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European Journal of Surgical Oncology :... May 2016Older age is associated with lower rates of breast reconstruction (BR) for women requiring mastectomy. The purpose was to assess the available evidence on uptake,... (Review)
Review
PURPOSE
Older age is associated with lower rates of breast reconstruction (BR) for women requiring mastectomy. The purpose was to assess the available evidence on uptake, outcome and quality of life (QoL) after BR in older women.
METHODS
A systematic literature review was performed via Medline, Embase and Cochrane databases using the search terms breast reconstruction, breast cancer, and mastectomy. Eligible studies reported rates of BR, rates of different reconstructive techniques, complication rates, and/or patient reported outcome measures (PROMs) of BR in women aged 60 years or older undergoing mastectomy for ductal carcinoma in situ or invasive carcinoma.
RESULTS
A total of 42 eligible studies were included, with 32 of these reporting BR rates, 10 reporting rates of different reconstructive techniques, 10 reporting rates of complications, and four reporting PROMs. The studies reported 24,746 cases of BR in 407,570 mastectomy patients aged 60 years or older from 1987 to 2012. Implant based BR was more common than autologous techniques. Mostly, complication rates were not higher in older women, and QoL outcomes were similar to younger women.
CONCLUSIONS
This review confirms that BR rates are lower in older women despite recent studies demonstrating its efficacy. The perception among some surgeons and women requiring mastectomy that the potential risks of BR in older women outweigh the benefits needs to be revisited. Education of consumers and surgeons along with public advocacy for offering BR to all clinically eligible women are the most promising means of changing practice.
Topics: Aged; Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Middle Aged; Outcome Assessment, Health Care; Postoperative Complications; Quality of Life
PubMed: 26965305
DOI: 10.1016/j.ejso.2016.02.010 -
Clinical Oncology (Royal College of... Dec 2016To determine the effect of delay in postoperative radiotherapy on local recurrence and overall survival in women receiving partial mastectomy for breast cancer. (Meta-Analysis)
Meta-Analysis Review
AIMS
To determine the effect of delay in postoperative radiotherapy on local recurrence and overall survival in women receiving partial mastectomy for breast cancer.
MATERIALS AND METHODS
This was a systematic review and meta-analysis of published literature. Relevant reports were identified from MEDLINE, EMBASE and the Cochrane Register of Controlled Trials in all languages from 1975 to April 2015, in addition to the abstracts from the annual meetings of major radiotherapy conferences from 2000 to 2011. Reference lists were hand searched to find additional relevant reports and OvidSP's 'Find Citing' function was used to find studies citing papers identified in the primary search. Studies were included if they met the following criteria: (i) all patients received partial mastectomy and radiotherapy, (ii) a delay from surgery to radiotherapy was reported and (iii) one or more of local control/failure and/or survival were reported. Observational studies and randomised controlled trials were included. Studies including patients with in situ disease were excluded. Studies were classified as high quality if they adequately controlled for factors known to be associated with the outcomes of interest. Study quality was independently assessed by three authors. Initial disagreements about three studies were resolved by consensus. Only high-quality studies were included in the primary analysis. Delay was modelled as a continuous variable and the relative risk of local recurrence and the relative risk of death are reported per month of delay. The study results were combined using a fixed-effects model.
RESULTS
Thirty-four relevant publications including 79 616 patients were identified in the systematic review. Ten high-quality publications reported on local recurrence (13 291 patients) and four high-quality studies reported on overall survival (2207 patients). The relative risk of local recurrence per month of delay was 1.08 (95% confidence interval 1.02-1.14). The relative risk of death per month of delay was 0.99 (95% confidence interval 0.94-1.05).
CONCLUSIONS
Delays in post-lumpectomy radiotherapy are associated with a significant increase in the risk of local recurrence. We recommend that waiting times for radiotherapy should be kept as short as reasonably achievable.
