Cancer care is full of difficult choices. Women who undergo a mastectomy as part of treatment for breast cancer face a potentially life-changing decision: whether to have reconstructive surgery to rebuild the breast — and if so, what kind. The main options are either to use artificial implants filled with silicone or saline or to use the patient’s own tissue transferred from elsewhere in the body, such as the abdomen, generally known as flap surgery.
This decision becomes even more challenging for women who receive radiation following mastectomy to reduce the risk of cancer returning to the area. Radiation increases the risk of complications from surgery, such as infection, and can lead to changes in skin color and tissue shrinkage — leaving more women unhappy with their long-term quality of life.
New findings presented today at the San Antonio Breast Cancer Symposium, a yearly gathering of thousands of oncologists and other cancer care professionals, add a critical piece of information that could help those facing this dilemma. Women receiving radiation after mastectomy reported significantly higher levels of satisfaction — and lower risk of complications — when they elected to have their breasts reconstructed using their own tissue.
“This is important information for women making a decision about reconstruction during a very stressful time,” says Memorial Sloan Kettering plastic and reconstructive surgeon Andrea Pusic, a study co-author. “It doesn’t mean they shouldn’t have implants — every decision should continue to be individualized and based on patient preference. But it is crucial to be fully informed about the pros and cons of the different methods, and this adds an essential piece of data.”
The results were reported by the Mastectomy Reconstruction Outcomes Consortium (MROC), a collaboration among 11 institutions to study patient attitudes toward various forms of breast reconstruction. Dr. Pusic leads the MROC along with Ed Wilkins, a reconstructive surgeon from the University of Michigan.
Radiation Widens Preference Gap
The study looked at complications and patient-reported outcomes two years after mastectomy among 553 women who received radiation and 1,461 who did not. Among those who received radiation, nearly 32% of those who got implants experienced at least one complication, compared with only about 24% of those who received their own tissue. In addition, in this same group a higher number of patients who received their own tissue reported being satisfied with the results (nearly 64%) compared with those who received an implant (about 48%).
Dr. Pusic says the findings align with what breast cancer surgeons already knew about reconstruction: that patients who receive their own tissue tend to be more satisfied than those who receive implants. But adding radiation to the mix appears to underscore this difference, making the gap even wider.
“Quantifying it in a study really makes a difference in clarifying how patients feel about the different types of reconstruction,” she explains. “Someone needing radiation often has worse disease, and they are less focused on the long term. This is very helpful in improving patients’ ability to make a good decision.”
Importance of Patient Perspective
Dr. Pusic explains that the findings highlight the benefits of initiatives undertaken by the MROC and MSK’s own Patient-Reported Outcomes and Surgical Experience program, which is led by Dr. Pusic and seeks to enhance the quality of surgical care by taking a more patient-centric approach.
“From the surgeon’s perspective, using implants or the patient’s own tissue were generally considered equal — the main difference being that flap surgery takes longer and leaves a scar where we take the tissue from,” she says. “The prevailing wisdom had been that if we thought a woman was going to need radiation, we would go with the implant, because we didn’t want to give radiation to the flap tissue. This new finding somewhat questions that prevailing wisdom because of how patients feel about the long-term outcomes.”
She emphasizes that reconstructive surgery choices still must be made within proven clinical guidelines. For example, a 75-year-old woman with heart problems would not be a good candidate for flap surgery, nor would someone who lacks adequate tissue for transfer.
“One method is not right for all women, but good information about expected outcomes is right for everyone,” she says.