Implications of the COVID-19 Pandemic on Immediate Breast Reconstruction Access.

AIMS: As a result of COVID-19, there have been restrictions on surgical interventions across Canada. Immediate breast reconstruction (IBR), while an essential component of cancer care, is classified as elective surgery and therefore has been restricted in access over the course of the pandemic. The purpose of this study was to compare wait times for breast cancer patients undergoing surgical intervention for IBR before and since the COVID-19 pandemic. METHODS: This was a retrospective cross-sectional study of consecutive patients who underwent IBR between July 2018 and October 2021 by 5 plastic surgeons at a single Canadian health center. Wait times to consultation and surgical intervention between pre- and post-COVID cohorts were analyzed. RESULTS: A total of 161 patients met inclusion criteria. For ablative surgery, there was no difference in wait times to surgical oncology consultation (14.0 ± 12.3 vs 14.0 ± 11.0 days, P = 0.991) and surgical intervention with IBR (41.0 ± 49.8 vs 35.0 ± 58.0 days, P = 0.621) between the pre- and post-COVID cohorts. For breast reconstruction, while time to consultation with plastic surgery (12.5 ± 14.8 vs 11.0 ± 12.8 days, P = 0.775) remained unchanged, usage of autologous techniques was reduced [n = 13 (16%) vs n = 2 (2%), P = 0.006], and time to second-stage alloplastic reconstruction increased (230 ± 102 vs 325 ± 224 days, P = 0.044) post-COVID. CONCLUSIONS: Swift adoption of evidence driven protocols has resulted in comparable wait times for breast cancer ablative procedures. However, utilization of autologous techniques and wait times to second-stage reconstructions have increased.

Management of patients requiring reconstructive breast surgery during the COVID-19 pandemic: recommendations from the BC Regional Breast Reconstruction Network.

Summary: The COVID-19 pandemic has caused unprecedented challenges in health care, threatening access and delivery of medical services across all sectors. Patients with breast cancer desiring breast reconstruction require timely interdisciplinary care; resource limitations threaten access to this elective reconstructive element of cancer care. An expert panel was convened to identify challenges, recommend preliminary solutions, and identify important future directions in anticipation of prolonged restrictions. This paper presents consensus recommendations for care of breast cancer reconstruction patients during the pandemic based on expert opinion from the BC Breast Reconstruction Network.

Prophylactic Surgery in the BRCA+ Patient: Do Women Develop Breast Cancer While Waiting?

Breast cancer susceptibility gene (BRCA) mutation carriers have an increased risk of breast cancer. Mitigation of this risk can be achieved via surveillance or prophylactic mastectomy with or without breast reconstruction. Those that choose surgery expect to reduce their chance of developing cancer. The purpose of this study was to determine the incidence of patients developing breast cancer prior to surgery and to identify modifiable contributing factors within the patient journey. This is a historical cohort study of all BRCA mutation carriers identified through the British Columbia Cancer Hereditary Cancer Program between 2000 and 2012. Patients were divided into two groups: surveillance (S) and prophylactic mastectomy with immediate breast reconstruction (PM/IBR). The incidence of cancer, time to PM/IBR and patient journeys were analyzed. A total of 333 women were identified. The time to surgery from mutation disclosure was a median of 31 (5.3, 75.7) months. During this period, 6% of patients developed breast cancer compared with a 14% incidence of breast cancer in patients choosing surveillance. The majority of time to surgery was attributed to the period between mutation disclosure and the decision to proceed with surgery. Strategies to facilitate decision-making as well as wait list prioritization and dedicated operative time should be targeted to this population to decrease the number of women developing an interval cancer prior to surgery.

Immediate Reconstruction Swing Room Scheduling Reduces Wait Times to Surgery and Increases Breast Reconstruction Rates.

BACKGROUND: Despite benefits in quality of life, patient satisfaction, overall healthcare costs, and number of surgeries, historically fewer than 30% of patients undergo immediate breast reconstruction following mastectomy for breast cancer. A paucity of qualified oncologic and plastic surgeons coupled with inefficient use of operating room (OR) resources presents challenges in offering immediate breast reconstruction in a timely manner. To address these challenges, an immediate reconstruction swing room (IRSW) program was developed. METHODS: IRSW scheduling leverages two concurrently running ORs, with the surgical oncologist and plastic surgeon moving between rooms to complete 2-4 combined mastectomy cases with immediate reconstruction, in addition to 1-2 independent cases, each operative day. The final year of traditional booking was compared with IRSW scheduling to assess wait times and reconstruction rates. RESULTS: Comparing the 2 years, fewer surgical breast cases were performed with IRSW scheduling (1250 vs. 1178), however the overall number of oncology cases increased from 735 (59%) to 857 (73%). The number of immediate reconstructions performed increased from 75 to 139 (p < 0.0001), which reflects a mean of 1.2 IR cases versus 2.9 combined cases in IRSW. Overall, this facilitated an increase in the rate of immediate reconstruction following therapeutic mastectomy from 35 to 49% (p = 0.0004) and decreased wait times from core biopsy to surgery from 70 to 52 days (p < 0.0001). CONCLUSIONS: A multidisciplinary model with optimized scheduling has the potential to improve resource utilization and access to breast cancer care.

