Neoadjuvant Chemotherapy Reduces Postoperative Morbidity in Women With Breast Cancer Undergoing Mastectomy
In a study reported in JAMA Surgery, Abt et al found that neoadjuvant chemotherapy is safe in women with breast cancer undergoing mastectomy with or without immediate breast reconstruction. Neoadjuvant chemotherapy was an independent predictor of reduced 30-day postoperative morbidity in women undergoing mastectomy without breast reconstruction and in those undergoing immediate tissue expander breast reconstruction.
Study Details
The study included women in the American College of Surgeons National Surgical Quality Improvement Program database undergoing mastectomy with or without immediate breast reconstruction from January 2005 through December 2011. Rates of 30-day overall, systemic, and surgical postoperative morbidity were compared between women who did and did not receive neoadjuvant chemotherapy.
Postoperative morbidity was defined as superficial and deep incisional surgical site infection, organ space surgical site infection, wound dehiscence, pneumonia, unplanned intubation, pulmonary embolism, > 48 hours of ventilatory assistance, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke or cerebrovascular accident, coma > 24 hours, cardiac arrest, myocardial infarction, bleeding requiring transfusion, prosthesis or flap failure, deep vein thrombosis requiring treatment, sepsis, septic shock, and return to the operating room within 30 days.
Among 85,851 women included in the analysis, 66,593 (77.6%) underwent mastectomy without breast reconstruction and 2,876 (4.3%) received neoadjuvant chemotherapy. Patients receiving neoadjuvant chemotherapy differed from those not receiving such therapy in numerous demographic and clinical characteristics, as indicated in the adjustments in the multivariate analysis.
Morbidity Rates
Rates of 30-day morbidity were 10.8% in women who underwent mastectomy without breast reconstruction, including 9.3% vs 11.3% in those receiving vs not receiving neoadjuvant chemotherapy, and 11.8% in those who underwent mastectomy with immediate breast reconstruction, including 11.5% vs 11.6% in those receiving vs not receiving neoadjuvant chemotherapy.
Risk Reductions
Multivariate analysis of risk for morbidity was adjusted for age, body mass index, smoking status, work relative value unit of procedure, operation year, inpatient status, American Society of Anesthesiologists classification, previous wound infection, wound classification, previous cardiovascular morbidity, previous respiratory morbidity, previous renal morbidity, previous hemato-oncologic morbidity, diabetic status, corticosteroid use for chronic condition, and length of operation.
On multivariate analysis, neoadjuvant chemotherapy was independently associated with lower overall 30-day morbidity among all patients (odds ratio [OR] = 0.64, P < .001), patients undergoing mastectomy without breast reconstruction (OR = 0.61, P < .001), and patients in the reconstruction subgroup who received immediate tissue expander reconstruction (OR = 0.49, P = .009). There were no significant differences among all patients who underwent immediate breast reconstruction (OR = 0.69, P = .08) or in the implant (OR = 0.96, P = .94) or flap (OR = 1.15, P = .72) reconstruction subgroups.
Reduced Systemic Morbidity
There were no signficant differences between groups or subgroups with regard to risk of surgical morbidity. However, neoadjuvant chemotherpay was associated with reduced risk of systemic mrbidity among all patients (OR = 0.59, P < .001), in those with mastectomy without breast reconstruction (OR = 0.59, P < .001), those with any immediate reconstruction (OR = 0.57, P = .01), and those undergoing tissue expander reconstruction (OR = 0.41, P = .002).
The investigators concluded: “Our study supports the safety of [neoadjuvant chemotherapy] 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 [neoadjuvant chemotherapy] remain unknown and warrant further investigation.”
Gedge D. Rosson, MD, of Johns Hopkins University School of Medicine, is the corresponding author for the JAMA Surgery article.
The study was supported in part by an award from the Avon Foundation for Women. Dr. Rosson reported having intellectual property licensed to Aegeria Soft Tissue, LLC.
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