National trends and regional variation in immediate breast reconstruction rates.

BACKGROUND: Previous studies have identified variation in immediate reconstruction (IR) rates following mastectomy for breast cancer across English regions during a period of service reorganization, a national audit and changing guidelines. This study analysed current variations in regional rates of IR in England. METHODS: Patient-level data from Hospital Episode Statistics were used to define a cohort of women who underwent primary mastectomy for invasive or in situ breast carcinoma in English National Health Service (NHS) hospitals between April 2000 and March 2014. A time series of IR rates was calculated nationally and within regions in 28 cancer networks. Regional IR rates before and after the national audit were compared, using logistic regression to adjust for patient demographics, tumour type, co-morbidity and year of mastectomy. RESULTS: Between 2000 and 2014, a total of 167 343 women had a mastectomy. The national IR rate was stable at around 10 per cent until 2005; it then increased to 23·3 per cent by 2013-2014. Preaudit (before January 2008), adjusted cancer network-level IR rates ranged from 4·3 to 22·6 per cent. Postaudit (after April 2009) adjusted IR rates ranged from 13·1 to 36·7 per cent, with 20 networks having IR rates between 15 and 24 per cent. The degree of change was not greatest amongst those that started with the lowest IR rates, with four networks with the largest absolute increase also starting with relatively high IR rates. CONCLUSION: The national IR rate increased throughout the study period. Substantial regional variation remains, although considerable time has elapsed since a period of service reorganization, guideline revision and a national audit.

Resource implications of risk-reducing mastectomy and reconstruction.

AIM: Risk-reducing mastectomy (RRM) is on the increase, now frequently combined with breast reconstruction (BR). However, the resource implications associated with bilateral mastectomy and reconstruction are unknown. This study assessed the overall cost of performing risk-reducing surgery. METHODS: All cases of RRM and BR performed between 1991 and 2011 at this hospital were identified from a prospectively collected database. All patients undergoing bilateral mastectomy were included, when at least one mastectomy was risk-reducing. Overall treatment costs for all surgical procedures, complications, revisional procedures and outpatient attendances were calculated and compared to the National Tariff allowed. Mann-Whitney U and Fischer's exact tests were used to calculate levels of significance. RESULTS: Fifty patients underwent bilateral mastectomy and BR (median follow up 20 [range 1-106] months), 72 were Latissimus Dorsi reconstructions (LDR) and 28 were Subpectoral reconstructions (SPR). LDR took longer than SPR (p = 0.001), with a greater length of stay (p = 0.024). Nine percent of patients returned to theatre for early complications, but the type of BR did not influence the early complication rate (LDR versus SPR, p = 0.345) or the need for additional unplanned procedures (LDR versus SPR, p = 0.671). The overall mean cost for bilateral RRM and BR was £14,797 per patient. The inpatient cost for bilateral RRM and LDR was £10,082 compared with £5,905 SPR. Both procedures exceeded the £5,697 tariff allowed in the UK. CONCLUSION: Bilateral RRM and BR is a safe procedure, but the resource implications are considerable and exceed the tariff allowed, particularly when performing more complex techniques.

Breast reconstruction using permanent Becker expander implants: an 18 year experience.

