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Is immediate breast reconstruction safe in women over 70? An analysis of the National Surgical Quality Improvement Program (NSQIP) database

Breast Cancer Research and Treatment volume 177, pages 215–224 (2019)Cite this article

Abstract

Purpose

The safety of immediate breast reconstruction (IBR) in older women is largely unknown. This study aimed to determine the 30-day postoperative complication rates following IBR (implant-based or autologous) in older women (≥ 70 years) with breast cancer and to compare them to younger women (18–69 years).

Methods

The National Surgical Quality Improvement Program (NSQIP) database was used to identify women with in situ or invasive breast cancer who underwent IBR (2005–2016). Outcomes included 30-day postoperative morbidity and mortality, which were compared across age groups stratified by type of reconstruction.

Results

Of 28,850 women who underwent implant-based and 9123 who underwent autologous reconstruction, older women comprised 6.5% and 5.7% of the sample, respectively. Compared to younger women, older women had more comorbidities, shorter operative times, and longer length of hospital stay. In the implant-based reconstruction group, the 30-day morbidity rate was significantly higher in older women (7.5% vs 5.3%, p < 0.0001) due to higher rates of infectious, pulmonary, and venous thromboembolic events. Wound morbidity and prosthesis failure occurred equally among age groups. In the autologous reconstruction group, there was no statistically significant difference in the 30-day morbidity rates (older 9.5% vs younger 11.6%, p = 0.15). Both wound morbidity and flap failure rates were similar between the two age groups. For both reconstruction techniques, mortality within 30 days of breast surgery was rare.

Conclusion

Immediate breast reconstruction is safe in older women. These data support the notion that surgeons should discuss IBR as a safe and integral part of cancer treatment in well-selected older women.

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Fig. 1

Abbreviations

ASA:

American Society of Anesthesiology

BMI:

Body mass index

CHF:

Congestive heart failure

COPD:

Chronic obstructive pulmonary disease

CPT:

Current procedural terminology

DCIS:

Ductal carcinoma in situ

DM:

Diabetes mellitus

IBR:

Immediate breast reconstruction

ICD-9:

International Classification of Diseases Ninth Revision

LN:

Lymph node

NSQIP:

National Surgical Quality Improvement Program

PACE:

Preoperative Assessment of Cancer in the Elderly

PCI:

Percutaneous coronary intervention

PUF:

Participant user data file

SSI:

Surgical site infection

SURPAS:

Surgical Risk Preoperative Assessment System

References

  1. Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA (2009) Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol 27:2758–2765

    Article  PubMed  Google Scholar 

  2. Biganzoli L, Wildiers H, Oakman C et al (2012) Management of elderly patients with breast cancer: updated recommendations of the International Society of Geriatric Oncology (SIOG) and European Society of Breast Cancer Specialists (EUSOMA). Lancet Oncol 13:e148–e160

    Article  PubMed  Google Scholar 

  3. Eltahir Y, Werners LL, Dreise MM et al (2013) Quality-of-life outcomes between mastectomy alone and breast reconstruction: comparison of patient-reported BREAST-Q and other health-related quality-of-life measures. Plast Reconstr Surg 132:201e–209e

    Article  CAS  PubMed  Google Scholar 

  4. Atisha D, Alderman AK, Lowery JC, Kuhn LE, Davis J, Wilkins EG (2008) Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study. Ann Surg 247:1019–1028

    Article  PubMed  Google Scholar 

  5. Nano MT, Gill PG, Kollias J, Brochner MA, Malycha P, Winefield HR (2005) Psychological impact and cosmetic outcome of surgical breast cancer strategies. ANZ J Surg 75:940–947

    Article  PubMed  Google Scholar 

  6. Oh DD, Flitcorft K, Brennan ME, Spillane AJ (2016) Patterns and outcomes of breast reconstruction in older women—a systematic review of the literature. Eur J Surg Oncol 42:604–615

    Article  CAS  PubMed  Google Scholar 

  7. Girotto JA, Schreiber J, Nahabedian MY (2003) Breast reconstruction in the elderly: preserving excellent quality of life. Ann Plast Surg 50:572–578

