|By Wallace, Anne M|
Breast reconstruction after mastectomy positively affects psychosocial well-being; however, the influence of reconstruction on cancer outcomes is unknown. The objective of our study was to compare survival in reconstructed versus nonreconstructed patients after mastectomy. All consecutive female patients diagnosed with invasive breast cancer and treated with mastectomy between 2002 and 2011 were identified from our single-institution database. All cancer operations were performed by two surgeons. Survival was calculated using the Kaplan-Meier method and compared using the log-rank test. To identify the effect of reconstruction on survival, a multivariate Cox regression analysis was performed. Of 474 patients treated, 340 (71.7%) underwent breast reconstruction. At a mean follow-up 3.3 years, reconstructed patients had a longer 5-year survival (91 vs 74%, P < 0.001). After controlling for age, race, payer source, cancer stage, triple negative status, and receipt of radiation or chemotherapy, reconstructed patients maintained a survival advantage over nonreconstructed patients (hazard ratio, 0.47; 95% confidence interval, 0.25 to 0.88; P = 0.02). Patients with breast cancer who undergo reconstruction have longer survival than nonreconstructed patients. The explanation for this finding may be related to improved psychosocial qualities of life versus possible antitumorigenic effects of implants.
THE SURGICAL MANAGEMENT of breast cancer continues to evolve as surgeons seek to minimize breast disfigurement and morbidity while maintaining oncologic safety. To this end, breast conservation surgery became the preferred treatment for early-stage breast cancer after studies proved equivalent survival compared with mastectomy,1 thus allowing surgeons to safely maintain the natural breast mound. However, despite this initial trend toward breast conservation, there has been an increase in mastectomy rates over the past decade and recent studies estimate nearly half of patients with early-stage breast cancer are undergoing mastectomy.2-4 For these patients who require or elect for mastectomy, breast reconstruction is an important part of their surgical care. It is known that the disfigurement associated with mastectomy negatively affects body image and sexual function and surgically conserving or restoring the breast mound enhances the psychosocial quality of life in patients undergoing mastectomy.5-9 However, there may be more benefit to reconstruction that is yet to be identified. Recent population-level data suggested a survival benefit for reconstructed patients compared with patients undergoingmastectomy without reconstruction10-13 and there is research to suggest possible anticarcinogenic effects of implant reconstruction.14, 15 Although these findings are intriguing, they are based on a few populationlevel studies with overall low reconstruction rates. Therefore, further investigations are needed to confirm a causal role of reconstruction on improved breast cancer outcomes and survival. Nearly all patients at our institution are offered postmastectomy reconstruction, resulting in a reconstruction rate of 70 per cent, which is nearly triple the modern rates reported in national databases (15 to 25%).16, 17 Thus, our breast cancer patient population represents an ideal cohort for studying differences related to reconstruction. We therefore sought to evaluate overall survival in patients who underwent immediate or delayed breast reconstruction at our institution.
Demographic and tumor characteristics were collected for study patients from the UCSD-MCC cancer registry and supplemented with additional retrospective chart review, as necessary. Demographic information included year of diagnosis, age at diagnosis (younger than 40, 41 to 64, older than 65 years), race (white, black, Asian, or Hispanic), and payer source (private insurance,
The primary outcome of our study was overall survival. Patients were grouped according to mastectomy with reconstruction or mastectomy without reconstruction. Demographic and tumor-specific data were categorized into ordinal groups and compared using the x2 test. Survival times were calculated using the Kaplan-Meier method from the date of diagnosis to the date of death or date of last follow-up. The logrank test was used to compare the equality of survival curves. A multivariate Cox proportional hazards model controlling for demographic (age, race, payer source) and cancer-specific (stage, presence of LVI, triple negative disease, adjuvant treatment) covariates was performed and presented as hazard ratios (HRs) with 95 per cent confidence intervals (CIs). All statistical tests were two-sided, and P values < 0.05 were considered statistically significant.
Of the 1716 patients treated for breast cancer at UCSD-MCC over our study period, 626 (36.5%) underwent mastectomy. We excluded 141 patients with DCIS and eight patients based on male sex. The remaining 474 female patients treated with mastectomy for invasive breast cancer during our study period comprised our study population. Demographic and tumor characteristics are described in Table 1. The majority of patients were white, age 41 to 64 years, and had ER/PR-positive tumors with ductal histology.