BACKGROUND: Single-stage reconstruction using permanent expander implants is an established technique following mastectomy. Short and long-term outcome data following breast reconstruction using Becker tissue expanders is limited. METHOD: A retrospective case note review of patients undergoing expander-based procedures between 1989 and 2007 was undertaken. Data recorded included postoperative symptoms and complications, the use of radiotherapy, revisional surgery, and device failure. RESULTS: Three hundred and thirteen expanders were used in 276 patients with a mean age of 48.3 (17-78) years, over the 18 year study period. The mean follow up period was 64.6 (1-199) months. 256 Becker expanders were used during 175 latissimus dorsi (LD) and 52 subpectoral (SP) reconstructions, 13 contralateral augmentations and 16 implant replacements. The postoperative infection rate was 5.8%, leading to an expander loss rate of 3.8%. The use of prophylactic antibiotics was associated with an increased postoperative infection rate (p = 0.046). Six haematomas (2.5%) and 12 cases of skin envelope necrosis (5.0%) required unscheduled intervention. Symptoms of pain, distortion and hardness were experienced by 21.3% of patients, and radiotherapy was associated with a significantly higher risk of adverse symptoms (p < 0.0001). No patient developed symptomatic implant rupture or silicone granuloma but 17.9% of reconstructions underwent revisional surgery, the rate being highest following SP reconstruction (p = 0.029). Nine patients developed injection port complications (3.8%), and the overall device failure rate was 1.3%. The original expander has been retained by 74.2% of women. CONCLUSION: The Becker permanent expander is a reliable implant associated with a low complication rate and a high retention rate when used during breast reconstruction.

Dramatic dietary fat reduction is feasible for breast cancer patients: Results of the randomised study, WINS (UK) - stage 1.

INTRODUCTION: The influence of dietary fat on breast tumour growth(1) and, more recently, on treatment outcomes,(2,3) suggests an important role for dietary advice in the future health of breast cancer patients. The Women's Intervention Nutrition Study (UK) - Stage 1 assessed the feasibility of achieving and maintaining a ≥ 50% reduction in reported fat intake in postmenopausal, early stage breast cancer patients in the UK. METHOD: This study recruited patients in South-east England between 2000 and 2005. They were randomly allocated into two groups. Group 1 (n = 54), received specific dietary counselling to halve their reported fat intake and maintain this low fat intake. Group 2 (n = 53) received healthy eating advice only. Dietitian-led group sessions provided support for women in both groups over 2 years.(4) Validated four-day diaries were used to measure intake. Data analysis used Generalised Linear Model (GLM) for repeated measures and logistic regression. RESULTS: A significantly greater proportion of women in Group 1 reported a fat intake reduction of ≥ 50% at 3 months (p < .001) and 24 months (p < .001) than in Group 2. The size of the effect of active dietary counselling was 37% at 3 months (95%CI: 21-54%) and 35% at 24 months (95%CI: 17-53%). Mean fat intake was halved at 3 months and 24 months in Group 1 only. CONCLUSION: Demonstrating such feasibility is a key step towards defining diet's role in the secondary prevention of breast cancer.

UK survey of partial mastectomy and reconstruction.

BACKGROUND: Partial mastectomy and reconstruction can extend the role of breast-conserving surgery, but the frequency of this type of surgery is unknown. MATERIALS AND METHODS: A UK survey was performed to determine the frequency, indications, techniques and outcomes of partial mastectomy and reconstruction. RESULTS: Seventy-one of 180 (39%) respondents offered partial mastectomy and reconstruction. Reasons for not offering partial mastectomy and reconstruction included lack of experience (61%), uncertain indications (33%), uncertain benefits (45%) and concerns about oncological safety (22%). Immediate reconstruction was performed by 50% of respondents and perioperative margin analysis was uncommon. Respondents performed volume displacement or volume replacement or both approaches (23%, 18% and 59%). Complications included fat necrosis (68%), haematoma formation (55%), positive margins (46%), infection (41%) and flap loss or poor cosmetic outcome (10%). CONCLUSIONS: Partial mastectomy and reconstruction is becoming popular in the UK as an alternative to full mastectomy. Safe introduction of this approach in clinical practice will require a clearer understanding of technique selection, safety and clinical outcomes.

Skin-sparing mastectomy.