Topics: Breast Neoplasms; Female; Humans; Mastectomy, Segmental; Radiotherapy, Adjuvant; Time Factors
PubMed: 27498044
DOI: 10.1016/j.clon.2016.07.010 -
European Journal of Pain (London,... Apr 2015Perioperative neuropathic pain is under-recognized and often undertreated. Chronic pain may develop after any routine surgery, but it can have a far greater incidence... (Review)
Review
BACKGROUND
Perioperative neuropathic pain is under-recognized and often undertreated. Chronic pain may develop after any routine surgery, but it can have a far greater incidence after amputation, thoracotomy or mastectomy. The peak noxious barrage due to the neural trauma associated with these operations may be reduced in the perioperative period with the potential to reduce the risk of chronic pain.
DATABASES AND DATA TREATMENT
A systematic review of the evidence for perioperative interventions reducing acute and chronic pain associated with amputation, mastectomy or thoracotomy.
RESULTS
Thirty-two randomized controlled trials met the inclusion criteria. Gabapentinoids reduced pain after mastectomy, but a single dose was ineffective for thoracotomy patients who had an epidural. Gabapentinoids were ineffective for vascular amputees with pre-existing chronic pain. Venlafaxine was associated with less chronic pain after mastectomy. Intravenous and topical lidocaine and perioperative EMLA (eutectic mixture of local anaesthetic) cream reduced the incidence of chronic pain after mastectomy, whereas local anaesthetic infiltration appeared ineffective. The majority of the trials investigating regional analgesia found it to be beneficial for chronic symptoms. Ketamine and intercostal cryoanalgesia offered no reduction in chronic pain. Total intravenous anaesthesia (TIVA) reduced the incidence of post-thoracotomy pain in one study, whereas high-dose remifentanil exacerbated chronic pain in another.
CONCLUSIONS
Appropriate dose regimes of gabapentinoids, antidepressants, local anaesthetics and regional anaesthesia may potentially reduce the severity of both acute and chronic pain for patients. Ketamine was not effective at reducing chronic pain. Intercostal cryoanalgesia was not effective and has the potential to increase the risk of chronic pain. TIVA may be beneficial but the effects of opioids are unclear.
Topics: Acute Pain; Anesthetics, Local; Chronic Pain; Humans; Mastectomy; Pain, Postoperative; Thoracotomy; Treatment Outcome
PubMed: 25088289
DOI: 10.1002/ejp.567 -
JAMA Network Open Dec 2022A discrepancy on current guidelines and clinical practice exists regarding routine imaging surveillance after mastectomy, mainly regarding the lack of adequate evidence... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
A discrepancy on current guidelines and clinical practice exists regarding routine imaging surveillance after mastectomy, mainly regarding the lack of adequate evidence for imaging in this setting.
OBJECTIVE
To investigate the usefulness of imaging surveillance in terms of cancer detection and interval cancer rates after mastectomy with or without reconstruction for patients with prior breast cancer.
DATA SOURCES
A comprehensive literature search was conducted in 3 electronic databases-PubMed, ISI Web of Science, and Scopus-without year restriction. References from relevant reviews and eligible studies were also manually searched.
STUDY SELECTION
Eligible studies were defined as those conducting surveillance imaging (mammography, ultrasonography, or magnetic resonance imaging [MRI]) of patients with prior breast cancer after mastectomy with or without reconstruction that presented adequate data to calculate cancer detection rates for each surveillance method.
DATA EXTRACTION AND SYNTHESIS
Independent data extraction by 2 investigators with consensus on discrepant results was performed. A quality assessment of studies was performed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) template. The generalized linear mixed model framework with both fixed-effects and random-effects models was used to meta-analyze the proportion of cases across studies including 3 variables: surveillance method, reconstruction after mastectomy, and surveillance measure.
MAIN OUTCOMES AND MEASURES
Three outcome measures were calculated for each eligible study and each surveillance imaging method within studies: overall cancer detection (defined as ipsilateral cancer, both palpable and nonpalpable) rate per 1000 examinations, clinically occult (nonpalpable) cancer detection rate per 1000 examinations, and interval cancer rate per 1000 examinations.