    Article  PubMed  Google Scholar 

  8. Figueiredo MI, Cullen J, Hwang YT, Rowland JH, Mandelblatt JS (2004) Breast cancer treatment in older women: does getting what you want improve your long-term body image and mental health? J Clin Oncol 22:4002–4009

    Article  PubMed  Google Scholar 

  9. Godfrey PM, Godfrey NV, Romita MC (1995) Immediate autogenous breast reconstruction in clinically advanced disease. Plast Reconstr Surg 95:1039–1044

    Article  CAS  PubMed  Google Scholar 

  10. Bowman CC, Lennox PA, Clugston PA, Courtemanche DJ (2006) Breast reconstruction in older women: should age be an exclusion criterion? Plast Reconstr Surg 118:16–22

    Article  CAS  PubMed  Google Scholar 

  11. Song D, Slater K, Papsdorf M et al (2016) Autologous breast reconstruction in women older than 65 years versus women younger than 65 years: a multi-center analysis. Ann Plast Surg 76:155–163

    Article  CAS  PubMed  Google Scholar 

  12. Johnson DB, Lapin B, Wang C et al (2016) Advanced age does not worsen recovery or long-term morbidity after postmastectomy breast reconstruction. Ann Plast Surg 76:164–169

    Article  CAS  PubMed  Google Scholar 

  13. Sisco M, Johnson DB, Wang C, Rasinski K, Rundell VL, Yao KA (2015) The quality-of-life benefits of breast reconstruction do not diminish with age. J Surg Oncol 111:663–668

    Article  PubMed  Google Scholar 

  14. Sabino J, Lucas DJ, Shriver CD, Vertees AE, Valerio IL, Singh DP (2016) NSQIP analysis: increased immediate reconstruction in the treatment of breast cancer. Am Surg 82:540–545

    PubMed  Google Scholar 

  15. Hoskin TL, Hieken TJ, Degnim AC, Jakub JW, Jacobson SR, Boughey JC (2016) Use of immediate breast reconstruction and choice for contralateral prophylactic mastectomy. Surgery 159:1199–1209

    Article  PubMed  Google Scholar 

  16. Habermann EB, Thomsen KM, Hieken TJ, Boughey JC (2014) Impact of availability of immediate breast reconstruction on bilateral mastectomy rates for breast cancer across the United States: data from the nationwide inpatient sample. Ann Surg Oncol 21:3290–3296

    Article  PubMed  Google Scholar 

  17. Holley DT, Toursarkissian B, Vasconez HC et al (1995) The ramifications of immediate reconstruction in the management of breast cancer. Am Surg 61:60–65

    CAS  PubMed  Google Scholar 

  18. Wilkins EG, Cederna PS, Lowery JC et al (2000) Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg 106:1014–1025

    Article  CAS  PubMed  Google Scholar 

  19. Sullivan SR, Fletcher DR, Isom CD, Isik FF (2008) True incidence of all complications following immediate and delayed breast reconstruction. Plast Reconstr Surg 122:19–28

    Article  CAS  PubMed  Google Scholar 

  20. Butler PD, Nelson JA, Fischer JP et al (2016) Racial and age disparities persist in immediate breast reconstruction: an updated analysis of 48,564patients from the 2005 to 2011. Am J Surg 212:96–101

    Article  PubMed  Google Scholar 

  21. Brennan ME, Spillane AJ (2013) Uptake and predictors of post-mastectomy reconstruction in women with breast malignancy–systematic review. Eur J Surg Oncol 39:527–541

    Article  CAS  PubMed  Google Scholar 

  22. In H, Jiang W, Lipsitz SR, Neville BA, Weeks JC, Greenberg CC (2013) Variation in the utilization of reconstruction following mastectomy in elderly women. Ann Surg Oncol 20:1872–1879

    Article  PubMed  Google Scholar 

  23. Morrow M, Mujahid M, Lantz PM et al (2005) Correlates of breast reconstruction: results from a population-based study. Cancer 104:2340–2346

    Article  PubMed  Google Scholar 

  24. Christian CK, Niland J, Edge SB, Ottesen RA, Hughes ME, Theriault R et al (2006) A multi-institutional analysis of the socioeconomic determinants of breast reconstruction: a study of the National Comprehensive Cancer Network. Ann Surg 243:241–249

