Socioeconomic and geographic differences in immediate reconstruction after mastectomy in the United States.

Disparities are evident in breast cancer diagnosis, treatment, and outcomes. This study examines multiple socioeconomic and geographic regions across the US to determine if disparities exist in the type of reconstruction obtained after mastectomy. This is a retrospective study evaluating socioeconomic and geographic variables of 14,764 women who underwent mastectomy in 2008 using the Nationwide Inpatient Sample (NIS). Statistical analysis was performed on three groups of women: patients without reconstruction (NR), patients who underwent breast implant/tissue expander reconstruction (TE), and patients with autologous reconstruction such as free or pedicled flaps (FLAP). The majority of patients (63.9%) had NR, while 23.9% had TE and 12.2% underwent FLAP. Compared to patients with NR, women with TE or FLAP were younger (64.9 years versus 51.3 and 51.1 years, p < 0.001), had fewer chronic conditions (2.60 and 2.54 chronic conditions for TE and FLAP respectively versus 3.85 for NR, p < 0.001) and higher mean hospital charges ($42,850 TE and $48,680 FLAP versus $22,300 NR, p < 0.001). Both Medicare and Medicaid insurance carriers had a higher proportion of women that did not get reconstructed compared to other insurance types (p < 0.001). Compared to NR, reconstructed women more often lived in urban areas and zip codes with higher average incomes (p < 0.001). This is the first national study analyzing insurance type and geographic variations to show statistically significant disparities in rate and type of immediate reconstruction after mastectomy. These inequalities need to be addressed to extend immediate reconstruction options to all women undergoing mastectomy.

Prediction of post-operative necrosis after mastectomy: a pilot study utilizing optical diffusion imaging spectroscopy.

INTRODUCTION: Flap necrosis and epidermolysis occurs in 18-30% of all mastectomies. Complications may be prevented by intra-operative detection of ischemia. Currently, no technique enables quantitative valuation of mastectomy skin perfusion. Optical Diffusion Imaging Spectroscopy (ViOptix T.Ox Tissue Oximeter) measures the ratio of oxyhemoglobin to deoxyhemoglobin over a 1 x 1 cm area to obtain a non-invasive measurement of perfusion (StO2). METHODS: This study evaluates the ability of ViOptix T.Ox Tissue Oximeter to predict mastectomy flap necrosis. StO2 measurements were taken at five points before and at completion of dissection in 10 patients. Data collected included: demographics, tumor size, flap length/thickness, co-morbidities, procedure length, and wound complications. RESULTS: One patient experienced mastectomy skin flap necrosis. Five patients underwent immediate reconstruction, including the patient with necrosis. Statistically significant factors contributing to necrosis included reduction in medial flap StO2 (p = 0.0189), reduction in inferior flap StO2 (p = 0.003), and flap length (p = 0.009). CONCLUSION: StO2 reductions may be utilized to identify impaired perfusion in mastectomy skin flaps.

Short-term, postoperative breast cancer outcomes in patients with advanced age.

BACKGROUND: This study compares early postoperative breast cancer outcomes between patients 80 years and older (older patients) and those younger than 80 years (<80 years). METHODS: The National Surgical Quality Improvement Program database was used to identify patients who had breast surgery between 2005 and 2013 for malignancy. RESULTS: Older patients had a significantly higher percentage of comorbidities and partial mastectomies. Postoperatively, they had higher rates of pneumonia, urinary tract infection, cardiac arrest, and mortality but had lower rates of wound dehiscence, deep wound, and organ space infections. Thirty-day mortality is independently associated with hypertension, coronary artery disease, American Society of Anesthesiology class IV, and older age. CONCLUSIONS: The overall perioperative morbidity and mortality after breast surgery, regardless of age, is low. Older patients had a significantly higher rate of mortality and systemic complications but a lower rate of wound complications, likely because of less invasive surgical procedures.

Noncompliance with adjuvant radiation, chemotherapy, or hormonal therapy in breast cancer patients.

INTRODUCTION: There is little information on patient-driven noncompliance of adjuvant therapies and its consequences. METHODS: This retrospective study compares clinical, pathological features and outcomes of breast cancer patients who were compliant to recommended radiation, chemotherapy, and hormonal therapies to those who were noncompliant. RESULTS: Noncompliance rates for chemotherapy, radiation, and tamoxifen were 31 of 421 (7%), 30 of 855 (4%), and 294 of (37%) respectively. Old age was associated with noncompliance to chemotherapy and radiation, but younger women tend to be more often noncompliant to tamoxifen. Noncompliance with chemotherapy or radiation did not significantly affect 5-year local and distant disease-free survival rates. Noncompliance with tamoxifen was associated with decreased 5-year local and distant disease-free survivals (87% versus 96%, 76% versus 87%, respectively, P < .001). CONCLUSION: Noncompliance with tamoxifen is the most common, resulting in significantly increased risk of local and distant disease recurrence.

Primary breast tumor characteristics predicting aggressive nodal involvement.

BACKGROUND: pN3 breast cancer is historically associated with a poor prognosis, but the biology of aggressive nodal involvement or lymphatotropism is not well understood. METHODS: This retrospective study compares clinical and pathological features for 1347 breast cancer patients with pN0 disease, 560 with pN1 disease, and 100 with > or = 10 positive nodes (pN3 [10] disease). RESULTS: Compared with pN1 disease, pN3 (10) disease was more frequently associated with T3-4 primaries (9% versus 38%, P < or = .001), lobular histology (11% versus 22%, P = .01), and inflammatory cancer (1% versus 5%, P = 0.01). pN3 (10) disease was not associated with early-onset or estrogen receptor-negative breast cancer. The 5- and 10-year overall survival for pN3 (10) patients was 64% and 21%, respectively. CONCLUSIONS: The data indicates that the prognosis for pN3 (10) patients may be improving with current treatment. Molecular pathways governing aggressive lymphatotropism appear to be independent of those associated with early-onset, estrogen receptor-negative breast cancer.