RESULTS
In total, 16 studies were eligible for the meta-analysis. The pooled overall cancer detection rates per 1000 examinations were 1.86 (95% CI, 1.05-3.30) for mammography, 2.66 (95% CI, 1.48-4.76) for ultrasonography, and 5.17 (95% CI, 1.49-17.75) for MRI. For mastectomy without reconstruction, the rate of clinically occult (nonpalpable) cancer per 1000 examinations (2.96; 95% CI, 1.38-6.32) and the interval cancer rate per 1000 examinations (3.73; 95% CI, 0.84-3.98) were lower than the overall cancer detection rate (including both palpable and nonpalpable lesions) per 1000 examinations (6.41; 95% CI, 3.09-13.25) across all imaging modalities. The interval cancer rate per 1000 examinations for mastectomy with reconstruction (3.73; 95% CI, 0.41-2.73) was comparable to the pooled cancer detection rate per 1000 examinations (4.73; 95% CI, 2.32-9.63) across all imaging modalities. In all clinical scenarios and imaging modalities, lower rates of clinically occult cancer compared with cancer detection rates were observed.
CONCLUSIONS AND RELEVANCE
Lower detection rates of clinically occult-compared with overall-cancer across all 3 imaging modalities challenge the use of imaging surveillance after mastectomy, with or without reconstruction. Findings suggest that imaging surveillance in this context is unnecessary in clinical practice, at least until further studies demonstrate otherwise. Future studies should consider using the clinically occult cancer detection rate as a more clinically relevant measure in this setting.
Topics: Humans; Female; Mastectomy; Breast Neoplasms; Mammography; Physical Examination; Consensus
PubMed: 36454573
DOI: 10.1001/jamanetworkopen.2022.44212 -
Journal of Plastic, Reconstructive &... May 2021Immediate post-mastectomy autologous breast reconstruction in breast cancer patients requiring post-mastectomy radiation therapy (PMRT) minimizes the number of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Immediate post-mastectomy autologous breast reconstruction in breast cancer patients requiring post-mastectomy radiation therapy (PMRT) minimizes the number of operations that patients must undergo and alleviates the psychological impact of living without a breast. However, the safety and impact of radiation on the reconstructed breast remains to be established. This study aimed to compare immediate versus delayed autologous reconstruction in the setting of PMRT to determine the optimal sequencing of reconstruction and adjuvant radiation.
METHODS
A systematic review of the literature identified 292 studies meeting criteria for full-text review, 44 of which underwent meta-analysis. This represented data on 1,927 immediate reconstruction (IR) patients and 1,546 delayed reconstruction (DR) patients (3,473 total patients). Early complications included flap loss, fat necrosis, thrombosis, seroma, hematoma, infection, and skin dehiscence. Late complications included fibrosis or contracture, severe asymmetry, hyperpigmentation, and decreased flap volume.
RESULTS
Immediate breast reconstruction did not demonstrate significantly increased complication rates. Reported mean complication rates in IR versus DR groups, respectively, were fat necrosis 14.91% and 8.12% (p = 0.076), flap loss 0.99% and 1.80% (p = 0.295), hematoma 1.91% and 1.14% (p = 0.247), infection 11.66% and 4.68% (p = 0.155), and thrombosis 1.51% and 3.36% (p = 0.150). Seroma rates were significantly lower in the immediate cohort at 2.69% versus 10.57% in the delayed cohort (p = 0.042).
CONCLUSION
Complication rates are comparable between immediate and delayed breast reconstruction in the setting of PMRT. Given the patient benefits incurred by an IR algorithm, immediate autologous breast reconstruction should be considered as a viable treatment option in patients requiring PMRT.
Topics: Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Postoperative Complications; Radiotherapy, Adjuvant; Surgical Flaps; Time Factors; Transplantation, Autologous
PubMed: 33423976
DOI: 10.1016/j.bjps.2020.11.027 -
Journal of Plastic, Reconstructive &... Dec 2014There are many known breast cancer risk factors, but traditionally the list has not included breast size. The aim of this study was to synthesize the literature on... (Review)
Review
BACKGROUND
There are many known breast cancer risk factors, but traditionally the list has not included breast size. The aim of this study was to synthesize the literature on breast size as a risk factor for breast carcinoma by examining studies addressing this question both directly and indirectly.