Evidence-Based Medicine: Alloplastic Breast Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the different advances that have resulted in improved outcomes in implant-based reconstruction. 2. Gain knowledge about specific techniques that have evolved rapidly in recent years and how to implement these. 3. Gain an understanding of controversies associated with alloplastic reconstruction. 4. Recognize undesirable outcomes in implant-based breast reconstruction and understand strategies for correction. SUMMARY: There have been multiple advances in implant-based breast reconstruction. Many of these have resulted in improvements in patient outcomes and care. Understanding new techniques and technologies ensures competence in providing care for the alloplastic breast reconstruction patient. This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

Evidence-Based Medicine: Autologous Breast Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Gain an understanding of the different methods of autologous reconstruction available. 2. Understand the timing of autologous breast reconstruction and the impact of adjuvant and neoadjuvant treatments. 3 Understand the factors necessary for a comprehensive patient assessment. 4. Gain knowledge of patient factors that will affect autologous reconstruction and potential contraindications. 5. Summarize the patient-reported and clinical outcomes of autologous breast reconstruction. SUMMARY: This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

Postmastectomy radiation therapy after immediate two-stage tissue expander/implant breast reconstruction: a University of British Columbia perspective.

BACKGROUND: An increasing number of women who undergo immediate two-stage tissue expander/implant breast reconstruction will require postmastectomy radiation therapy. An important variable is the timing of radiotherapy relative to surgery. The authors report their experience treating a large consecutive series of patients who underwent postmastectomy radiation therapy to the tissue expander before exchange for a permanent implant. METHODS: Patients who had their tissue expander irradiated before implant exchange were identified. Complications, capsular contracture, revision surgery, and autologous salvage rates of irradiated patients were compared with a control group of nonirradiated patients. RESULTS: Immediate two-stage tissue expander/implant reconstruction was initiated in 604 patients, with 113 irradiated breasts meeting inclusion criteria. Three hundred thirty-nine nonirradiated breasts constituted the control group. There was a 4.2 increased odds of major complications in the irradiated group, after adjusting for plastic surgeon, age, body mass index, smoking, chemotherapy, and cancerous breast (OR, 4.2; p=0.001). The grade III and IV capsular contracture rate was significantly higher in the irradiated group compared with the control group (21.7 percent versus 10 percent; p<0.008). The revision rate in the control group was higher compared with the irradiated group (30.2 percent versus 20.9 percent; p<0.001). CONCLUSIONS: Postmastectomy irradiation to the tissue expander is associated with high complications; however, these patients have an acceptable capsular contracture rate that compares favorably with other implant-based radiotherapy algorithms. Revision rates were less than expected in irradiated breasts. This study suggests that immediate tissue expander/implant reconstruction is a reasonable surgical option in the setting of postmastectomy radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Re-excision of incompletely excised cutaneous squamous cell carcinoma: histological findings influence prognosis.

INTRODUCTION: We have previously shown 28.6% of re-excisions for margin-positive cutaneous SCC to yield residual tumour (positive re-excision). Original tumour diameter and thickness conferred significant risks for positive re-excision. We now report a 5-year prospective follow-up of our re-excision cohort. RESULTS: Of 676 consecutive SCC patients, 84 underwent wider-excision for positive margins. 79 of these patients completed a mean of 28 months follow-up. Overall, 9/79 (11%) of this re-excision cohort experienced locoregional recurrence, all within 2 years of primary resection. Of the positive re-excisions, 29% experienced recurrence, vs 5% in those with negative re-excisions. Logistic-regression analysis revealed positive re-excision to predict recurrence (P<0.05, RR 10.1), independent from tumour-grade, anatomical site, size, and delay to re-excision. CONCLUSION: Factors associated with residual tumour on re-excision are similar to characteristics of high-risk SCCs; larger tumours in particular are more likely to persist and may benefit from wider excision-margins at original resection. Positive re-excision is newly identified as a significant risk for locoregional recurrence, whilst negative re-excision is associated with a return to a low-risk prognosis, for all tumours. Our findings thus support the treatment of cutaneous SCC through to completion. We also recommend re-excision where narrow or close margins are reported. Patients with a positive re-excision should be considered at high risk for recurrence, requiring extended follow-up.