Comparison of the Reconstructed and Nonreconstructed Cohorts
Of the 474 study patients, 340 (71.7%) underwent breast reconstruction, whereas 134 (28.3%) underwent mastectomy alone. Of the reconstructed women, 320 (94%) underwent immediate breast reconstruction. Women who underwent breast reconstruction were more likely to be younger, have private payer insurance, and undergo bilateral mastectomy compared with women who underwent mastectomy alone. Reconstructed and nonreconstructed patients were similar in all measured oncologic characteristics including stage, histologic subtype, lymph node status, presence of LVI, and hormone status. Reconstruction status did not affect whether a patient underwent adjuvant radiation or chemotherapy.
At mean follow-up of 3.4 and 3.3 years for the reconstructed and nonreconstructed cohorts, respectively, overall survival was significantly longer in the reconstructed cohort (mean survival 11.2 vs 8.5 years; 3-year survival 94 vs 81%; P < 0.001) (Fig. 1).
On multivariate analysis (Table 2), after controlling for age, race, payer source, cancer stage, receipt of chemotherapy, adjuvant radiotherapy, triple negative disease status, and presence of LVI, reconstruction status was an independent predictor of survival (HR, 0.47; 95% CI, 0.25 to 0.88; P40.02). Triple negative disease and advanced cancer stage were also independent predictors of survival (HR, 3.60; 95% CI, 1.84 to 7.05; P < .001 and HR, 5.12; 95% CI, 1.61 to 16.2; P 4 0.01, respectively).
Our finding of improved survival in reconstructed patients is consistent with recent population-level studies. An analysis of the Surveillance, Epidemiology and End Results (SEER) data evaluating 52,000 female patients diagnosed with breast cancer between 1998 and 2002 demonstrated longer survival times in reconstructed patients compared with patients undergoing mastectomy alone, even after controlling for other clinicopathologic factors.12 Three additional analyses of SEER data from similar time periods, but with slightly different inclusion criteria, all report improved breast cancer-specific survival among reconstructed patients.10, 11, 13
Although collectively these studies provide convincing evidence that reconstruction may be playing a role in improved survival, population-level studies are limited by surgeon selection bias that may be reconstructing a healthier population that lives longer based on tumor characteristics regardless of their reconstruction status. Despite an attempt to promote reconstruction with passage of the
The survival benefit for reconstructed patients may be related to a protective effect of implant reconstruction. A survival analysis of reconstructed patients stratified by reconstruction type found a greater survival advantage in young patients undergoing implant reconstruction over use of autologous tissue only.10 Further evidence from the Los Angeles Augmentation Mammaplasty study, which followed over 50,000 women who underwent noncancer-related cosmetic breast implants for 17 years, found these women had a lower incidence of breast cancer than expected of the general population.22 Some studies support a biological mechanism for this finding, postulating that breast implants may create a hostile tissue environment retarding cancer growth by stimulating a local immune response or by means of physically compressing breast tissue, which impairs blood flow to any potential or surviving cancer cells.14, 15
Another possible explanation for our finding is the psychosocial benefit realized in the reconstructed population may be translating into a survival advantage. In a study evaluating the psychosocial predictors of survival in patients with breast cancer, a minimizing coping style (e.g., minimizing the impact of cancer diagnosis) was the most significant independent predictor of survival.23 Surgically restoring the breast mound to re-establish a pretreatment body image may minimize the perceived impact of breast cancer diagnosis among reconstructed patients, thus conferring a survival advantage.
Limitations to our study include that it is retrospective with a relatively short follow-up. Additionally, although our preferred method of reconstruction is tissue expander implant-based or combined autologous and implant-based reconstruction, we did not stratify our population by type of reconstruction so we cannot determine how reconstruction method affects survival. Our study contributes to prior studies by its single-institution design and relatively large population undergoing reconstruction.
An analysis of patients with invasive breast cancer treated at our institution demonstrates longer survival times for those undergoing reconstruction versus nonreconstructed ones. We have postulated several reasons for this association including possible psychosocial benefit translating into a survival advantage versus antitumorigenic effects of breast implants versus other. Although the exact mechanism is unclear, the results from our study further support the growing amount of data suggesting oncologic benefits to breast reconstruction.
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Presented at the 24th Annual Scientific Meeting of the
Address correspondence and reprint requests to Jennifer L Baker, M.D., Resident,
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