Allograft vs Xenograft Bioprosthetic Mesh in Tissue Expander Breast Reconstruction: A Blinded Prospective Randomized Controlled Trial.

BACKGROUND: With the increased use of acellular dermal matrix (ADM) in breast reconstruction, the number of available materials has increased. There is a relative paucity of high-quality outcomes data for use of different ADMs. OBJECTIVES: The goal of this study was to compare the outcomes between a human (HADM) and a bovine ADM (BADM) in implant-based breast reconstruction. METHODS: A prospective, single-blinded, randomized controlled trial was conducted to evaluate differences in outcomes between HADM and BADM for patients undergoing immediate tissue expander breast reconstruction. Patients with prior radiation to the index breast were excluded. Patient and surgical characteristics were collected and analyzed. RESULTS: From April 2011 to June 2016, a total of 90 patients were randomized to a mesh group, with 68 patients (HADM, 36 patients/55 breasts; BADM, 32 patients/48 breasts) included in the final analysis. Baseline characteristics were similar between the 2 groups. No significant differences in overall complication rates were identified between HADM (n = 14, 25%) and BADM (n = 13, 27%) (P = 0.85). Similar trends were identified for major complications and complications requiring reoperation. Tissue expander loss was identified in 7% of HADM patients (n = 4) and 17% of BADM patients (n = 8) (P = 0.14). CONCLUSIONS: Similar complication and implant loss rates were found among patients undergoing immediate tissue expander breast reconstruction with HADM or BADM. Regardless of what material is used, careful patient selection and counseling, and cost consideration, help to improve outcomes and sustainability in immediate breast reconstruction.

Cancer Risk after Fat Transfer: A Multicenter Case-Cohort Study.

BACKGROUND: Fat transfer is an increasingly popular method for refining postmastectomy breast reconstructions. However, concern persists that fat transfer may promote disease recurrence. Adipocytes are derived from adipose-derived stem cells and express adipocytokines that can facilitate active breast cancer cells in laboratory models. The authors sought to evaluate the association between fat transfer to the reconstructed breast and cancer recurrence in patients diagnosed with local or regional invasive breast cancers. METHODS: A multicenter, case-cohort study was performed. Eligible patients from four centers (Memorial Sloan Kettering, M. D. Anderson Cancer Center, Alvin J. Siteman Cancer Center, and the University of Chicago) were identified by each site's institutional tumor registry or cancer data warehouse. Eligibility criteria were as follows: mastectomy with immediate breast reconstruction between 2006 and 2011, age older than 21 years, female sex, and incident diagnosis of invasive ductal carcinoma (stage I, II, or III). Cases consisted of all recurrences during the study period, and controls consisted of a 30 percent random sample of the study population. Cox proportional hazards regression was used to evaluate for association between fat transfer and time to recurrence in bivariate and multivariate models. RESULTS: The time to disease recurrence unadjusted hazard ratio for fat transfer was 0.99 (95 percent CI, 0.56 to 1.7). After adjustment for age, body mass index, stage, HER2/Neu receptor status, and estrogen receptor status, the hazard ratio was 0.97 (95 percent CI, 0.54 to 1.8). CONCLUSION: In this population of breast cancer patients who had mastectomy with immediate reconstruction, fat transfer was not associated with a higher risk of cancer recurrence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Improving Antimicrobial Regimens for the Treatment of Breast Tissue Expander-Related Infections.

BACKGROUND: Infectious complications in tissue expander (TE) breast reconstruction can be devastating and costly. Therefore, to optimize care, we examined patient's demographics, microbiology of TE infections, and the efficacy of empiric antimicrobial regimens and thereafter generated an algorithm for the treatment of these complex infections. METHODS: We retrospectively reviewed all patients who underwent TE breast reconstruction between 2003 and 2012 and analyzed those patients who developed a "definite" device-related infection leading to TE explantation and had a positive intraoperative culture. RESULTS: A total of 3,082 patients underwent immediate breast reconstruction with TE. Of these, 378 patients (12.3%) developed an infection, 189 (6.1%) eventually proceed with explantation, and 118 (3.8%) had a positive intraoperative culture. Gram-positive organisms caused 73% of infections, and Gram-negative organisms caused 27% of infections. Narrow-spectrum empiric antimicrobials with predominantly Gram-positive coverage were deemed appropriate in only 62% of cases, and those with Gram-negative coverage were appropriate in 46%. Broad-spectrum antimicrobials were used in 47% of cases, mainly recommended by infectious disease specialists, and were considered appropriate in >90% of the occasions. CONCLUSIONS: Current empiric antibiotic regimens do not cover the vast spectrum of organisms causing TE infections. To increase the salvage rate of an infected TE, at the first sign of infection, in addition to benefiting with an infectious diseases consultation, empiric coverage with broad-spectrum antibiotics active against biofilm-embedded organisms should be administered.

