Racial Disparity in Immediate Breast Reconstruction; a Gap That is not Closing

Background: Immediate breast reconstruction (IBR) is offered as part of the standard-of-care to females undergoing mastectomy. Racial disparity in IBR has been previously reported with a longstanding call for its elimination, though unknown if this goal is achieved. The aim of this study was to examine the current association between race and IBR and to investigate whether racial disparity is diminishing. Methods: Data was extracted from the National Cancer Database (NCDB) from 2004 to 2016. All variables in the database were controlled so that the comparison would be made solely between Black and White females. We also analyzed the trend in racial disparity to see if there has been a change from 2004 to 2016 after several calls for healthcare equality. Results: After propensity score matching, 69,084 White females were compared to 69,084 Black females. There was a statistically significant difference between the rate of IBR and race (23,386 [33.9%] in White females vs 20,850 [30.2%] in Black females, P-value < .001). Despite a twofold increase in the rate of IBR in both White and Black females, a persistent gap of about 4% was observed over the study period, which translates to more than 2,500 Black females not receiving IBR. Conclusions: Using the NCDB database, a racial disparity was identified for IBR between White and Black females from 2004 and 2016. Unfortunately, the gap between the groups remained constant over this 13-year period.

Patterns of Post-Mastectomy Radiotherapy in Immediate Breast Reconstruction – Results from the iBRA-2 Cohort Study

PurposeLong-term data indicates that post-mastectomy radiotherapy (PMRT) is associated with improved overall survival in all node-positive breast cancer patients. Immediate breast reconstruction (IBR) remains controversial in the context of planned PMRT, but rates of IBR are increasing. The aim of this study was to examine current practice of PMRT in patients undergoing mastectomy +/- IBR.MethodsData were collected from 2,526 patients enrolled in the iBRA-2 prospective cohort study undergoing mastectomy +/- IBR between 1st July and 31st December 2016, recruited consecutively at 71 centres across the United Kingdom, Ireland, and five international centres.ResultsOf a total of 2,590 breast procedures included in the analysis, 696 were implant-based, 105 pedicled flap and 230 free-flap reconstruction. 31.4% of implant-based, 34.3% of pedicled, and 32.5% of free-flap reconstructions were recommended for PMRT. PMRT recommendation by cancer stage was 21% for T1-2 N0, 65% for T1-2 N1, and 89% for Tany N2 and T3 Nany disease. On multivariate analysis, patients undergoing IBR were no less likely to be recommended for PMRT than patients having mastectomy only. However, patients in Northern Ireland/Ireland, the North of England, and Scotland were less likely to be recommended for PMRT.ConclusionAlthough IBR was more likely to be performed for lower stage cancers and younger patients with fewer co-morbidities, patients undergoing IBR were no less likely to be recommended for PMRT, irrespective of reconstruction technique. This study also highlighted regional variation in PMRT practice within the UK which merits further investigation.

Influencers of Immediate Post-Mastectomy Reconstruction: A National Cancer Database Analysis

Background The literature examining decision-making related to treatment and reconstruction for women with breast cancer has established that patient, clinical, and facility factors all play a role. Objectives Using the National Cancer Database (NCDB), determine how patient, clinical, and facility factors influence: 1) the receipt of immediate breast reconstruction; and 2) the type of immediate breast reconstruction received (implant-based, autologous, or a combination). Methods A total of 638,772 female patients with TIS-T3, N0-N1, M0 breast cancers were identified in the NCDB from 2004-2017 who received immediate reconstruction following mastectomy. Univariate and multivariable logistic regression models were conducted to identify characteristics associated with immediate breast reconstruction and type of reconstruction. Results Immediate breast reconstruction was more frequently associated with patients of white race, younger age, with private insurance, with lesser comorbidities, who resided in zip-codes with higher median incomes or higher rate of high-school graduation, in urban areas, with Tis-T2 disease, or with &lt;4 lymph node involvement (all odds ratios (OR) &gt; 1.1). Negative predictors of immediate breast reconstruction were insurance status with Medicaid, Medicare, other government insurance, and none or unknown insurance (all ORs &lt;0.79). Implant-based reconstruction was associated with non-black race, uninsured status, completion of higher education, undifferentiated disease, and stage T0 disease (all ORs &gt;1.10). Conclusions These findings confirm some previous studies on what patient, clinical, and facility factors affect decision making, but also raise new questions that relate to the impact of third-party payor on receipt and type of reconstruction post-mastectomy for breast cancer.

Volumetric change of the latissimus dorsi muscle after postoperative chemotherapy and radiotherapy in immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap: final results from serial studies

Background Breast reconstruction using an extended latissimus dorsi (eLD) flap can supplement more volume than reconstruction using various local flaps after partial mastectomy, and it is a valuable surgical method since the reconstruction area is not limited. However, when performing reconstruction, the surgeon should consider latissimus dorsi (LD) volume reduction due to postoperative chemotherapy (POCTx) and postoperative radiotherapy (PORTx). To evaluate the effect of POCTx and PORTx on LD volume reduction, the effects of each therapy—both separately and jointly—need to be demonstrated. The present study quantified LD volume reduction in patients who underwent POCTx and PORTx after receiving breast-conserving surgery (BCS) with an eLD flap.Methods This study included 48 patients who received immediate breast reconstruction using an eLD flap from January 2013 to March 2017, had chest computed tomography (CT) 7–10 days after surgery and 10–14 months after radiotherapy completion, and were observed for more than 3 years postoperatively. One surgeon performed the breast reconstruction procedures, and measurements of breast volume were obtained from axial CT views, using a picture archiving and communication system. A P-value <0.05 was the threshold for statistical significance.Results The average volume reduction of LD at 10–14 months after completing POCTx and PORTx was 64.5% (range, 42.8%–81.4%) in comparison to the volume measured 7–10 days after surgery. This change was statistically significant (P<0.05).Conclusions Based on the findings of this study, when harvesting an eLD flap, surgeons should anticipate an average LD volume reduction of 64.5% if chemotherapy and radiotherapy are scheduled after BCS with an eLD flap.

Robotic harvest of a latissimus dorsi flap using a single-port surgical robotic system in breast reconstruction

Robot-assisted surgery is evolving to incorporate a higher number of minimally invasive techniques. There is a growing interest in robotic breast reconstruction that uses autologous tissue. Since a traditional latissimus dorsi (LD) flap leads to a long donor scar, which can be an unpleasant burden to patients, there have been many attempts to decrease the scar length using minimally invasive approaches. This study presents the case of a patient who underwent a robot-assisted nipple-sparing mastectomy followed by immediate breast reconstruction with an LD flap using a single-port robotic surgery system. With the assistance of a single-port robot, a simple docking process using a short and less visible incision is possible. Compared to multiport surgery systems, single-port robots can reduce the possibility of collision between robotic arms and provide a clear view of the medial border of the LD where the curvature of the back restricts the visual field. We recommend the use of single-port robots as a minimally invasive approach for harvesting LD flaps.