Although many studies have concluded that breast ...



Benefits of Breast Reconstruction: A Systematic Review

Introduction

Mastectomy is the most common surgical treatment for breast cancer in the United States. It has been associated with several negative outcomes, including impaired body image and diminished quality of life.1 2 Breast reconstruction after mastectomy has the theoretical potential to reverse some of the negative effects of mastectomy.

As breast cancer survival has improved, interest in the quality of survivorship after breast cancer has grown. Demand for the availability of breast reconstruction culminated in the Women’s Health Act of 1998, a federal law that requires insurers who cover mastectomy to cover breast reconstruction as well. Several recent studies examining rates of breast reconstruction after mastectomy have found that the majority of women undergoing mastectomy do not undergo reconstruction, and that significant disparities exist by race, age, income level, and geographic location.3, 4 Researchers have sought to explain these disparities.

In order to understand the significance of disparities in breast reconstruction rates and to develop coherent recommendations, the benefits to patients of breast reconstruction after mastectomy, compared to mastectomy alone, must be known. Although many studies have concluded that breast reconstruction is beneficial to women undergoing mastectomy, they often measure outcomes that are of interest to surgeons rather than patients or do not compare reconstruction to no reconstruction. A systematic review of the literature was conducted on the question: Does breast reconstruction after mastectomy result in better outcomes than mastectomy alone?

Methods

Studies were identified through a search strategy consisting of database queries (Pubmed, Cochrane), hand searching of journals, and searching of references. Inclusion criteria were as follows: The population must consist of women undergoing mastectomy for breast cancer. The interventions evaluated could be any type of breast reconstruction after mastectomy. Outcomes measured must be patient-centered, clinical and psychosocial outcomes, such as quality of life, or patient satisfaction. The study design must compare outcomes of reconstruction to outcomes of no reconstruction. Studies published after 1980 in English were included. Quality assessment criteria were based on the representativeness of the sample, representativeness of interventions, use of validated outcome measures, length of follow-up, study design, and method of analysis.

Results

870 studies were identified by the search strategy, and 9 studies fit the inclusion criteria. The most common reason for exclusion was failure to measure a patient-oriented outcome, such as quality of life, satisfaction, or patient assessment of appearance. Most studies measured outcomes of primary interest to the surgeon, such as surgeon assessment of appearance and complication rate.

The next most common reason for exclusion was failure to compare outcomes of reconstruction to outcomes without reconstruction. Most studies only examined outcomes in patients who had chosen reconstruction. Only one study controlled for baseline psychosocial differences.1 Of the included studies, the most common outcome measured was health-related quality of life. Most studies used validated instruments.

Three studies found that outcomes after reconstruction were better than outcomes of mastectomy without reconstruction.5-7 Two studies found poorer outcomes with reconstruction compared to mastectomy alone.1, 8 Three studies found equivalent outcomes.2, 9, 10 One study was inconclusive.11 Earlier studies and studies with longer follow-up were more likely to find better outcomes with reconstruction. Excluded studies were more likely than included studies to conclude that breast reconstruction was beneficial. No significant relationship between study quality and findings about benefits was found.

Conclusions

The benefits of breast reconstruction have not been convincingly demonstrated. Quality of life outcomes after reconstruction may be equivalent to or worse than no reconstruction for some women. Few studies utilize patient-oriented outcomes and compare reconstruction to no reconstruction. Future studies should identify which women are most likely to benefit from reconstruction.

References

1. Nissen MJ, Swenson KK, Ritz LJ, Farrell JB, Sladek ML, Lally RM. Quality of life after breast carcinoma surgery: a comparison of three surgical procedures. Cancer. Apr 1 2001;91(7):1238-1246.

2. Ganz PA, Desmond KA, Leedham B, Rowland JH, Meyerowitz BE, Belin TR. Quality of life in long-term, disease-free survivors of breast cancer: a follow-up study. J Natl Cancer Inst. Jan 2 2002;94(1):39-49.

3. Alderman AK, McMahon L, Jr., Wilkins EG. The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors. Plast Reconstr Surg. Feb 2003;111(2):695-703; discussion 704-695.

4. Morrow M, Mujahid M, Lantz PM, et al. Correlates of breast reconstruction: results from a population-based study. Cancer. Dec 1 2005;104(11):2340-2346.

5. Dean C, Chetty U, Forrest AP. Effects of immediate breast reconstruction on psychosocial morbidity after mastectomy. Lancet. Feb 26 1983;1(8322):459-462.

6. Goldberg P, Stolzman M, Goldberg HM. Psychological considerations in breast reconstruction. Ann Plast Surg. Jul 1984;13(1):38-43.

7. Lantz PM, Janz NK, Fagerlin A, et al. Satisfaction with surgery outcomes and the decision process in a population-based sample of women with breast cancer. Health Serv Res. Jun 2005;40(3):745-767.

8. Rowland JH, Desmond KA, Meyerowitz BE, Belin TR, Wyatt GE, Ganz PA. Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst. Sep 6 2000;92(17):1422-1429.

9. Avis NE, Crawford S, Manuel J. Psychosocial problems among younger women with breast cancer. Psychooncology. May 2004;13(5):295-308.

10. Anderson SG, Rodin J, Ariyan S. Treatment considerations in postmastectomy reconstruction: their relative importance and relationship to patient satisfaction. Ann Plast Surg. Sep 1994;33(3):263-270; discussion 270-261.

11. Mock V. Body image in women treated for breast cancer. Nurs Res. May-Jun 1993;42(3):153-157.

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