Outcomes of contralateral prophylactic mastectomy in relation to familial history: a decision analysis (BRCR-D-16-00033).

BACKGROUND: Family history of breast cancer is associated with an increased risk of contralateral breast cancer (CBC) even in the absence of mutations in the breast cancer susceptibility genes BRCA1/2. We compared quality-adjusted survival after contralateral prophylactic mastectomy (CPM) with surveillance only (no CPM) among women with breast cancer incorporating the degree of family history. METHODS: We created a microsimulation model for women with first-degree, second-degree, and no family history treated for a stage I, II, or III estrogen receptor (ER)-positive or ER-negative breast cancer at the ages of 40, 50, 60, and 70. The model incorporated a 10-year posttreatment period for risk of developing CBC and/or dying of the primary cancer or CBC. For each patient profile, we used 100,000 microsimulation trials to estimate quality-adjusted life expectancy for the clinical strategies CPM and no CPM. RESULTS: CPM showed minimal improvement on quality-adjusted life expectancy among women age 50-60 with no or a unilateral first-degree or second-degree family history (decreasing from 0.31 to -0.06 quality-adjusted life-years (QALYs)) and was unfavorable for most subgroups of women age 70 with stage III breast cancer regardless of degree of family history (range -0.08 to -0.02 QALYs). Sensitivity analysis showed that the highest predicted benefit of CPM assuming 95 % risk reduction in CBC was 0.57 QALYs for a 40-year-old woman with stage I breast cancer who had a first-degree relative with bilateral breast cancer. CONCLUSIONS: Women age 40 with stage I breast cancer and a first-degree relative with bilateral breast cancer have a QALY benefit from CPM similar to that reported for BRCA1/2 mutation carriers. For most subgroups of women, CPM has a minimal to no effect on quality-adjusted life expectancy, irrespective of family history of breast cancer.

Computation of breast ptosis from 3D surface scans of the female torso.

Stereophotography is now finding a niche in clinical breast surgery, and several methods for quantitatively measuring breast morphology from 3D surface images have been developed. Breast ptosis (sagging of the breast), which refers to the extent by which the nipple is lower than the inframammary fold (the contour along which the inferior part of the breast attaches to the chest wall), is an important morphological parameter that is frequently used for assessing the outcome of breast surgery. This study presents a novel algorithm that utilizes three-dimensional (3D) features such as surface curvature and orientation for the assessment of breast ptosis from 3D scans of the female torso. The performance of the computational approach proposed was compared against the consensus of manual ptosis ratings by nine plastic surgeons, and that of current 2D photogrammetric methods. Compared to the 2D methods, the average accuracy for 3D features was ~13% higher, with an increase in precision, recall, and F-score of 37%, 29%, and 33%, respectively. The computational approach proposed provides an improved and unbiased objective method for rating ptosis when compared to qualitative visualization by observers, and distance based 2D photogrammetry approaches.

Provider and Patient Gender Influence on Timing of Do-Not-Resuscitate Orders in Hospitalized Patients with Cancer.

