Women with breast cancer who have a mastectomy often wish to proceed with reconstruction at the time of the mastectomy because of psychological, cosmetic and practical reasons. However, oncologists debate whether the reconstruction should be done before or after the radiation therapy.
In a single-institution study conducted at Fox Chase Cancer Center, researchers have found low complication rates when breast cancer patients receive radiation therapy after reconstruction. Penny R. Anderson, M.D., a radiation oncologist at Fox Chase, presented the study results at the 45th annual meeting of the American Society for Therapeutic Radiology and Oncology (ASTRO) in Salt Lake City, Utah.
"Prior studies have shown a high rate of complications among breast cancer patients who undergo reconstruction and then post-mastectomy radiation therapy," said Anderson. "Anecdotally speaking, we weren't seeing major complications regularly at Fox Chase, and that observation became the impetus for this study."
The study involves 85 breast cancer patients who underwent a modified radical mastectomy, breast reconstruction and post-operative radiation therapy between 1987 and 2002. Reconstruction consisted of tissue expander placement with or without a subsequent permanent implant in 50 patients, and an autologous transverse rectus abdominis myocutaneous (TRAM) flap in 35 patients.
The median age of the women was 45 years. Seventy patients received radiation therapy after their mastectomy and reconstruction. The median time from reconstruction to radiation therapy was seven months. Fifteen patients received radiation therapy before their reconstruction.
The study defined major complications as those requiring corrective surgery or loss of reconstruction. Minor complications included infection, chest wall fibrosis, fat necrosis or contracture. Some of the clinical and treatment-related factors analyzed for a significant impact on complication rate include age, smoking history, type of reconstruction, timing of reconstruction/radiation therapy, chemotherapy and tamoxifen.
After five years of follow-up, none of the patients who received a TRAM flap had major complications or required any corrective surgery. Only 5 percent of the implant patients had a major complication; two of these patients required implant removal. After five years, 39 percent of the TRAM group had minor complications and 14 percent of the women with implants had minor complications.
"What's interesting about this reported complication rate for breast implants is that not only is it low compared to other studies involving radiation after reconstruction, it is also low when considering the rate of major complications following reconstruction when radiation is not a factor," Anderson said.
100% of the TRAM patients with complications had statistically significant superior cosmetic scores of excellent/good compared to only 17% of the implant patients.
"While these Fox Chase results are excellent, there's no clear reason why," said Anderson. "There could be several factors attributing to these results, including surgical techniques and the type of preparation and planning used before radiation therapy. This study was not designed to determine those reasons."
SOURCES:
Annual Meeting of the American Society for Therapeutic Radiology and Oncology, October 22, 2003, Salt Lake City, Utah
Fox Chase Cancer Center (http://www.fccc.edu)
