Some Surgical Complications Greater With Bilateral Versus Unilateral Mastectomy

Mark Sisco, MD

Postsurgery complications are infrequent among breast cancer patients undergoing surgery with reconstruction; however, according to a large database study, the rates of certain complications, including reoperation, blood transfusion, and implant loss, are higher with bilateral mastectomy versus unilateral mastectomy.¹ The study was presented at a presscast held in advance of the 2014 Breast Cancer Symposium.

Over the past 10 to 15 years, there has been a major increase in women with cancer isolated to one breast who are choosing to undergo a double mastectomy, lead author Mark Sisco, MD, clinical assistant professor of  Surgery at the University of Chicago Pritzker School of Medicine, said during the presscast. “This is despite evidence that the survival rate for breast cancer is not improved after removing the healthy breast,” he added. 

Sisco also noted, “The data regarding the negative effects of double mastectomy are limited to a few relatively small studies that have shown inconsistent conclusions.” He and his colleagues sought to offer additional information to women with breast cancer considering their options.

In their study, Sisco et al identified 18,229 women with breast cancer from the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database who received a bilateral or unilateral mastectomy with reconstruction between 2005 and 2012. The majority of women, 11,727 (64.3%), received single mastectomy, compared with 6502 women (35.7%) who received double mastectomy.

Most women had reconstruction that was implant-based–15,000 overall, including 88.6% and 79.4% of the double- and single-mastectomy groups, respectively. The remainder of patients received autologous reconstruction.   

The researchers assessed complications experienced by patients within 30 days postsurgery. Regression analysis accounted for variation in age, hypertension, diabetes, obesity, and smoking.

In the entire study population, the overall rate of complications was 5.3%. Rates of wound disruption, medical complications (eg, pneumonia, heart problems, kidney failure), and surgical site infection were similar across all surgery and reconstruction options.

In the implant-based reconstruction group, the rate of reoperation within 30 days postsurgery was 7.6% versus 6.8% for patients receiving bilateral versus unilateral mastectomy (adjusted odds ratio [aOR] = 1.14; P = .05). In this group, implant loss rates were also higher with double mastectomy (1% vs 0.7%; aOR = 1.55; P = .02).

The need for blood transfusions was higher with double mastectomy, regardless of the reconstruction method used. In the autologous reconstruction group, 7.9% versus 3.4% of patients in the double- versus single-mastectomy groups, respectively, received a transfusion (aOR = 2.34; P <.001). The transfusion rates were 0.8% versus 0.3% in the implant-based group (aOR = 2.20; P <.001).

As anticipated, patients receiving bilateral mastectomy spent more time in the hospital than those receiving unilateral surgery. In the implant-based group, double mastectomy increased the average hospital stay versus single mastectomy from 1 day to 2 days, with an increase from 4 days to 5 days in the autologous reconstruction group.

Sisco et al’s study was supported by the Section of Plastic Surgery at the University of Chicago Pritzker School of Medicine.

A study published today in The Journal of the American Medical Association underscored the disconnect Sisco et al highlighted between women increasingly choosing double mastectomy and the lack of an actual survival benefit. In the study, there was a 14.3% annual increase in bilateral mastectomy rates between 1998 and 2011 among women with early-stage breast cancer in California.² However, the increased use of double mastectomy was not associated with improved survival compared with breast-conserving surgery with radiation.

The researchers compared surgical treatments in 189,734 patients from the California Cancer Registry with stage 0-III unilateral breast cancer. The bilateral mastectomy rate in this population increased from 2% in 1998 to 12.3% in 2011. However, over the same period, there was not a significant mortality difference in breast-conserving surgery with radiation versus double mastectomy (HR = 1.02; 95% CI, 0.94-1.11).

“In a time of increasing concern about overtreatment, the risk-benefit ratio of bilateral mastectomy warrants careful consideration and raises the larger question of how physicians and society should respond to a patient’s preference for a morbid, costly intervention of dubious effectiveness,” the study authors wrote.

Reference

1. Silva AK, Lapin B, Yao K, et al. A NSQIP analysis of 30-day complications after bilateral versus unilateral mastectomy with immediate reconstruction. Presented at: 2014 Breast Cancer Symposium; September 4-6, 2014; San Francisco, CA. Abstract 62.
2. Kurian AW, Lichtensztajn DY, Keegan THM, et al. Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011. JAMA. 2014;312(9):902-914. doi:10.1001/jama.2014.10707.

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