Postmastectomy radiation is becoming more commonly used to treat breast cancer, and at the same time, there is an increasing trend among women to have breast reconstruction. Until now, oncologists have had little evidence on what the best reconstruction options are in women who require radiation after mastectomy.
The largest study to date to evaluate the impact of postmastectomy radiation therapy on breast reconstruction results was presented at the 2016 San Antonio Breast Cancer Symposium. The study showed higher rates of complication and failure in radiated women who had implant reconstruction compared with autologous breast reconstruction.1
Radiation compromises outcomes of implant reconstruction. Autologous reconstruction appears to have superior patient-reported outcomes and a lower risk of complications than implant-based approaches in patients receiving radiation.— Reshma Jagsi, MD, DPhil
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“The benefits of postmastectomy radiation for selected women with breast cancer are well established. Breast reconstruction is also known to provide substantial benefits in terms of quality of life. However, less is known about how best to integrate radiation and reconstruction, and the impact of radiation therapy on the outcomes of reconstruction is widely feared but poorly understood,” said Reshma Jagsi, MD, DPhil, Deputy Chair in the Department of Radiation Oncology at the University of Michigan, Ann Arbor. Dr. Jagsi reported results of the large, prospective multicenter Mastectomy Reconstruction Outcomes Consortium (MROC) study. “Given the limitations of the existing evidence, practice in the United States varies widely and often reflects traditions and institutional culture rather than informed, shared decision-making,” she added.
The study included 553 radiated and 1,461 nonirradiated postmastectomy patients who received either implant or autologous reconstruction at 11 institutions in the United States between 2012 and 2015. The median age of patients was 49 years. The study endpoints included complication rate, failure rate, and patient-reported outcomes.
Key Study Findings
In an analysis adjusted for several relevant covariates (including extent of disease, timing of reconstruction, management of nodes, bilateral or unilateral reconstruction, and treatment with chemotherapy), the 2-year complication rate was 33.4% in radiated patients compared with 23.5% in nonirradiated patients; 38.9% of radiated implant patients had at least one complication compared with 25.6% of radiated patients with autologous reconstruction. In nonirradiated patients, at least one complication occurred in 21.8% of implant patients and 28.3% of those who had autologous breast reconstruction.
In a multivariable analysis, radiation therapy was associated with a 2.64 times higher odds of complications by 2 years in implant patients compared with no radiation (P < .001), whereas no significant difference was observed in patients who had autologous breast reconstruction whether they were radiated or not.
Radiation Therapy and Breast Reconstruction
- Radiation leads to a higher complication and failure rate in postmastectomy breast reconstructions compared with women who are not treated with radiation.
- The complication and failure rates are higher in radiated women with implant reconstruction than with autologous breast reconstruction.
- These data are the first from a prospective cohort study to assess complications and failures as well as patient satisfaction following radiation and postmastectomy reconstruction. Oncologists can now give women information on which to base shared decision-making.
Reconstruction failure was reported in 11.4% of radiated patients and 3.4% of nonirradiated patients. This difference was largely driven by failure rates in radiated implant patients (18.7%) compared with 3.7% in nonirradiated implant patients. The failure rate associated with autologous breast reconstruction was 1.0% in radiated patients and 2.4% in nonirradiated patients.
Bilateral reconstructions were performed in 45.6% of radiated patients and 53.3% of nonirradiated patients. Bilateral treatment and higher body mass index were predictors of complications.
Patient-reported outcomes on the BREAST-Q (a validated quality-of-life instrument) were consistent with these findings. Radiated patients had a lower satisfaction rate with their reconstruction than nonirradiated patients and were more satisfied with outcomes of autologous breast reconstruction than implant reconstruction.
Takeaway Message
“The main takeaway point from this large prospective trial is that radiation compromises outcomes of implant reconstruction. Autologous reconstruction appears to have superior patient-reported outcomes and a lower risk of complications than implant-based approaches in patients receiving radiation. These data are critical to inform the growing number of radiated patients considering reconstruction,” Dr. Jagsi stated.
However, she cautioned that all patients are not necessarily candidates for autologous reconstruction, and that it is a long and involved procedure.
Audience Discussion
During the question-and-answer session following her talk, Dr. Jagsi was asked about the timing of reconstruction for women enrolled in this trial. “This is an important question, “she said, noting that 83% of radiated patients and 96% of nonirradiated patients had immediate reconstruction, and the remaining patients had delayed reconstruction. The data on the effect of timing of reconstruction among patients with autologous reconstruction are being analyzed separately. “Here is a spoiler. There was no impact of timing on autologous reconstruction, although it’s important to note that almost all of the immediate autologous reconstructions were performed at a single one of the centers,” she added.
A patient advocate in the audience said that these data allowed shared decision-making, which is key for patients to make informed decisions. “It has been very challenging to answer any questions before this study. With breast reconstruction and radiation, clinicians have been in an uncomfortable position with limited data. Now we can give patients robust outcomes data with or without radiation,” Dr. Jagsi noted.
Marisa Weiss, MD
Marisa Weiss, MD, of breastcancer.org, brought up the issue of the effect of implant size on complication rates, especially in women who want bigger breasts than they originally had, overtaxing the skin envelope. “We should be more aware of how the size of the eventual reconstruction will affect outcome,” Dr. Weiss said, and Dr. Jagsi agreed, noting that the study data set did not have detailed information on the size of expansion. ■
Disclosure: Drs. Jagsi and Weiss reported no potential conflicts of interest.
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