    Article  PubMed  PubMed Central  Google Scholar 

  25. Alderman AK, McMahon L, Wilkins EG (2003) The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors. Plast Reconstr Surg 111:695

    Article  PubMed  Google Scholar 

  26. Agarwal S, Pappas L, Neumayer L, Agarwal J (2011) An analysis of immediate postmastectomy breast reconstruction frequency using the Surveillance, Epidemiology, and End Results Database. Breast J 17:352–358

    Article  PubMed  Google Scholar 

  27. Reaby LL (1998) Reasons why women who have mastectomy decide to have or not to have breast reconstruction. Plast Reconstr Surg 101:1810–1818

    Article  CAS  PubMed  Google Scholar 

  28. Handel N, Silverstein MJ, Waisman E, Waisman JR (1990) Reasons why mastectomy patients do not have breast reconstruction. Plast Reconstr Surg 86:1118–1125

    Article  CAS  PubMed  Google Scholar 

  29. Howard-McNatt M, Forsberg C, Levine EA, DeFranzo A, Marks M, David L (2011) Breast cancer reconstruction in the elderly. Am Surgeon 77:1640–1643

    PubMed  Google Scholar 

  30. Kamali P, Curiel D, van Veldhuisen CL et al (2017) Trends in immediate breast reconstruction and early complication rates among older women: a big data analysis. J Surg Oncol 115:870–877

    Article  PubMed  Google Scholar 

  31. Hershman DL, Richards CA, Kalinsky K, Wilde ET, Lu YS, Ascherman JA et al (2012) Influence of health insurance, hospital factors and physician volume on receipt of immediate post-mastectomy reconstruction in women with invasive and non-invasive breast cancer. Breast Cancer Res Treat 136:535–545

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Agarwal S, Kidwell KM, Kraft CT et al (2015) Defining the relationship between patient decisions to undergo breast reconstruction and contralateral prophylactic mastectomy. Plast Reconstr Surg 135:661–670

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. August DA, Wilkins E, Rea T (1994) Breast reconstruction in older women. Surgery 115:663–668

    CAS  PubMed  Google Scholar 

  34. Muss HB (2010) Coming of age: breast cancer in Seniors. Oncologist 15(suppl 5):57–65

    Article  CAS  PubMed  Google Scholar 

  35. Oeffinger KC, Fontham ET, Etzioni R et al (2015) Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA 314:1599–1614

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. American College of Surgeons (2016) User Guide for the ACS NSQIP Participant Use Data File (PUF). https://www.facs.org/~/media/files/quality%20programs/nsqip/nsqip_puf_userguide_2016.ashx. Accessed 11 Marh 2019

  37. Meguid RA, Bronsert MR, Juarez-Colunga E, Hammermeister KE, Henderson WG (2016) Surgical Risk Preoperative Assessment System (SURPAS): I. Parsimonious, clinically meaningful groups of postoperative complications by factor analysis. Ann Surg 263:1042–1048

    Article  PubMed  Google Scholar 

  38. McCarthy CM, Mehrara BJ, Riedel E et al (2008) Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk. Plast Reconstr Surg 121:1886–1892

    Article  CAS  PubMed  Google Scholar 

  39. Sinha I, Pusic AL, Wilkins EG et al (2017) Late surgical-site infection in immediate implant-based breast reconstruction. Plast Reconstr Surg 139:20–28

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Carminati M, Sempf D, Bonfirraro PP et al (2018) Immediate implant-based breast reconstruction with acellular dermal matrix compared with tissue-expander breast reconstruction: rate of infection. Plast Reconstr Surg Glob Open 6:e1949

    Article  PubMed  PubMed Central  Google Scholar 

  41. Throckmorton AD, Boughey JC, Boostrom SY et al (2009) Postoperative prophylactic antibiotics and surgical site infection rates in breast surgery patients. Ann Surg Oncol 16:2464–2469

    Article  PubMed  Google Scholar 

  42. Massenburg BB, Sanati-Mehrizy P, Ingargiola MJ, Rosa JH, Taub PJ (2015) Flap failure and wound complications in autologous breast reconstruction: a national perspective. Aesthetic Plast Surg 39:902–909