BACKGROUND: Skin-sparing mastectomy (SSM) is a new technique being used in a variety of clinical settings. This article reviews the published data on SSM to establish its current role in clinical practice. METHODS: A Medline search was carried out using the key words 'skin-sparing mastectomy' to identify English-language articles published between 1990 and 2004 and further material referenced in these publications. RESULTS: SSM is most commonly used for surgical prophylaxis and to treat in situ and early invasive disease in patients who request immediate breast reconstruction. SSM and non-SSM result in similar surgical and oncological outcomes, but skin flap ischaemia is more common after SSM and is associated with a range of risk factors, including smoking. CONCLUSION: SSM has become an established procedure in breast surgery, but there is a lack of prospective data on which to make evidence-based decisions about its use in individual patients.

Skin-sparing mastectomy in the UK--a review of current practice.

BACKGROUND: Skin-sparing mastectomy (was first described in 1991 and has achieved popularity because it facilitates immediate breast reconstruction, preserving the infra-mammary fold and breast envelope. Little is known about the use of skin-sparing mastectomy in the UK. METHODS: All members of the BASO Breast Specialty Group were contacted in June 2001 with a questionnaire to determine the popularity of skin-sparing mastectomy, techniques used, indications, contra-indications and outcomes. RESULTS: Of 300 questionnaires sent, 130 were returned by September 2001. The number of respondents using skin-sparing mastectomy increased from 27 (21%) in 1997 to 95 (73%) in 2001. Of respondents, 35 (23%) avoided skin-sparing mastectomy because of their uncertainty about the benefits (22/35), indications (16/35) or oncological safety (13/35). Where skin-sparing mastectomy was performed, it was combined with immediate breast reconstruction in 90% of cases, using latissimus dorsi (84%), subpectoral (70%) or TRAM flap reconstruction (54%). Skin-sparing mastectomy was performed by breast surgeons alone (62%), or with a plastic surgeon (47%) and the preferred incisions were peri-areolar (68%) and elliptical (26%). Most respondents used skin-sparing mastectomy for prophylaxis, in situ cancer and early invasive disease and avoided skin-sparing mastectomy in patients with skin tethering (62%), where radiotherapy was planned (49%) and in smokers (28%). Complications seen by respondents included skin envelope necrosis (68%), haematoma formation (46%), cosmetic failure (41%) and local recurrence (12%). CONCLUSIONS: Skin-sparing mastectomy is becoming popular in the UK, but experience is limited. The variation in indications and techniques indicate the need to establish evidence-based guidelines for the wider practice of skin-sparing mastectomy in the UK.

The timing of surgery affects the detection of residual disease after wide local excision of breast carcinoma.

AIMS: To compare the frequency of residual tumour in the cavity wall in patients with positive resection margins undergoing either immediate re-excision (IR) at the time of surgery or delayed re-excision (DR) to investigate the effects of recent surgery on the detection of residual disease. METHODS: Records of 125 patients who had undergone wide local excision with positive margins were examined. In 64 patients re-excision was performed immediately and in 61 it was delayed by 13-69 days. The presence or absence of residual disease in the re-excision specimens was recorded. RESULTS: Residual tumour was detected in 40/64 (62%) and 20/61 (33%) DR specimens (P<0.001). DR specimens contained areas of fibrosis, fat necrosis and foreign body giant cell changes. CONCLUSIONS: The detection of residual disease is significantly lower in DR compared to IR specimens. Local repair mechanisms may account for this difference.

Impact of skin-sparing mastectomy with immediate reconstruction and breast-sparing reconstruction with miniflaps on the outcomes of oncoplastic breast surgery.

BACKGROUND: The aim of this study was to compare the outcomes of skin-sparing mastectomy (SSM) with immediate myocutaneous flap reconstruction and partial mastectomy with latissimus dorsi miniflap reconstruction (LDMF) for breast cancer. METHODS: Some 106 disease-free patients (57 SSM, 49 LDMF) who had breast reconstruction between 1991 and 1999 participated in this retrospective review. The mean duration of follow-up was 42 (range 6-102) months. Measured outcomes included surgical complications, functional disability, cosmetic result and psychological morbidity. RESULTS: SSM outcomes were less favourable than LDMF outcomes with regard to postoperative complications (14 versus 8 per cent), further surgical interventions (79 versus 12 per cent), nipple sensory loss (98 versus 2 per cent), restricted activities (73 versus 54 per cent) and cosmetic outcome by panel assessment. Anxiety about residual cancer and ease of breast self-examination were similar in both groups. CONCLUSION: LDMF was associated with fewer adverse surgical and physical sequelae than SSM, without compromising local control or cosmetic outcome. Both operations were associated with low psychological morbidity.

