Complications After Mastectomy and Immediate Breast Reconstruction for Breast Cancer: A Claims-Based Analysis

Abstract

Objective: To evaluate complications after postmastectomy breast reconstruction, particularly in the setting of adjuvant radiotherapy.

Background: Most studies of complications after breast reconstruction have been conducted at centers of excellence; relatively little is known about complication rates in irradiated patients treated in the broader community. This information is relevant for decision making in patients with breast cancer.

Methods: Using the claims-based MarketScan database, we described complications in 14,894 women undergoing mastectomy for breast cancer from 1998 to 2007 and who underwent immediate autologous reconstruction (n = 2637), immediate implant-based reconstruction (n = 3007), or no reconstruction within the first 2 postoperative years (n = 9250). We used a generalized estimating equation to evaluate associations between complications and radiotherapy over time.

Results: Wound complications were diagnosed within the first 2 postoperative years in 2.3% of patients without reconstruction, 4.4% patients with implants, and 9.5% patients with autologous reconstruction (P < 0.001). Infection was diagnosed within the first 2 postoperative years in 12.7% of patients without reconstruction, 20.5% with implants, and 20.7% with autologous reconstruction (P < 0.001). A total of 5219 (35%) women received radiation. Radiation was not associated with infection in any surgical group within the first 6 months but was associated with an increased risk of infection in months 7 to 24 in all 3 groups (each P < 0.001). In months 7 to 24, radiation was associated with higher odds of implant removal in patients with implant reconstruction (odds ratio = 1.48; P < 0.001) and fat necrosis in those with autologous reconstruction (odds ratio = 1.55; P = 0.01).

Conclusions: Complication risks after immediate breast reconstruction differ by approach. Radiation therapy seems to modestly increase certain risks, including infection and implant removal.

Figure 1. Adverse Outcomes by Surgery Type

This figure presents the proportion of patients who developed the following complications by type of initial breast surgery: (1) rehospitalization within 30 days of initial mastectomy, (2) a diagnosis code indicating wound complications within 2 years of initial mastectomy, and (3) a diagnosis code indicating infection within 2 years of initial mastectomy. P-values for all three outcomes by type of initial surgery were statistically significant at P<0.001. Abbreviations: Mast (mastectomy), Implant (implant-based reconstruction).

Figure 2. Adverse Outcomes with and without Radiotherapy Among Reconstructed Patients Over Time

The top row of panels depicts rehospitalization rates; the second row wound complications; the third row wound complications; and the fourth row reconstruction-specific complications in the cohort of 14,894 women undergoing mastectomy for breast cancer from 1998-2007 who received no reconstruction within the first two postoperative years (n=9250), immediate implant-based reconstruction (n=3007), or immediate autologous reconstruction (n=2637), respectively. In each panel, the solid vertical line shows the median interval from mastectomy to start of radiotherapy, and the two dotted vertical lines show the interquartile range. Panel A shows that radiation was not associated with rehospitalization in patients not receiving reconstruction, either within the first 6 months (P=0.07) or in months 7 to 24 (P=0.08). Panel B shows that radiation was not associated with rehospitalization in patients receiving implant-based reconstruction, either within the first 6 months (P=0.56) or in months 7 to 24 (P=0.57). Panel C shows that radiation was associated with increased risk of rehospitalization in patients receiving autologous reconstruction, both within the first 6 months (OR=1.40; P=0.02) and in months 7 to 24 (OR=1.67; P<0.001). Panel D shows that within the first 6 months of mastectomy without reconstruction, wound complications were not associated with radiation (P=0.70); in months 7-24, radiation was associated with a modest increase in wound complications (OR=1.84, P=0.04), but absolute risks were extremely low. Panel E shows that radiation was not associated with wound complication risk within the first six months (P=0.40) or in months 7 to 24 (P=0.07) after mastectomy with immediate implant-based reconstruction. Panel F shows that radiation was not associated with wound complications either within the first 6 months (P=0.85) or in months 7 to 24 (P=0.87) after mastectomy with immediate autologous reconstruction. Panel G shows that within the first 6 months of mastectomy without reconstruction, infection was not associated with radiation (P=0.75), but in months 7 to 24, infection was more likely in radiated patients (OR=1.79; P<0.001). Panel H shows that within the first 6 months of mastectomy with immediate implant-based reconstruction, infection was not associated with radiation (P=0.90), but in months 7 to 24, infection was more likely in radiated patients (OR=1.66; P<0.001). Panel I shows that within the first 6 months of mastectomy with autologous reconstruction, infection was not associated with radiation (P=0.08), but in months 7 to 24, infection was more likely in radiated patients (OR=2.07; P<0.001). Panel J shows that after implant reconstruction, implant removal was not associated with radiation receipt (P=0.30), but in months 7 to 24, implant removal was more likely in radiated patients (OR=1.48; P<0.001). Panel K shows that radiation was not associated with increased risk of fat necrosis among patients receiving mastectomy with immediate autologous reconstruction within the first 6 months of surgery (P=0.88) but was associated with high risk of fat necrosis in months 7 to 24 (OR=1.55; P=0.01).