BACKGROUND: End-of-life decisions and advance directives require timely physician-patient discussions but barriers exist to these discussions. OBJECTIVE: To evaluate the influence of physician and patient gender on the timing of inpatient do-not-resuscitate (DNR) orders. DESIGN: Retrospective cohort study. SETTING/SUBJECTS: All adult patients (≥18 years) with cancer who received inpatient DNR orders at The University of Texas MD Anderson Cancer Center between January 2011 and December 2013. MEASUREMENTS: Gender interaction between physicians and patients towards timing of the DNR order. RESULTS: We identified 4,157 unique patients with a cancer diagnosis. These patients were treated by 353 physicians, of whom 123 (34.8%) were females and 230 (65.2%) were males. Multivariate analysis showed female patients were 1.3 times more likely to have early DNR orders written during hospital admission than were male patients (odds ratio [OR] 1.27; 95% confidence interval [CI] 1.07-1.50). When comparing gender interaction between physicians and patients, our results showed that female physicians were 1.5 times more likely to write early DNR orders with their female patients than for their male patients (OR, 1.48; 95% CI, 1.13-1.94). Same gender physician-patient dyads were not found between male physician and their patients (OR, 1.09; 95% CI, 0.91-1.31). Higher age, more comorbid conditions, and progression of diseases were also associated with early DNR orders (all p < 0.01). CONCLUSION: Female patients are more likely to receive early DNR orders from their female physicians. Gender and gender interaction between physician and patients may potentially influence the timing of receiving DNR order.

A Prospective, Randomized, Controlled Trial of Paravertebral Block versus General Anesthesia Alone for Prosthetic Breast Reconstruction.

BACKGROUND: Paravertebral blocks have gained popularity because of ease of implementation and a shift toward ambulatory breast surgery procedures. Previous retrospective studies have reported potential benefits of paravertebral blocks, including decreased narcotic and antiemetic use. METHODS: The authors conducted a prospective controlled trial of patients undergoing breast reconstruction over a 3-year period. The patients were randomized to either a study group of paravertebral blocks with general anesthesia or a control group of general anesthesia alone. Demographic and procedural data, in addition to data regarding pain and nausea patient-reported numeric scores and consumption of opioid and antiemetic medications, were recorded. RESULTS: A total of 74 patients were enrolled to either the paravertebral block (n = 35) or the control group (n = 39). There were no significant differences in age, body mass index, procedure type, or cancer diagnosis between the two groups. Patients who received a paravertebral block required less opioid intraoperatively and postoperatively combined compared with patients who did not receive paravertebral blocks (109 versus 246 fentanyl equivalent units; p < 0.001), and reported significantly lower pain scores at 0 to 1 (3.0 versus 4.6; p = 0.02), 1 to 3 (2.0 versus 3.2; p = 0.01), and 3 to 6 (1.9 versus 2.7; p = 0.04) hours postoperatively. The study group also consumed less antiemetic medication (0.7 versus 2.1; p = 0.05). CONCLUSIONS: Incorporating paravertebral blocks carries considerable potential for improving pathways for breast cancer patients undergoing breast reconstruction--with minimal procedure-related morbidity. This is the first prospective study designed to assess paravertebral blocks in the setting of prosthetic breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Comprehensive Evaluation of Risk Factors and Management of Impending Flap Loss in 2138 Breast Free Flaps.

Loss of a breast free flap is a relatively rare but catastrophic occurrence. Our study aims to identify risk factors for flap loss and to assess whether different salvage techniques affect flap salvage. We performed a retrospective review of all breast free flaps performed at a single institution from 2000 to 2010. Overall, 2138 flaps were performed in 1608 patients (unilateral, 1120 and bilateral, 488) with 44 flap losses (2.1%). Age, body mass index, smoking, radiation, chemotherapy, and surgeon experience did not affect flap loss. Abdominal flaps based on a single perforator were at significantly higher risk for flap loss compared with flaps based on multiple perforators (P = 0.0007). Subgroup analysis of the subset of 166 compromised free flaps (flaps requiring a return to the operating room, an intraoperative anastomotic revision, or loss/partial loss of a free flap) demonstrated deep inferior epigastric perforator, and other flaps (superficial inferior epigastric artery and superior gluteal artery perforator) were significantly associated with flap loss [odds ratio (OR) 5.20; P = 0.03 and OR 6.91; P = 0.0004, respectively] compared with transverse rectus abdominis myocutaneous and muscle-sparing transverse rectus abdominis myocutaneous flaps. Although an intraoperative complication was not associated with a flap loss, the need for a reoperation was strongly predictive (P < 0.0001). Flap salvage was the highest within the first 24 hours (83.7%) and significantly less between days 1 and 3 (38.6%; P < 0.0001) and beyond 4 days (29.4%; P < 0.0001). Longer ischemia time was significantly associated with flap loss (P = 0.04). Salvage techniques (aspirin, heparinzation, thrombectomy, and thrombolytic) had no impact on flap salvage rates. Heparinization and thrombolytics were associated with higher loss rates (OR 3.40; P = 0.003 and OR 10.36; P < 0.0001, respectively). Free flap loss following breast reconstruction is multifactorial with higher losses in superficial inferior epigastric artery and gluteal flaps, single-perforator abdominal flaps, and longer ischemia times. Salvage rates are most successful within the first 24 hours, and the use of heparinization, aspirin, and thrombolytics does not improve salvage rates.