Breast-sparing reconstruction with latissimus dorsi miniflaps.

Volume loss following breast-conserving surgery (BCS) is the key reason for major local deformity and a bad cosmetic outcome. Latissimus dorsi miniflaps can be used to reconstruct central and upper quadrant resection defects, replacing the volume excised with autogenous tissue. Partial mastectomy, axillary dissection, flap harvest and reconstruction of the resection defect is performed as a one-stage procedure through a single lateral incision. This oncoplastic approach allows extensive local excision during BCS without cosmetic penalties in a group of patients normally treated by mastectomy.

Breast reconstruction in the United Kingdom and Ireland.

BACKGROUND: Although it is becoming more common, previous surveys have identified concerns regarding the safety of immediate reconstruction following mastectomy. The aims of this study were to define current practice of breast reconstruction in the UK and Ireland, and to identify the characteristics of surgeons who use immediate breast reconstruction. METHODS: : A postal questionnaire survey of 498 consultant breast surgeons in the UK and Ireland was performed in January 2000. RESULTS: There were 376 responses (response rate 76 per cent). Eighty-eight per cent of surgeons 'always' or 'usually' discuss reconstruction with patients due to undergo mastectomy; clinicians with a heavy caseload were significantly more likely to discuss it (odds ratio (OR) 18.45 (95 per cent confidence interval 1.99 to 171.07)). The majority of respondents (57 per cent) preferred delayed to immediate breast reconstruction; 70 per cent believed that immediate reconstruction has disadvantages, most commonly that it interferes with adjuvant therapy (56 per cent). Older surgeons were significantly less likely to perform immediate reconstruction (OR 5.18 (2.21 to 12.11)), and were significantly more likely to believe that immediate breast reconstruction has disadvantages (OR 2.02 (1.01 to 4.05)). Surgeons from Ireland were less likely to discuss and perform breast reconstruction (OR 0.20 (0.10 to 0.43) and 0.27 (0.12 to 0.60) respectively), or to have access to a plastic surgeon (OR 0.22 (0.11 to 0.44)). CONCLUSION: : Significant variation exists in the delivery of breast reconstruction after mastectomy in the UK and Ireland. The age, workload and personal characteristics of the surgeon are important in determining reconstructive practice.

Fine needle aspiration cytology prior to breast ultrasonography does not alter ultrasound diagnostic accuracy or patient management.

INTRODUCTION: Fine needle aspiration cytology (FNAC) prior to serial sonographic (USS) examination of the breast is said to impede accurate diagnosis. This study aimed to test the effect of performing FNAC prior to USS in a one-stop symptomatic breast clinic. METHODS: All patients (n=368) attending a one-stop clinic over a 1-year period were stochastically allocated to imaging prior to (Group 1) or after (Group 2) clinical examination and FNAC. Additional procedures required for diagnosis (open or core biopsies), false negative USS grade and final outcome were recorded. Statistical analysis was performed using the Fisher's exact test. RESULTS: There was no statistical difference between the two groups. CONCLUSION: In the clinical setting of a one-stop visit, FNAC prior to breast USS does not alter ultrasound diagnostic accuracy or patient management.

Ultra-conservative skin-sparing 'keyhole' mastectomy and immediate breast and areola reconstruction.

