Authors' objectives: Background Approximately 8000 Swedish women are diagnosed with breast cancer annually. Most breast cancers are treated with surgery: breast conserving (60%) or mastectomy (40%). Mastectomy is performed when, e.g., the tumour is large, or staged as T4 (the tumour has grown into the chest wall, the skin or both or is an inflammatory cancer) after neoadjuvant (before surgery) chemotherapy. Postmastectomy radiotherapy (PMRT) is given for tumours >5 cm and/or if axillary lymph node metastases are diagnosed, factors which are often unknown before surgery. One-stage (primary implant) or two-stage (tissue expander first) breast reconstruction is increasingly often performed as an immediate (IBR) or delayed procedure (DBR) after mastectomy. Eighty to one hundred IBR are performed annually at Sahlgrenska University Hospital (SU). Pre- or postmastectomy radiotherapy is reported to be associated with a higher rate of breast-related complications after IBR. The current policy in VGR is to avoid implant-based reconstruction when PMRT is anticipated or radiotherapy has been given previously. Although the tumour stage is different in patients who subsequently will need PMRT compared with those who will not need RT, the mastectomy and the IBR are performed in a standardised manner, allowing comparison of breast-related outcomes in this HTA-report. Radiotherapy is not an optional treatment. It is decided pre-operatively based on clinical data or postoperatively based on histopathological examination. Knowledge of results of IBR in patients who either must undergo PMRT or have no radiotherapy after mastectomy is important information duringpre-operative counselling when discussing method of reconstruction. Question at issue Is there a difference in health-related quality of life (HRQoL), complication rates, re-operations or risk of developing capsular contraction or lymphedema when PMRT is given compared with not given (no RT) after implant/tissue expander based IBR in one or two stages? The concepts implant and tissue expander are sometimes used interchangeably in the text, as a tissue expander also is a form of implant. In addition, there are different types of tissue expanders: temporary tissue expanders that subsequently are changed to permanent implant in a second stage and permanent tissue expanders that can be used to operate a patient in one-stage.

Authors' results and conclusions: This systematic review including 29 cohort studies with some or serious study limitations and three case series shows that HRQoL (Breast-Q score) may slightly decrease for breast cancer patients undergoing immediate breast reconstruction receiving PMRT compared with no RT (GRADE ⊕⊕). The rate of implant/tissue expander loss (GRADE ⊕⊕⊕) as well as reoperation and capsular contracture rates (both outcomes GRADE ⊕⊕) were statistically and clinically significantly increased for PMRT compared with no RT patients. These findings are important when informing and advising mastectomy patients when discussing method of reconstruction, especially when it is already known that the patient will undergo PMRT. Furthermore, these results suggest that IBR has to be used with caution when PMRT is anticipated. There is still a lack of high quality studies that evaluate the impact of PMRT compared with no RT on breast-related outcome of immediate implant or tissue expander based breast reconstruction after mastectomy.

Project Status: Completed

Year Published: 2019

URL for published report: https://mellanarkiv-offentlig.vgregion.se/alfresco/s/archive/stream/public/v1/source/available/sofia/su4372-1728378332-344/native/2019_106%20HTA-rapport%20Br%c3%b6strekonstruktion%20vid%20mastektomi.pdf

English language abstract: An English language summary is available

Publication Type: Full HTA

Organisation Name: The Regional Health Technology Assessment Centre

Contact Address: The Regional Health Technology Assessment Centre, Region Vastra Gotaland, HTA-centrum, Roda Straket 8, Sahlgrenska Universitetssjukhuset, 413 45 GOTHENBORG, Sweden

Contact Name: hta-centrum@vgregion.se

Contact Email: hta-centrum@vgregion.se