Novel in situ liquefying antimicrobial wrap for preventing tissue expander infections following breast reconstructive surgeries.

Breast reconstruction surgeries using tissue expanders (TEs) have highly reported infection rates. To decrease this, we developed a method for disinfecting TEs and surgical pockets, where an antimicrobial solution was applied as a solid film at implantation that subsequently liquefied in situ to provide extended prophylaxis. Silicone discs cut from TEs were covered with gelatin-based films containing minocycline (M) and rifampin (R). Discs and films soaked in saline were subsequently challenged with pathogen at days 1, 3, 7, and 10 and quantified for potential biofilm formation. Discs that were not harvested at each specific time points were refreshed with sterile saline. The discs were challenged with clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE), and multidrug-resistant Pseudomonas aeruginosa (MDR-PA). Recoveries of adherent organisms from uncovered silicone discs and gelatin-wrapped discs without added antimicrobial agents were >5 × 10(4) CFU/disc for each organism at each time point. Experimental 0.1%M/0.05%R gelatin films completely inhibited all challenge organisms from attaching to the silicone (p < 0.05) at each time point through day 10. Cytotoxicity was assessed by incubating films with HEK-293T human fibroblasts. There were no significant differences in HEK-293T cell survival between controls and any of the antimicrobial films. The in situ liquefying, bioabsorable, antimicrobial wrap prevented biofilm formation by microorganisms on silicone surfaces in vitro with minimal cytotoxicity.

Prospective Study of Surgical Decision-making Processes for Contralateral Prophylactic Mastectomy in Women With Breast Cancer.

OBJECTIVE: We prospectively examined the psychosocial predictors and the decision-making process regarding contralateral prophylactic mastectomy (CPM) among women with sporadic breast cancer. BACKGROUND: Increasing numbers of women with breast cancer are seeking CPM. Data are limited about the surgical decision-making process and the psychosocial factors that influence interest in CPM. METHODS: Women with early-stage unilateral breast cancer (n = 117) were recruited before their first surgical visit at MD Anderson and completed questionnaires assessing knowledge of and interest in CPM and associated psychosocial factors. After the appointment, women and their surgeons completed questions about the extent that various surgical options (including CPM) were discussed; also, the women rated their perceived likelihood of having CPM and the surgeons rated the appropriateness of CPM. RESULTS: Before their first visit, 50% of women were moderately to extremely interested in CPM and 12 (10%) of women had CPM at the time of their primary breast cancer surgery. Less knowledge about breast cancer (P = 0.02) and greater cancer worry (P = 0.03) predicted interest in CPM. Greater cancer worry predicted who had CPM (P = 0.02). Interest in CPM before surgical visit and the likelihood of having CPM after the visit differed (P ≤ 0.001). Surgeons' rating of the appropriateness of CPM and the patient's reported likelihood of having CPM were not significantly different (P = 0.49). CONCLUSIONS: Interest in CPM is common among women with sporadic breast cancer. The informational and emotional aspects of CPM may affect the decision to have CPM and should be addressed when discussing surgical options.

Body image and quality of life of breast cancer patients: influence of timing and stage of breast reconstruction.