METHODS
A systematic review was performed searching MEDLINE from 1950 to November 2010, and updated again in February 2014. Literature was sought to assess the relationship between the following variables and breast cancer: 1) breast size; 2) breast reduction; 3) breast augmentation; and 4) prophylactic subcutaneous mastectomy. Findings were summarized and the levels of evidence were assessed.
RESULTS
50 papers were included in the systematic review. Increasing breast size appears to be a risk factor for breast cancer, but studies are limited by their retrospective nature, imperfect size measurement techniques and confounding variables. The evidence is stronger for risk reduction with breast reduction, including prophylactic subcutaneous mastectomy at the extreme. Generally the breast augmentation population has a lower risk of breast cancer than the general population, but it is unclear whether or not this is related to the bias of small breasts in this patient population and the presence of other confounders.
CONCLUSIONS
There is direct and indirect evidence that breast size is an important factor in the risk of developing breast cancer. Plastic surgeons are in a unique position to observe this effect. Well-designed prospective studies are required to further assess this risk factor.
Topics: Breast; Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy, Subcutaneous; Organ Size; Risk Factors
PubMed: 25456291
DOI: 10.1016/j.bjps.2014.10.001 -
Aesthetic Plastic Surgery Jun 2022Seroma formation is a common complication following mastectomy. The objective of this systematic review and meta-analysis is to evaluate the impact of flap fixation... (Meta-Analysis)
Meta-Analysis Review
Comparison of Flap Fixation to Its Bed and Conventional Wound Closure with Drainage in Preventing Seroma Formation Following Mastectomy for Breast Cancer: Systematic Review and Meta-analysis.
BACKGROUND
Seroma formation is a common complication following mastectomy. The objective of this systematic review and meta-analysis is to evaluate the impact of flap fixation techniques that omit drainage versus conventional closed drainage on seroma formation and related complications after mastectomy.
METHODS
Clinical studies of flap fixation techniques versus the conventional closure technique in patients undergoing mastectomy with or without axillary clearance were retrieved from the PubMed, Embase and Cochrane databases. Papers were eligible for inclusion if the outcome was described in terms of seroma formation. Studies older than 20 years, animal studies and studies involving patients undergoing direct breast reconstruction were excluded.
RESULTS
Four randomized controlled trials (RCTs) and four cohort studies were included in our examination. Compared with the conventional drainage group, the flap fixation group had a similar incidence of seroma formation (OR 0.76, 95% CI 0.30-1.93, p = 0.57).
CONCLUSION
Based on current evidence, mechanical flap fixation can replace conventional drainage without increasing seroma formation after mastectomy. Further well-designed RCTs are warranted to evaluate the effects of flap fixation.
LEVEL OF EVIDENCE III
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Topics: Breast Neoplasms; Drainage; Female; Humans; Mastectomy; Postoperative Complications; Seroma
PubMed: 35226117
DOI: 10.1007/s00266-022-02814-w -
Plastic and Reconstructive Surgery Oct 2022
Meta-Analysis
Topics: Breast Neoplasms; Female; Humans; Mammaplasty; Mastectomy; Prophylactic Mastectomy; Retrospective Studies
PubMed: 36170450
DOI: 10.1097/PRS.0000000000009543 -
Annals of Surgical Oncology Oct 2022The standard surgical management of ipsilateral breast cancer recurrence (IBCR) in patients previously treated with breast-conserving surgery (BCS) and radiotherapy (RT)... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
The standard surgical management of ipsilateral breast cancer recurrence (IBCR) in patients previously treated with breast-conserving surgery (BCS) and radiotherapy (RT) is mastectomy. Recent international guidelines provide conflicting recommendations. The aim of this study was to perform a systematic literature review and meta-analysis of the oncological outcomes in patients with IBCR treated with repeat BCS (rBCS).
METHODS
The MEDLINE and EMBASE databases were searched for relevant English-language publications, with no date restrictions. All relevant studies providing sufficient data to assess oncological outcomes (second local recurrence [LR] and overall survival [OS]) of rBCS for the management of IBCR after previous BCS and RT were included (PROSPERO registration CRD42021286123).
