Breast Reconstruction: Outcomes Analysis

1. Breast Reconstruction: Outcomes Analysis Michael J Bass, MD, JD www.drmichaeljbass.com Michael J Bass Plastic Surgery, PLLC

2. Disclosures • None • Still need some

3. Analysis Factors • What affects outcome • Neoadjuvant chemotherapy (Malata) • Radiation (Cordeiro) • Overall Satisfaction • Unilateral versus bilateral reconstruction (Craft)

4. Neoadjuvant Chemotherapy and Immediate Breast Reconstruction • 171 patients (198 breasts) by one surgeon • 64 free flaps, 74 pedicled flaps, 60 implant based • 53 neoadjuvant, 118 controls • Neoadjuvant phase III randomized trial Malata, et al, Plastic and Reconstructive Surgery July 2010;126(1):1-11

5. Neoadjuvant Chemo (cont.) Malata, et al, Plastic and Reconstructive Surgery July 2010;126(1):1-11

6. Neoadjuvant Chemo (cont.) • Minor complications: • 6 (10%) neoadjuvant, 9 (6%) controls (p=.380) • Major complications: • 1 (2%) neoadjuvant; 3 (2%) controls (p=1.0) • No effect of neoadjuvant chemotherapy on risk of complications nor delay in adjuvant radiation • Paper did not evaluate patient or surgeon satisfaction of reconstruction Malata, et al, Plastic and Reconstructive Surgery July 2010;126(1):1-11

7. Radiation and Implant Based Reconstruction • 143 patients with 1 year of follow up receiving immediate tissue expander reconstruction (1995-2001); no autologous reconstruction patients • 68 patients with chest wall radiation (CWR) four weeks after placement of permanent prosthesis • 75 control patients during same period Cordeiro, et al, Plastic and Reconstructive Surgery March 2004;113(3):877-81

8. Radiation and Implants (cont.) • Patients received 50 Gray in 25-28 fractions • 6 MV to reconstructed breast, axillary apex, and supraclavicular region • 68% of irradiated patients had grade II-IV capsular contracture; 40% control group (p=.006) Cordeiro, et al, Plastic and Reconstructive Surgery March 2004;113(3):877-81

9. Radiation and Implants (cont.) • Doctors: 80% of irradiated patients marked good-excellent; 88% for non-irradiated patients • Patient satisfaction based upon self assessment questionnaire • 67% irradiated, 88% non-irradiated patients satisfied (p=.004) Cordeiro, et al, Plastic and Reconstructive Surgery March 2004;113(3):877-81

10. Radiation and Implants (cont.) • No discussion on tumor grade or disease stage • 72% of irradiated patients and 85% of non-irradiated patients would have again elected for tissue expander based reconstruction Cordeiro, et al, Plastic and Reconstructive Surgery March 2004;113(3):877-81

11. Unilateral Versus Bilateral Reconstruction and Satisfaction • 702 women (910 reconstructions) identified between 1999-2006 • 494 unilateral reconstructions, 416 bilateral reconstructions Craft, et al, Plastic and Reconstructive Surgery April 2011;127(4):1417-24

12. Unilateral Versus Bilateral (cont.) Craft, et al, Plastic and Reconstructive Surgery April 2011;127(4):1417-24

13. Unilateral Versus Bilateral (cont.) • Patient surveys mailed • Minimum post reconstruction time 13 months, average of 56 months for unilateral and 49 months for bilateral patients • Survey response: 75% unilateral, 79% bilateral Craft, et al, Plastic and Reconstructive Surgery April 2011;127(4):1417-24

14. Unilateral Versus Bilateral (cont.) Reconstruction (cont.) Craft, et al, Plastic and Reconstructive Surgery April 2011;127(4):1417-24

15. Barriers To Reconstruction • Doctor recommendation to seek counseling with a plastic surgeon • 7/10 women eligible for reconstruction after a mastectomy are not informed that the option exists (ASPS poll, 2009) • Logistical problem of coordinating consultations and immediate reconstruction • Immediate reconstruction: 23.4% for invasive breast cancer, 36.4% for DCIS • Medicaid kerfuffle quadrification in Kentucky • Age >50, rural living, black least likely to get reconstruction

16. Thank You For Coming • Your participation in this lecture creates new opportunities for newly diagnosed women • Breast cancer is far away from being treated with a pill