OBJECTIVE: The process of cancer-related breast reconstruction is typically multi-staged and can take months to years to complete, yet few studies have examined patient psychosocial well-being during the reconstruction process. We investigated the effects of reconstruction timing and reconstruction stage on body image and quality of life at specific time points during the breast reconstruction process. METHODS: In this cross-sectional study, 216 patients were grouped into four reconstructive stages: pre-reconstruction, completed stage 1, completed stage 2, and final stages. Multiple regression analyses examined the roles of reconstruction timing (immediate vs delayed reconstruction) and reconstruction stage as well as their interaction in predicting body image and quality of life, controlling for patient age, BMI, type of reconstruction, chemotherapy, radiation therapy, and major complication(s). RESULTS: A difference in pattern of body image was observed across the reconstructive stages, with those receiving delayed reconstruction showing significant decrease in body image dissatisfaction compared with those with immediate reconstruction. At pre-reconstruction, patients awaiting delayed reconstruction reported significantly lower social well-being compared with those awaiting immediate reconstruction. Reconstruction stage predicted emotional well-being, with higher emotional well-being observed in those who had commenced reconstruction. CONCLUSIONS: Timing and stage of reconstruction are important to consider when examining psychosocial outcomes of breast cancer patients undergoing reconstruction. Those waiting to initiate delayed reconstruction appear at particular risk for body image, emotional, and social distress. Our findings have implications for delivery of psychosocial treatment to maximize body image and quality of life of patients undergoing cancer-related breast reconstruction.Copyright © 2015 John Wiley & Sons, Ltd.

Optimization of Free-Flap Limb Salvage and Maximizing Function and Quality of Life Following Oncologic Resection: 12-Year Experience.

INTRODUCTION: A knowledge gap exists regarding factors to optimize limb salvage and function following oncologic resection. METHODS: We conducted a retrospective review of all free flaps performed for upper extremity (UE) and lower extremity (LE) salvage from 2000 to 2012. RESULTS: Overall, 220 patients underwent free-flap reconstruction for limb salvage (UE: 64, and LE: 156). Flaps were classified as muscle-only (n = 77), myocutaneous (MC; n = 67), or fasciocutaneous (FC; n = 76). Smoking, diabetes, peripheral vascular disease, and prior chemotherapy or radiation had no impact on complications, while osteomyelitis significantly increased the risk of infection (odds ratio [OR] 19.5, confidence interval [95% CI] 3.77-100.64; p = 0.0004), wound healing complications (OR 7.51, 95% CI 2.21-25.49; p = 0.001), and amputation (OR 4.63, 95% CI 1.41-15.19; p = 0.01). Hardware increased the risk for flap loss (OR 4.92, 95% CI 1.33-18.23; p = 0.017). MC and FC flaps had increased risks for hematoma (p = 0.02) and reoperation for microvascular complications (p = 0.005) but were at lower risk for infection (OR 0.14, 95% CI 0.02-0.87; p = 0.03) compared with muscle-only flaps. There were a total of seven total flap losses (3.2%), with significantly increased risks for MC/FC flaps (OR 2.58, 95% CI 1.06-6.26; p = 0.03). For LE, 103 patients (66.3%) were fully ambulatory, while 23 (14.7%) were ambulatory with assistance (mean Musculoskeletal Tumor Society score (MSTS) 80.2, and Karnofsky score 84.0). For UE, 49 patients (76.6%) were able to perform their activities of daily living independently (mean MSTS 80.2, and Karnofsky score 86.0). Overall, 190 patients (86.4%) were successfully salvaged. CONCLUSIONS: Free flaps can be performed reliably for limb salvage following tumor extirpation. While MC/FC flaps demonstrated improved postoperative function, they were at significantly higher risk for take-backs and total flap loss.

Multimodality Imaging of the Reconstructed Breast.

The purpose of this article is to illustrate the imaging characteristics and pathologic findings associated with various types of breast reconstruction in women who have undergone mastectomy to treat breast cancer. As the use of breast reconstruction becomes more prevalent, it is imperative that radiologists interpreting imaging studies identify normal and abnormal imaging findings associated with differing breast reconstruction techniques, recognize imaging manifestation of expected complications, and reliably distinguish these from malignancy.

Automated calculation of ptosis on lateral clinical photographs.