RESULTS
Forty-two observational studies met the criteria and were included in the analysis. The pooled second LR rate after rBCS was 15.7% (95% confidence interval [CI] 12.1-19.7), and 10.3% (95% CI 6.9-14.3) after salvage mastectomy. On meta-analysis of comparative studies (n = 17), the risk ratio (RR) for second LR following rBCS compared with mastectomy was 2.103 (95% CI 1.535-2.883; p < 0.001, I = 55.1%). Repeat RT had a protective effect (coefficient: - 0.317, 95% CI - 0.596 to - 0.038; p = 0.026, I = 40.4%) for second LR. Pooled 5-year OS was 86.8% (95% CI 83.4-90.0) and 79.8% (95% CI 74.7-84.5) for rBCS and salvage mastectomy, respectively. Meta-analysis of comparative studies (n = 20) showed a small OS benefit in favor of rBCS (RR 1.040, 95% CI 1.003-1.079; p = 0.032, I = 70.8%). Overall evidence certainty was very low.
CONCLUSIONS
This meta-analysis suggests rBCS could be considered as an option for the management of IBCR in patients previously treated with BCS and RT. Shared decision making, appropriate patient selection, and individualized approach are important for optimal outcomes.
Topics: Breast; Breast Neoplasms; Female; Humans; Mastectomy; Mastectomy, Segmental; Neoplasm Recurrence, Local
PubMed: 35849299
DOI: 10.1245/s10434-022-12197-6 -
Annals of Surgical Oncology Oct 2015Nipple-sparing mastectomy (NSM) is an increasingly common procedure; however, concerns exist regarding its oncological safety due to the potential for residual breast... (Meta-Analysis)
Meta-Analysis Review
Overall Survival, Disease-Free Survival, Local Recurrence, and Nipple-Areolar Recurrence in the Setting of Nipple-Sparing Mastectomy: A Meta-Analysis and Systematic Review.
BACKGROUND
Nipple-sparing mastectomy (NSM) is an increasingly common procedure; however, concerns exist regarding its oncological safety due to the potential for residual breast tissue to harbor occult malignancy or future cancer.
METHODS
A systematic literature review was performed. Studies with internal comparison arms evaluating therapeutic NSM versus skin-sparing mastectomy (SSM) and/or modified radical mastectomy (MRM) were included in a meta-analysis of overall survival (OS), disease-free survival (DFS), and local recurrence (LR). Studies lacking comparison arms were only included in the systematic review to evaluate mean OS, DFS, LR, and nipple-areolar recurrence (NAR).
RESULTS
The search yielded 851 articles. Twenty studies with 5594 patients met selection criteria. The meta-analysis included eight studies with comparison arms. Seven studies that compared OS found a 3.4% risk difference between NSM and MRM/SSM, five studies that compared DFS found a 9.6% risk difference between NSM and MRM/SSM, and eight studies that compared LR found a 0.4% risk difference between NSM and MRM/SSM. Risk differences for all outcomes were not statistically significant. The systematic review included all 20 studies and evaluated OS, DFS, LR, and NAR. Studies with follow-up intervals of <3 years, 3-5 years, and >5 years had mean OS of 97.2, 97.9, and 86.8%; DFS of 93.1, 92.3, and 76.1%; LR of 5.4, 1.4, and 11.4%; and NAR of 2.1, 1.0, and 3.4%, respectively.
CONCLUSIONS
This study did not detect adverse oncologic outcomes of NSM in carefully selected women with early-stage breast cancer. Use of prospective data registries, notably the Nipple-Sparing Mastectomy Registry, will add clarity to this important clinical question.
Topics: Breast Neoplasms; Disease-Free Survival; Female; Humans; Mammaplasty; Mastectomy, Modified Radical; Neoplasm Recurrence, Local; Nipples; Organ Sparing Treatments; Prognosis; Survival Rate
PubMed: 26242363
DOI: 10.1245/s10434-015-4739-1