Outcomes after total skin-sparing mastectomy and immediate reconstruction in 657 breasts.

BACKGROUND: Total skin-sparing mastectomy (TSSM), a technique comprising removal of all breast and nipple tissue while preserving the entire skin envelope, is increasingly offered to women for therapeutic and prophylactic indications. However, standard use of the procedure remains controversial as a result oft concerns regarding oncologic safety and risk of complications. METHODS: Outcomes from a prospectively maintained database of patients undergoing TSSM and immediate breast reconstruction from 2001 to 2010 were reviewed. Outcome measures included postoperative complications, tumor involvement of the nipple-areolar complex (NAC) on pathologic analysis, and cancer recurrence. RESULTS: TSSM was performed on 657 breasts in 428 patients. Indications included in situ cancer [111 breasts (16.9%)], invasive cancer [301 breasts (45.8%)], and prophylactic risk-reduction [245 breasts (37.3%)]. A total of 210 patients (49%) had neoadjuvant chemotherapy, 78 (18.2%) had adjuvant chemotherapy, and 114 (26.7%) had postmastectomy radiotherapy. Nipple tissue contained in situ cancer in 11 breasts (1.7%) and invasive cancer in 9 breasts (1.4%); management included repeat excision (7 cases), NAC removal (9 cases), or radiotherapy without further excision (4 cases). Ischemic complications included 13 cases (2%) of partial nipple loss, 10 cases (1.5%) of complete nipple loss, and 78 cases (11.9%) of skin flap necrosis. Overall locoregional recurrence rate was 2% (median follow-up 28 months), with a 2.4% rate observed in the subset of patients with at least 3 years' follow-up (median 45 months). No NAC skin recurrences were observed. CONCLUSIONS: In this large, high-risk cohort, TSSM was associated with low rates of NAC complications, nipple involvement, and locoregional recurrence.

Long-term reconstructive outcomes after expander-implant breast reconstruction with serious infectious or wound-healing complications.

INTRODUCTION: Immediate expander-implant breast reconstruction has been associated with postoperative complications, including infection and wound-healing problems. In extreme cases, these issues can lead to expander-implant loss. Little is known about the long-term reconstructive outcomes for patients who develop major complications threatening their expander-implant reconstructions. METHODS: A review of all patients who underwent mastectomy and immediate expander-implant reconstruction at University of California, San Francisco (UCSF) from 2005 to 2007 was performed. A prospective database was queried for patients who developed a major postoperative complication related to infection or wound-healing problems requiring unplanned operative intervention. Only patients who had a minimum of 3 years' follow-up were included in the study. RESULTS: Twenty-nine patients were identified who met study criteria. Mean follow-up time was 52.5 months (range, 41-71 months). Six of the 29 (20.7%) patients had received prior breast irradiation, and 9 patients (31%) underwent postoperative radiation therapy. Reasons for unplanned return to the operating room included infection (n = 11, 37.9%), expander-implant exposure (n = 5, 17.2%), nonhealing wounds without underlying exposure (n = 3, 1.3%), or >1 of these indications (n = 10, 34.5%). Unplanned operative intervention (such as wound debridement or expander-implant exchange or removal) was required once in 10 patients (34.5%), twice in 10 patients (34.5%), 3 times in 4 patients (13.8%), 4 times in 1 patient (3.4%), and 5 or greater times in 4 patients (13.8%). At the conclusion of all operative interventions, 15 patients (51.7%) had successful breast reconstruction using an expander-implant technique. Five additional patients (17.3%) ultimately achieved successful salvage reconstruction with either a transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flap. Nine patients (31%) did not have successful breast reconstruction. Of these 9 patients, 5 elected to abandon reconstructive efforts after 1 unplanned return to the operating room for expander-implant removal, whereas the rest underwent at least 1 attempt at expander-implant salvage, with the overall rate of final successful reconstruction after attempt at salvage 83.3% (20 of 24 patients). CONCLUSIONS: Even when unplanned operative intervention is required to address postoperative wound-healing or infectious complications after expander-implant reconstruction, the majority of patients can achieve successful reconstructive outcomes at long-term follow-up, including those patients requiring multiple operative interventions to treat their complication.

Development and implementation of an Internet-based survivorship care program for cancer survivors treated with hematopoietic stem cell transplantation.

