Breast Reconstruction and Radiation Therapy: A Decision Analysis

PURPOSE: The ideal timing and type of breast reconstruction following mastectomy is unknown in the setting of potential post-mastectomy radiation (PMRT). Decision analysis is an effective approach to compare methods based on variable rates of complications and the probability of PMRT. Decision analysis also accounts for the value of various health states in the form of utilities. The purpose of this study is to compare the expected utility of four methods of breast reconstruction with a decision analysis.

METHODS: A decision tree was created to compare: 1) immediate tissue expander/implant reconstruction (ITE), 2) immediate autologous tissue reconstruction (IATR), 3) delayed TE (DTE), and 4) delayed ATR (DATR). Variables for rates of complications and reconstructive failure were obtained from a systematic review of the literature. Utility values were obtained from the literature as well as expert opinion. Sensitivity analyses were performed to test the impact of varying the different variables on the outcome of the model.

RESULTS: In the base case analysis, IATR yielded the highest utility (0.7854), followed by DATR (0.7511), ITE (0.7414), and DTE (0.6707). However, the rates of complications varied widely in the 69 studies reviewed, partially due to the varied definition of complications between studies. The rate of complications was conservatively defined as the higher rate of either grade III/IV capsular contracture, fat necrosis, or the need for surgical revision. Using this definition, the rates of complications for the four methods of reconstruction with PMRT ranged from 10-75% for ITE, 0-67% for IATR, 14-87.5% for DTE, and 0-22% for DATR. In sensitivity analyses, the utility of ITE surpassed IATR when the rate of complications was ≤22% and the rate of failure was ≤5%. ITE yielded higher utility than DATR when the probability of PMRT was ≤20%.

CONCLUSIONS: ITE reconstruction yields the highest utility of the reconstructive methods if the rates of complications and failure are low. As the rates increase above 22% and 5% respectively, IATR gains superiority. Interestingly, despite the variance of low rates of complication and failure with delayed procedures, the expected utilities still did not surpass the utility of immediate reconstruction.