Multidisciplinary assessment for immediate breast reconstruction: A new approach

Patients and clinical setting

SHSC and Women's College Hospital (WCH) are academic institutions affiliated with the University of Toronto. The IBRC at the Odette Cancer Centre, located within SHSC, was founded in February 2011. Patient referral to the clinic was from one of three surgical oncologists or two breast reconstructive surgeons, which staffed the clinic on a rotating schedule. Outside referrals were also accepted and triaged by the Odette Cancer Centre new patient booking office. Radiation oncologists were available to offer an opinion regarding the potential need for postmastectomy radiation therapy. In addition, dedicated nurses, specialized in breast surgery, were assigned to the clinic. Nurses optimized the flow of patients and physicians during this multidisciplinary clinic, and were available to answer specific questions that patients might have had regarding follow-up appointments and scheduling. There was also a subset of patients who were referred from high-risk screening clinics for consideration of prophylactic mastectomy. In each half-day biweekly clinic, approximately five patients were seen in joint consultation. Each clinic visit lasted approximately 1 h in addition to an educational teaching session by the plastic surgeon prior to consultation. This group visual educational session occurred in the morning before the consultation, and was conducted by one of our plastic surgeons or specialized educational nurses. It introduced women to their reconstructive options and provided them with baseline knowledge. This allowed for more focused and individual questions and concerns to be addressed in the afternoon at the IBRC.

Inclusion criteria for the study were women who had active invasive or in situ breast cancer unsuitable for breast conserving surgery, women in remission from a remote history of breast cancer contemplating completion mastectomies, and women contemplating prophylactic mastectomy. Exclusion criteria were men and patients with metastatic disease. Women with locally-advanced clinical stage 3 breast cancer with a high likelihood of requiring adjuvant radiation therapy were occasionally considered for assessment in the clinic if the woman wanted an opinion regarding immediate breast reconstruction (IBR). There were three possible outcomes for those patients seen at the IBRC: (i) the patient received IBR; (ii) the patient received only a mastectomy without reconstruction, but with the possibility for delayed reconstruction; and (iii) there was no surgery performed, and surgery was deferred, which was the case in patients considering prophylactic mastectomies. The reconstructive procedures performed at our institution, separated into autologous and alloplastic options, are illustrated in Table 1.

Impact of IBRC on IBR rates

Patients who were seen in consultation at the IBRC between 4 February 2011 and 4 February 2012 were identified through our institution's oncology patient information system that registers all SHSC patients with a cancer diagnosis. We identified all patients who attended the clinic and had an immediate reconstructive procedure by performing a retrospective chart review. Patients had to have had surgery prior to 4 February 2012 in order to be identified as a patient who had immediate reconstruction. This allowed us to determine the rate of reconstruction for clinic attendees during the study period (objective 1). To address our second objective, which was to compare the institutional immediate reconstruction rates prior to and after the clinic was created, we determined the rate of immediate reconstruction by performing two electronic searches of all operating room cases performed at the two institutions using the keyword ‘mast’ within the operating room procedure description to identify mastectomy cases. Those cases were then searched to see if a plastic surgeon was present at the operation. Finally, a retrospective chart review of all operative notes was performed. A historical control cohort was identified to determine the institutional immediate reconstruction rate for a 1-year period (1 January 2009 to 31 December 2009) at both SHSC and WCH, as the two hospitals at the time were affiliated, and reconstruction was performed at WCH. This rate was compared to the rate of immediate reconstruction between 4 February 2011 and 4 February 2012, after the introduction of the IBRC. The present rate was determined using only patients from SHSC, as an affiliation with WCH no longer exists, and all breast surgery, including reconstruction, is now done at SHSC. Not all patients who underwent immediate reconstruction within the study timeframe were seen at the IBRC, and instead were seen separately by a plastic surgeon and surgical oncologist.

Prospective QoL assessment

All women with breast cancer undergoing IBR were eligible to participate in the prospective component of the study that assessed QoL before and after breast reconstruction. Participants completed the BREAST-Q reconstruction module preoperatively and 3 months' postoperatively. The six domains of the BREAST-Q are as follows: (i) domain 1: satisfaction with breasts; (ii) domain 2: psychosocial wellbeing; (iii) domain 3: sexual wellbeing; (iv) domain 4: physical wellbeing with respect to chest; (v) domain 5: physical wellbeing with respect to abdomen donor site; and (vi) domain 6: satisfaction with information (excluded from study). Domains are scored from zero to 100, with higher scores indicating greater satisfaction or QoL.

