Effects of Radiation on Risks and Patient-Reported Outcomes in Expander-Implant Reconstruction: Is There a "Best" Time to Radiate?

Introduction: The oncologic benefit of radiation therapy for node positive breast cancer is well-known. However, studies have also shown poorer aesthetic outcomes, lower satisfaction, and higher complication rates in patients undergoing breast reconstruction with post-mastectomy radiation therapy (PMRT), compared to non-radiated patients.^1,2 The timing of radiation treatment in two-staged, expander-implant reconstruction, whether to radiate before or after expander-implant exchange, has been a subject of contention. Previous research attempting to answer this question has been limited by small sample sizes and single center designs. In the current study, we evaluated the effects of radiation timing on patient reported outcomes (PROs) and complications in patients undergoing immediate expander-implant reconstruction. 

Methods: Patients receiving immediate expander-implant reconstruction and PMRT at 11 Mastectomy Reconstruction Outcomes Consortium (MROC) study sites were assessed preoperatively and two years following expander placement. Demographic and clinical data (age, BMI, diabetes, race, laterality, mastectomy type, extent of disease, acellular dermal matrix use, and chemotherapy) were collected. Patient-reported outcomes were assessed with BREAST-Q, PROMIS, and EORTC QLQ-BR23 surveys. Complications and reconstructive failures within two years were also recorded, with complications requiring reoperation or rehospitalization designated as “major”.  Survey scores and complication rates were compared across cohorts using multivariate regressions, controlling for demographic and clinical variables. 

Results: Of the 3120 patients recruited in the MROC study, 317 met inclusion criteria. Of those, 237 patients received radiation treatment before expander-implant exchange (TE-XRT), and 80 received radiation treatment after exchange (Implant-XRT). Controlling for covariates, radiation timing had no significant effects on PRO subscale scores at two years postoperatively. Compared with preoperative assessments, two year PRO scores were significantly lower in both cohorts for satisfaction with breast, physical well-being, and sexual well-being subscales of BREAST-Q (p < 0.05). In addition, for the TE-XRT cohort, the two year PRO scores were significantly lower in the body image subscale of EORTC as well (p < 0.05). Finally, timing of radiation had no significant effects on odds of overall complications, major complications or reconstructive failure.  

Conclusion: In this multicenter, prospective analysis, the timing of radiation (before or after exchange) appeared to have no significant effects on either PROs or complication risks in immediate expander-implant reconstruction. Regardless of radiation timing, two year measures of satisfaction and other PROs did not appear to return to preoperative levels among women undergoing immediate expander-implant reconstruction in conjunction with PMRT. These findings provide patients and providers with additional evidence for treatment decision-making.    

References:

1. Cowen D, Gross E, Rouannet P, et al. Immediate post-mastectomy breast reconstruction followed by radiotherapy: risk factors for complications. Breast Cancer Research and Treatment. 2010;121(3):627-634

2. Eriksson M, Anveden L, Celebioglu F, et al. Radiotherapy in implant-based immediate breast reconstruction: risk factors, surgical outcomes, and patient-reported outcome measures in a large Swedish multicenter cohort. Breast Cancer Research and Treatment. 2013;142(3):591-601.