Original Study

Timing of Postmastectomy Reconstruction Does Not Impair Breast Cancer-Specific Survival: A Population-Based Study Michael Bezuhly,1 Yan Wang,2 Jason G. Williams,3 Leif J. Sigurdson4 Abstract Using a provincial cancer registry, medical insurance, and vital statistics data, we compared breast cancerspecific survival between mastectomy patients who did or did not undergo reconstruction using Cox proportional hazards models. We demonstrate that timing of postmastectomy reconstruction does not negatively affect breast cancer-specific survival. Our findings support the oncologic safety of breast reconstruction, regardless of whether it is performed immediately at the time of mastectomy or in a delayed fashion. Background: Debate remains over the optimal timing of breast reconstruction after mastectomy. Immediate reconstruction has demonstrated superior psychosocial and aesthetic outcomes, but might delay adjuvant therapy. Conversely, delayed reconstruction allows for timely initiation of adjuvant therapy, but with potentially inferior aesthetic results. The authors examined whether any significant breast cancer-specific survival difference exists on the basis of the timing of reconstruction after mastectomy. Patients and Methods: Using a cancer registry, medical insurance, and vital statistics sources, all Nova Scotia women who underwent unilateral mastectomy for breast cancer between 1989 and 2007 were followed to 2012 or time of death. Breast cancer-specific survival was compared for mastectomy patients who did or did not undergo reconstruction. Cox proportional hazards models were fitted adjusting for known demographic, disease severity variables, comorbidities, and reconstruction timing. Results: Of 6790 subjects included in the study, 331 (4.9%) underwent breast reconstruction. Of those who underwent reconstruction, 209 (63%) and 122 (37%) underwent immediate and delayed reconstruction, respectively. Univariate analysis showed improved breast cancer-specific survival among all breast reconstruction patients compared with patients who underwent mastectomy alone (hazard ratio [HR], 0.64; 95% confidence interval [CI], 0.48-0.86). In a multivariate model fitting a time-varying covariate to adjust for timing of reconstruction from mastectomy, no difference in survival was observed between patients who underwent reconstruction at any time and those who underwent mastectomy only (HR, 0.75; 95% CI, 0.56-1.00). No differences in breast cancer-specific survival were observed on the basis of type of reconstruction. Conclusion: Results of the current study suggest that breast reconstruction, regardless of its timing, carries no increased risk of breast cancer-specific mortality compared with mastectomy alone. Clinical Breast Cancer, Vol. 15, No. 6, 519-26 ª 2015 Elsevier Inc. All rights reserved. Keywords: Breast reconstruction, Disease-specific survival, Cox proportional hazards models, Immediate reconstruction, Delayed reconstruction

Introduction The optimal timing of reconstruction after mastectomy remains a hotly debated topic. The decision to perform reconstruction immediately at the time of mastectomy or in a delayed fashion has 1 Division of Plastic and Reconstructive Surgery, IWK Health Centre, Halifax, Nova Scotia, Canada 2 Health Data Nova Scotia, Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada 3 Division of Plastic and Reconstructive Surgery, Queen Elizabeth II Health Sciences Centre, Halifax Infirmary, Halifax, Nova Scotia, Canada 4 Section of Plastic Surgery, Winnipeg Health Science Centre, Winnipeg, Manitoba, Canada

1526-8209/$ - see frontmatter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clbc.2015.06.003

largely been driven by aesthetic and psychosocial considerations. Many believe that if there is a potential need for postmastectomy radiation, reconstruction is best delayed because radiation can adversely affect aesthetic results.1,2 Others believe that immediate Submitted: Feb 19, 2015; Accepted: Jun 11, 2015; Epub: June 18, 2015 Address for correspondence: Michael Bezuhly, MD, MSc, SM, FRCSC, FAAP, Division of Plastic and Reconstructive Surgery, Dalhousie University, IWK Health Centre, 5850/5980 University Ave, PO Box 9700, Halifax, Nova Scotia B3K 6R8, Canada Fax: 902-470-7939; e-mail contact: [email protected]

Clinical Breast Cancer December 2015

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Postmastectomy Reconstruction and BC-Specific Survival Table 1 Demographic and Tumor Characteristics Among Female Unilateral Mastectomy Patients With Breast Cancer (1989-2007) Mastectomy Only Patients Variable Sample Size

All Breast Reconstruction Patients

n

%

n

%

6459

95.1

331

4.9

Timing of Postmastectomy Reconstruction Does Not Impair Breast Cancer-Specific Survival: A Population-Based Study.

Debate remains over the optimal timing of breast reconstruction after mastectomy. Immediate reconstruction has demonstrated superior psychosocial and ...
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