An age- and procedure-matched (autologous or alloplastic) group of women undergoing delayed breast reconstruction was identified from a database of prospectively-collected BREAST-Q scores collected at the same time points. These women had similarly completed the BREAST-Q preoperatively and at 3 months' postoperative. Comparisons were made between BREAST-Q scores of the IBRC group and the matched control group at both time points. Mean differences between prereconstruction and postreconstruction values were also compared between groups.

Statistics

Descriptive statistics were calculated for all continuous variables. Parametric and non-parametric data underwent comparison using Student's t-test and Mann–Whitney U-tests, respectively. All tests were two tailed and had a level of statistical significance of P < 0.05. In addition, effect sizes of BREAST-Q score comparisons were measured using Cohen's d statistic. Effect sizes of less than 0.2 are considered insignificant, between 0.21–0.5 are small, 0.51–0.8 are moderate and greater than 0.8 are of large clinical significance. Analyses were performed using the SPSS statistical software package (version 17.0; SPSS, Chicago, IL, USA).

QoL assessment in immediate versus delayed reconstruction

Thirteen of the twenty-seven breast cancer patients (48 per cent) undergoing IBR completed the BREAST-Q preoperatively and postoperatively at 3 months. Delayed breast reconstruction controls completed the preoperative BREAST-Q an average of 14 months' postmastectomy. The average age of the immediate and delayed reconstruction groups were 49.4 and 52.2 years, respectively (P > 0.05). Women in the delayed reconstruction group had significantly lower preoperative BREAST-Q scores for ‘satisfaction with breasts’, ‘psychosocial wellbeing’ and ‘sexual wellbeing’ (P < 0.05) (Table 5), which corresponded to a large effect size (0.89, 0.94 and 1.4, respectively). Three months' postoperatively, there were no significant differences between any of the BREAST-Q domain scores for delayed versus immediate reconstruction groups (P > 0.05); however, in the immediate group, a response to undergoing the mastectomy and reconstruction was evidenced by the lower domain scores for ‘physical wellbeing, chest’, ‘physical wellbeing, abdomen’ and ‘satisfaction with breasts’ (P > 0.05), with moderate effect sizes (0.74, 0.54 and 0.7, respectively).

Comparisons were made between immediate and delayed groups for the mean difference in preoperative and postoperative BREAST-Q domain scores (Table 6). All but one of the domain scores improved for the delayed group following reconstruction, while only the ‘satisfaction with breasts’ and ‘psychosocial wellbeing’ domain scores improved for the immediate group. The mean difference between preoperative and postoperative scores was significantly greater for the domains ‘psychosocial wellbeing’ and ‘sexual wellbeing’, and demonstrated large effect sizes (1.39 and 1.08, respectively).

Study limitations

Our analysis was based on the data collected for the first year of operation of the IBRC. Because we were collecting data at two time points (preoperative and 3 months' postoperative), this led to a 9-month window during which we could enrol patients so that all participants had completed the 3-month follow-up BREAST-Q. In addition, a lack of completed data for age- and procedure-matched women undergoing delayed reconstruction by the SHSC plastic surgeons limited the numbers available for comparison of BREAST-Q data.

The percentage of patients that have undergone immediate reconstruction is underestimated, as additional patients have had reconstruction since the data-collection cut-off date of 4 February 2012. At the time of submission of this paper, 12 additional patients seen in the IBRC within the study period have undergone immediate reconstruction, increasing the rate from 31 per cent to 43 per cent. Despite a small sample size, we were able to identify statistically- and clinically-significant differences between those patients who have had IBR and those who have not. This finding corresponds with what other authors have reported.

Another shortcoming of this study is the lack of long-term (e.g. upon completion of the reconstruction) BREAST-Q scores, which might identify an improvement following completion of treatment with secondary procedures. Finally, it is difficult to separate the effects of the hiring of two plastic surgeons and having a dedicated IBRC on the IBR rate. In all likelihood, there was a cumulative effect.

This study presents a practical solution to a long-standing problem in Canada and throughout developed countries. A multidisciplinary approach to assessing women in need of a mastectomy is fundamental in increasing the rate of immediate reconstruction. High rates of immediate reconstruction can be achieved and have the potential to have a profound positive impact on women with breast cancer. We hope that our clinic concept acts as a template for the creation of similar clinics in developed countries.