    Article  PubMed  Google Scholar 

  43. Sorensen LT, Horby J, Friis E, Pilsgaard B, Jorgensen T (2002) Smoking as a risk factor for wound healing and infection in breast cancer surgery. Eur J Surg Oncol 28:815–820

    Article  CAS  PubMed  Google Scholar 

  44. Bertin ML, Crowe J, Gordon SM (1998) Determinants of surgical site infection after breast surgery. Am J Infect Control 26:61–65

    Article  CAS  PubMed  Google Scholar 

  45. Hart A, Funderburk CD, Chu CK et al (2017) The impact of diabetes mellitus on wound healing in breast reconstruction. Ann Plast Surg 78:260–263

    Article  CAS  PubMed  Google Scholar 

  46. de Blacam C, Ogunleye AA, Momoh AO et al (2012) High body mass index and smoking predict morbidity in breast cancer surgery: a multivariate analysis of 26,988 patients from the national surgical quality improvement program database. Ann Surg 255:551–555

    Article  PubMed  Google Scholar 

  47. Bergey M, Kovach S, Selber J, Serletti J, Sonnad S, Wu L (2009) Free flap breast reconstruction in advanced age: is it safe? Plast Reconstr Surg 124:1015–1022

    Article  CAS  PubMed  Google Scholar 

  48. Angarita FA, Acuna SA, Cordeiro E et al (2018) Thirty-day postoperative morbidity and mortality in elderly women with breast cancer: an analysis of the NSQIP database. Breast Cancer Res Treat 170:373–379

    Article  PubMed  Google Scholar 

  49. Noda S, Eberlein TJ, Eriksson E (1994) Breast reconstruction. Cancer 74:376–380

    Article  CAS  PubMed  Google Scholar 

  50. Disa JJ, Ad-El DD, Cohen SM, Cordeiro PG, Hidalgo DA (1999) The premature removal of tissue expanders in breast reconstruction. Plast Reconstr Surg 104:1662–1665

    Article  CAS  PubMed  Google Scholar 

  51. Rifkin WJ, Kantar RS, Cammarata MJ et al (2019) Impact of diabetes on 30-day complications in mastectomy and implant-based breast reconstruction. J Surg Res 235:148–159

    Article  PubMed  Google Scholar 

  52. Fischer JP, Wes AM, Tuggle CT 3rd, Serletti JM, Wu LC (2013) Risk analysis of early implant loss after immediate breast reconstruction: a review of 14,585 patients. J Am Coll Surg 217:983–990

    Article  PubMed  Google Scholar 

  53. Fischer JP, Nelson JA, Serletti JM, Wu LC (2013) Peri-operative risk factors associated with early tissue expander (TE) loss following immediate breast reconstruction (IBR): a review of 9305 patients from the 2005-2010 ACS-NSQIP datasets. J Plast Reconstr Aesthet Surg 66:1504–1512

    Article  PubMed  Google Scholar 

  54. Piper ML, Roussel L, Koltz PF et al (2017) Characterizing infections in prosthetic breast reconstruction: a validity assessment of national health databases. J Plast Reconstr Aesthet Surg 70:1345–1353

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada

    Fernando A. Angarita, Fahima Dossa, Jesse Zuckerman, David R. McCready & Tulin D. Cil

  2. Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada

    Fahima Dossa

  3. Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada

    David R. McCready & Tulin D. Cil

  4. Department of Surgery, Women’s College Hospital, Toronto, ON, Canada

    Tulin D. Cil

  5. Division of General Surgery, University Health Network, 610 University Ave, OPG- 6th Floor, Toronto, ON, M5G 2M9, Canada

    Tulin D. Cil

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  1. Fernando A. Angarita
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  2. Fahima Dossa
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  5. Tulin D. Cil
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Correspondence to Tulin D. Cil.

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Angarita, F.A., Dossa, F., Zuckerman, J. et al. Is immediate breast reconstruction safe in women over 70? An analysis of the National Surgical Quality Improvement Program (NSQIP) database. Breast Cancer Res Treat 177, 215–224 (2019). https://doi.org/10.1007/s10549-019-05273-1

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  • DOI: https://doi.org/10.1007/s10549-019-05273-1

Keywords

  • Aged
  • Breast neoplasm
  • Breast reconstruction
  • Postoperative outcomes