstruction||1.31||0.89-1.94||2.01||0.54-7.51|
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