INTRODUCTION: The Internet provides a widely accessible modality for meeting survivorship care needs of cancer survivors. In this paper, we describe the development and implementation of an Internet site designed as a base from which to conduct a randomized controlled trial to meet psycho-educational needs of hematopoietic stem cell transplantation (HSCT) survivors. METHODS: A cross-disciplinary team designed, wrote content, and programmed an Internet site for online study registration, consent, assessment, and study implementation. All survivors who were 3-18 years after HSCT for hematologic malignancy and treated at one transplant center were approached by mail for participation. All study activities could be conducted without study staff contact. However, participants had options for phone or email contact with study staff as desired. RESULTS: Of 1,775 participants approached for the study, 775 (58% of those eligible) consented and completed baseline assessment. Mean age was 51.7 (SD, 12.5; age range, 18-79 years), with 56% male. Fifty-seven percent required staff contact one or more times; a majority were for minor technical issues or delays in completion of enrollment or baseline assessment. DISCUSSIONS/CONCLUSIONS: This study demonstrated the potential for providing Internet-based survivorship care to long-term survivors of HSCT. Although building a survivorship Internet site requires a team with diverse expertise, once built, these resources can be implemented rapidly with large numbers of survivors. IMPLICATIONS FOR CANCER SURVIVORS: While Internet-based services will not meet all the needs of cancer survivors, this methodology represents an important modality for augmenting onsite clinical services as a method for meeting psycho-educational, information, and resource needs of cancer survivors.

Measuring musculoskeletal symptoms in cancer survivors who receive hematopoietic cell transplantation.

INTRODUCTION: Beyond documentation of high prevalence rates, research has not examined the qualities and characteristics of musculoskeletal symptoms in cancer survivors, possibly because measures have not been validated specifically for the assessment of these symptoms in survivors. We report here on a new measure of muscle and joint symptoms for survivors of hematologic malignancies and hematopoietic cell transplantation (HCT). METHODS: In a cross-sectional design, 130 adults, 5-20 years after HCT, completed patient-reported outcomes. Assessment included musculoskeletal symptoms on the Muscle and Joint Measure (MJM), as well as health-related quality of life and treatments. RESULTS: Principal components analysis using promax rotation revealed four subscales for the MJM with item factor loadings above 0.50: muscle aches or stiffness (myalgias), joint pain, stiffness or swelling (arthralgias), muscle cramps, and muscle weakness. Variance explained by the total score was 77%. Internal consistency reliabilities of the subscales and total score ranged from 0.86 to 0.93. Validity was confirmed by correlations with the Short Form-36 bodily pain, physical function and vitality subscales, the Fatigue Symptom Inventory, and the Symptom Checklist-90-R depression (all P < .001). CONCLUSIONS: Musculoskeletal symptoms in survivors who received HCT can be measured reliably and validly with the MJM. The measure requires testing to establish its psychometric properties with other diagnostic and treatment groups. IMPLICATIONS FOR CANCER SURVIVORS: The MJM has potential research and clinical value for addressing the musculoskeletal symptoms of survivors. The measure may assist with examining the mechanisms as well as treatments for these symptoms, which are among the most prevalent in long-term cancer survivors.

Measuring social activities and social function in long-term cancer survivors who received hematopoietic stem cell transplantation.

OBJECTIVE: Cancer survivors report deficits in social functioning even years after completing treatment. Commonly used measures of social functioning provide incomplete understanding of survivors' social behavior. This study describes social activities of survivors and evaluates the psychometric properties of the Social Activity Log (SAL) in a cohort of long-term survivors of hematopoietic stem cell transplantation (HSCT) for cancer. METHODS: One hundred and two (5-20 year) survivors completed the SAL, Short-Form-36 Health Survey (SF-36), and other patient-reported outcomes. Principal components analysis determined the factor structure of the SAL along with correlations and regressions to establish validity. RESULTS: Principal component analysis yielded three factors in the SAL: 'non-contact events' (e.g. telephone calls), 'regular events' (e.g. played cards), and 'special events' (e.g. concerts), which explained 59% of the total variance. The SAL possessed good internal consistency (Cronbach's alpha=0.82). SF-36 social function and SAL were moderately correlated (r=0.31). In linear regressions, physical function and depression explained 16% of the variance in the SAL (P<0.001), while physical function, depression, and fatigue predicted 55% of the variance in SF-36 social function (P<0.001). CONCLUSIONS: Results support the use of the SAL as a measure of social activity in cancer survivors who received HSCT. Although the SAL is designed to measure social behaviors, SF-36 social function assesses subjective experience and is more strongly associated with depression and fatigue. The SAL appears to be a promising tool to understand the behavioral social deficits reported by long-term survivors of cancer.