Impact of Radiotherapy on Complications and Patient-Reported Outcomes After Breast Reconstruction

Abstract

Background: Patients considering postmastectomy radiation and reconstruction require information regarding expected outcomes to make preference-concordant decisions.

Methods: A prospective multicenter cohort study of women diagnosed with breast cancer at 11 centers between 2012 and 2015 compared complications and patient-reported outcomes of 622 irradiated and 1625 unirradiated patients who received reconstruction. Patient characteristics and outcomes between irradiated and unirradiated patients were analyzed using ttests for continuous variables and chi-square tests for categorical variables. Multivariable mixed-effects regression modelsassessed the impact of reconstruction type and radiotherapy on outcomes after adjusting for relevant covariates. All statistical tests were two-sided.

Results: Autologous reconstruction was more commonly received by irradiated patients (37.9% vs 25.0%, P < .001). Immediate reconstruction was less common in irradiated patients (83.0% vs 95.7%, P < .001). At least one breast complication had occurred by two years in 38.9% of irradiated patients with implant reconstruction, 25.6% of irradiated patients with autologous reconstruction, 21.8% of unirradiated patients with implant reconstruction, and 28.3% of unirradiated patients with autologous reconstruction. Multivariable analysis showed bilateral treatment and higher body mass index to be predictive of developing a complication, with a statistically significant interaction between radiotherapy receipt and reconstruction type. Among irradiated patients, autologous reconstruction was associated with a lower risk of complications than implant-based reconstruction at two years (odds ratio [OR] = 0.47, 95% confidence interval [CI] = 0.27 to 0.82, P = .007); no between-procedure difference was found in unirradiated patients. The interaction was also statistically significant for satisfaction with breasts at two years (P = .002), with larger adjusted difference in satisfaction between autologous vs implant approaches (63.5, 95% CI = 55.9 to 71.1, vs 47.7, 95% CI = 40.2 to 55.2, respectively) in irradiated patients than between autologous vs implant approaches (67.6, 95% CI = 60.3 to 74.9, vs 60.5, 95% CI = 53.6 to 67.4) in unirradiated patients.

Conclusions: Autologous reconstruction appears to yield superior patient-reported satisfaction and lower risk of complications than implant-based approaches among patients receiving postmastectomy radiotherapy.

Figure 1.

Model-predicted scores for BREAST-Q domains. Model-predicted scores are shown for the BREAST-Q domain of (A) satisfaction with breast, (B) satisfaction with outcome, (C) psychosocial well-being, and (D) physical well-being. A, C, and D) Scores were derived from the models in Supplementary Table 2 (available online) and adjust for baseline score, reconstruction timing, age, extent of disease, bilateral vs unilateral reconstruction, chemotherapy receipt, nodal management, body mass index, smoking, diabetes, race, ethnicity, education, employment, income, and hospital site. B) Scores were derived from the models in Supplementary Table 2 (available online) and adjust for reconstruction timing, age, extent of disease, bilateral vs unilateral reconstruction, chemotherapy receipt, nodal management, body mass index, smoking, diabetes, race, ethnicity, education, employment, income, and hospital site. Error bars represent the 95% confidence intervals.