Do Women with a History of Radiation Therapy Fair Better Than Those Undergoing Post-Mastectomy Radiation Therapy in the Setting of Immediate Implant-Based Breast Reconstruction?

Background:

Women undergoing implant-based breast reconstruction in the setting of radiation therapy (RT) are more likely to experience clinical complications.¹ However, immediate implant-based reconstruction is still frequently performed in the United States for women who undergo post-mastectomy radiation therapy (PMRT) and in patients with remote histories of RT.^2-4 The objectives of this study were to determine whether women with histories of RT prior to mastectomy and immediate, implant-based reconstruction have similar complication rates and patient reported outcomes (PROs) to women undergoing PMRT following immediate implant-based reconstruction.

 Methods:

The Mastectomy Reconstruction Outcomes Consortium (MROC) is an 11 center, prospective cohort study assessing clinical outcomes and PROs following post-mastectomy breast reconstruction. The current analysis includes all women undergoing immediate implant-based reconstruction, further categorized into three groups (history of RT prior to mastectomy, PMRT, and no RT). Controlling for clinical covariates, multivariate regressions evaluated the effects of radiation timing on complication rates (any complication, major complications, and reconstruction failure) and PROs (satisfaction with outcome and satisfaction with breasts) at two years.

Results:

The analysis included 84 women with previous RT, 329 who received PMRT, and 1,181 with no history of radiation therapy. Comparing prior RT, PMRT and no RT groups, the unadjusted rates for any complications were 35.7%, 40.1%, and 22.9%, respectively (p<0.001); major complication rates were 26.2%, 34.0%, and 15.8%, respectively (p<0.001); while rates of reconstructive failure were 13.1%, 17.0%, and 4.1%, respectively, (p<0.001).  After adjusting for covariates, there was a trend towards higher risks for the PMRT cohort, compared to the prior RT group:  OR 1.54, p=0.13 for any complications, and OR 1.63, p=0.12 for major complications. There were no significant differences in failure rates between the prior RT and PMRT cohorts. For PROs, the adjusted models indicated that while prior RT had no significant effects on patient satisfaction, women receiving PMRT reported significantly lower satisfaction compared with the no RT group. (satisfaction with breast: p<0.001, overall satisfaction p=0.004).     

Conclusions:

Based on these results, the effects of radiation on complication rates and PROs in immediate implant-based breast reconstruction appear to vary depending on whether RT was delivered prior to mastectomy/reconstruction or following these procedures.  Our findings may facilitate more nuanced and individualized discussions between surgeons and women considering immediate implant-based reconstruction in the setting of radiation therapy. 

Citations

1. Kronowitz, Steven J., and Geoffrey L. Robb. “Radiation Therapy and Breast Reconstruction: A Critical Review of the Literature.” Plastic and Reconstructive Surgery, vol. 124, no. 2, 2009, pp. 395–408.
2. Jagsi, Reshma, et al. “Impact of Radiotherapy on Complications and Patient-Reported Outcomes After Breast Reconstruction.” JNCI: Journal of the National Cancer Institute, vol. 110, no. 2, 2017, pp. 157–165.
3. Aliu, Oluseyi, et al. “Comparing Health Care Resource Use between Implant and Autologous Reconstruction of the Irradiated Breast.” Plastic and Reconstructive Surgery, vol. 139, no. 6, 2017
4. Chetta, Matthew D., et al. “Reconstruction of the Irradiated Breast.” Plastic and Reconstructive Surgery, vol. 139, no. 4, 2017, pp. 783–792.