RATIONALE, AIMS AND OBJECTIVES: The goal is to fully automate the calculation of a breast ptosis measure from clinical photographs through automatic localization of fiducial points relevant to the measure. METHODS: Sixty-eight women (97 clinical photographs) who underwent or were scheduled for breast reconstruction were included. The photographs were divided into a development set (N = 49) and an evaluation set (N = 48). The breast ptosis measure is obtained automatically from distances between three fiducial points: the nipple, the lowest visible point of breast (LVP), and the lateral terminus of the inframammary fold (LT). The nipple is localized using the YIQ colour space to highlight the contrast between the areola and the surrounding breast skin. The areola is localized using its shape, location and high Q component intensity. The breast contour is estimated using Dijkstra's shortest path algorithm on the gradient of the photograph in greyscale. The lowest point of the estimated contour is set as the LVP. To locate the anatomically subtle LT, the location of patient's axilla is used as a reference. RESULTS: The algorithm's efficacy was evaluated by comparing manual and automated localizations of the fiducial points. The average nipple diameter was used as a cut-off to define success. The algorithm showed 90, 91 and 83% accuracy for locating the nipple, LVP and LT in the evaluation set, respectively. CONCLUSION: This study presents a new automated algorithm that may facilitate the quantification of breast ptosis from lateral views of patients' photographs.

Challenging a traditional paradigm: 12-year experience with autologous free flap breast reconstruction for inflammatory breast cancer.

BACKGROUND: Inflammatory breast cancer is a rare but aggressive breast cancer with an overall poor prognosis. Traditionally, reconstruction has not been offered, because of poor long-term survival, the need for multimodality treatment, and complex treatment sequencing. The authors examined the safety and feasibility of free flap breast reconstruction for inflammatory breast cancer. METHODS: A retrospective analysis of all patients who underwent reconstruction for inflammatory breast cancer from January of 2000 to December of 2012 was conducted. RESULTS: Of 830 inflammatory breast cancer patients, 59 (7.1 percent; median age, 48 years; range, 27 to 65 years) underwent free flap reconstruction. All patients received chemotherapy and radiation therapy. Most patients (n = 52) underwent delayed reconstruction. Five patients with a history of prior partial mastectomy and irradiation developed inflammatory breast cancer and underwent immediate reconstruction following completion mastectomy. Two others underwent immediate chest wall and breast reconstruction following resection. Thirteen patients underwent bilateral reconstruction, and seven required a bipedicled abdominal flap for the unilateral mastectomy defect. Thirty-seven patients (62.7 percent) required revision of the reconstructed breast, and 29 (49.2 percent) had a contralateral balancing procedure to optimize symmetry. Complications occurred in 21 patients (35.6 percent), with one total flap loss (1.7 percent). The median length of follow-up was 43.9 months; 49 patients (83.1 percent) were alive without evidence of recurrent disease. CONCLUSIONS: Autologous free flap breast reconstruction can be performed safely in inflammatory breast cancer patients, with acceptable complication rates and without an increased risk for flap loss. Inflammatory breast cancer should not preclude free flap breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Helping patients make choices about breast reconstruction: a decision analysis approach.

Decision analysis can help breast reconstruction patients and their surgeons to methodically evaluate clinical alternatives and make hard decisions. The purpose of this article is to help plastic surgeons guide patients in making decisions though a case study in breast reconstruction. By making good decisions, patient outcomes may be improved. This article aims to illustrate decision analysis techniques from the patient perspective, with an emphasis on her values and preferences. The authors introduce normative decision-making through a fictional breast reconstruction patient and systematically build the decision basis to help her make a good decision. The authors broadly identify alternatives of breast reconstruction, propose types of outcomes that the patient should consider, discuss sources of probabilistic information and outcome values, and demonstrate how to make a good decision. The concepts presented here may be extended to other shared decision-making problems in plastic and reconstructive surgery. In addition, the authors discuss how sensitivity analysis may test the robustness of the decision and how to evaluate the quality of decisions. The authors also present tools to help implement these concepts in practice. Finally, the authors examine limitations that hamper adoption of patient decision analysis in reconstructive surgery and health care in general. In particular, the authors emphasize the need for routine collection of quality-of-life information, out-of-pocket expense, and recovery time.

Assessing Women's Preferences and Preference Modeling for Breast Reconstruction Decision-Making.