The popularity of skin-sparing mastectomy (SSM) which preserves the breast skin envelope is increasing, but the risks and benefits of this approach are only beginning to emerge. A technique involving ultra-conservative SSM and immediate breast reconstruction (IBR) has been evaluated to establish the surgical and oncological sequelae of skin conservation. Between 1994-1998, 67 consecutive patients underwent 71 SSM and expander-assisted immediate latissimus dorsi (LD) breast reconstructions (follow up, 24.1 months; range, 2-52 months). Breast resection, axillary dissection and reconstruction were performed through a 5-6 cm circular peri-areolar 'keyhole' incision. Patients were discharged 6.5 days (range, 5-15 days) after the 3.9 h (range, 3.0-5.5 h) procedure, and expansion was completed by 4.0 months (range, 0-10 months). Local recurrence occurred in 3% of breasts at risk, skin envelope necrosis occurred in 10%, and contralateral surgery was required to achieve symmetry in 14%. SSM and IBR is an oncologically safe, minimal-scar procedure which can be performed by surgeons trained in 'oncoplastic' techniques. It results in low rates of local recurrence and complication, and reduces the need for contralateral surgery.

Detection of residual disease following breast-conserving surgery.

BACKGROUND: Assessment of completeness of tumour excision has become an integral part of breast-conserving surgery, but the accuracy of margin analysis has been questioned. This study compared the results of resection margin analysis with an examination of tumour bed biopsies and of the excised cavity wall. METHODS: One hundred and forty-four patients underwent breast-conserving surgery for T1-2 N0-1 breast cancer. Following wide local excision, four bed biopsies were taken from the cavity wall which was then completely excised. The presence of invasive and in situ disease at the inked resection margin (IRM) and in the adjacent bed biopsies and cavity wall was recorded. RESULTS: Positive margins and/or residual disease in either the bed biopsies or cavity wall was found in 62 (43 per cent) of 144 cases. Residual disease (invasive or in situ) was present at the IRM in 39 specimens (27 per cent) and was present in 25 bed biopsy (17 per cent) and 39 cavity wall (27 per cent) specimens. These comprised different but overlapping groups of patients. CONCLUSION: Margin analysis of wide local excision specimens is a poor predictor of completeness of excision. Routine resection and examination of the entire cavity wall increases the detection of residual disease compared with examination of bed biopsies alone and is a useful adjuvant to conventional margin evaluation.

Extending the role of breast-conserving surgery by immediate volume replacement.

BACKGROUND: Cosmetic failure following breast-conserving surgery is commonly caused by volume loss, and the effect of immediate volume replacement on cosmetic outcome using a latissimus dorsi miniflap (LDMF) has been investigated. The technique avoids a frontal scar and allows a wide retromammary excision via a lateral approach. METHODS: Twenty patients who had LDMF reconstruction were compared with 38 who had wide local excision (WLE) without reconstruction between 1991 and 1994. Cosmetic outcome was judged using (1) breast retraction assessment and (2) panel assessment, recording the frequency of cosmetic failure. RESULTS: Patients who had LDMF reconstruction were younger (mean 45.1 versus 58.6 years; P < 0.0001) with larger tumours (mean 2.5 versus 1.3 cm; P < 0.0001) and underwent wider specimen excision (57 versus 13 per cent more than 150 g; P = 0.004) with reduced margin involvement (10 versus 37 per cent positive margins; P = 0.03) compared with those who had WLE. Cosmetic failure was uncommon after immediate volume replacement (LDMF 10 per cent versus WLE 34 per cent; P = 0.045). CONCLUSION: LDMF reconstruction extends the role of breast-conserving surgery without cosmetic penalties, and may reduce the need for mastectomy.

Size isn't important; the Forrest Unit.

The early success of breast screening in the UK is encouraging, and has been achieved by cooperation between multidisciplinary teams working together in large screening units. Future market forces may serve to disintegrate this arrangement with the resulting emergence of smaller, self-sufficient units. Winchester's 'first round' screening results suggest that with appropriately trained team members, such units can provide a convenient, high quality local service without compromising cancer detection.