BACKGROUND: Women considering breast reconstruction must make challenging trade-offs amongst issues that often conflict. It may be useful to quantify possible outcomes using a single summary measure to aid a breast cancer patient in choosing a form of breast reconstruction. METHODS: In this study, we used multiattribute utility theory to combine multiple objectives to yield a summary value using nine different preference models. We elicited the preferences of 36 women, aged 32 or older with no history of breast cancer, for the patient-reported outcome measures of breast satisfaction, psychosocial well-being, chest well-being, abdominal well-being, and sexual wellbeing as measured by the BREAST-Q in addition to time lost to reconstruction and out-of-pocket cost. Participants ranked hypothetical breast reconstruction outcomes. We examined each multiattribute utility preference model and assessed how often each model agreed with participants' rankings. RESULTS: The median amount of time required to assess preferences was 34 minutes. Agreement among the nine preference models with the participants ranged from 75.9% to 78.9%. None of the preference models performed significantly worse than the best performing risk averse multiplicative model. We hypothesize an average theoretical agreement of 94.6% for this model if participant error is included. There was a statistically significant positive correlation with more unequal distribution of weight given to the seven attributes. CONCLUSIONS: We recommend the risk averse multiplicative model for modeling the preferences of patients considering different forms of breast reconstruction because it agreed most often with the participants in this study.

Cost of contralateral prophylactic mastectomy.

PURPOSE: To compare the healthcare costs of women with unilateral breast cancer who underwent contralateral prophylactic mastectomy (CPM) with those of women who did not. METHODS: We conducted a retrospective study of 904 women treated for stage I-III breast cancer with or without CPM. Women were matched according to age, year at diagnosis, stage, and receipt of chemotherapy. We included healthcare costs starting from the date of surgery to 24 months. We identified whether care was immediate or delayed (CPM within 6 months or 6-24 months after initial surgery, respectively). Costs were converted to approximate Medicare reimbursement values and adjusted for inflation. Multivariable regression analysis was performed to evaluate the effect of CPM on total breast cancer care costs adjusting for patient characteristics and accounting for matched pairs. RESULTS: The mean difference between the CPM and no-CPM matched groups was $3,573 (standard error [SE] $455) for professional costs, $4,176 (SE $1,724) for technical costs, and $7,749 (SE $2,069) for total costs. For immediate and delayed CPM, the mean difference for total costs was $6,528 (SE $2,243) and $16,744 (SE $5,017), respectively. In multivariable analysis, the CPM group had a statistically significant increase of 16.9 % in mean total costs compared with the no-CPM group (p < 0.0001). Human epidermal growth factor receptor 2/neu-positive status, receipt of radiation, and reconstruction were associated with increases in total costs. CONCLUSIONS: CPM significantly increases short-term healthcare costs for women with unilateral breast cancer. These patient-level cost results can be used for future studies that evaluate the influence of costs of CPM on decision making.

Impact of surgical techniques, biomaterials, and patient variables on rate of nipple necrosis after nipple-sparing mastectomy.

BACKGROUND: Nipple-sparing mastectomy is appropriate for selected patients with early-stage breast cancer or high breast cancer risk. However, the postoperative rate of nipple necrosis is relatively high (10 to 30 percent). This study analyzed the impact of clinicopathologic and surgical variables on partial and total nipple necrosis rates after nipple-sparing mastectomy and compared overall complication rates between nipple-sparing and skin-sparing mastectomy. METHODS: The study included 233 cases; 113 had nipple-sparing mastectomy and immediate breast reconstruction and 120 were matched cases of skin-sparing mastectomy and immediate reconstruction performed at the authors' institution from September of 2003 through May of 2011. RESULTS: The overall complication rate was 28 percent for nipple-sparing mastectomy and 27 percent for skin-sparing mastectomy (p > 0.99). In patients who did not have axillary surgery (those undergoing risk-reducing mastectomy), the overall rate was significantly higher in the nipple-sparing group (26 percent versus 9 percent; p = 0.06). However, in patients who had axillary surgery (either sentinel lymph node biopsy or axillary lymphadenectomy), the rate did not differ between the two groups. For nipple-sparing mastectomy, the overall incidence of any (partial or total) nipple necrosis was 20 percent. Only two cases (2 percent) had total necrosis. Larger breasts (C cup or larger) were associated with a higher rate of nipple necrosis (p = 0.003). CONCLUSIONS: The authors found no significant difference in the overall incidence of complications in patients who had nipple-sparing mastectomy or skin-sparing mastectomy. Exclusion of axillary lymphatic surgery in nipple-sparing mastectomy patients did not decrease the incidence of complications.