No major difference seen among different techniques; delayed reconstruction also helps
ANN ARBOR, Mich. - Women who have a breast reconstructed after a mastectomy gain large improvements in their emotional, social and functional well-being, regardless of the technique or timing they choose for their reconstruction, a new study led by the University of Michigan finds.
But the biggest psychological boost, the study shows, comes to those who opt for reconstruction during the same operation as their mastectomy, rather than those who have reconstructive surgery later. Choosing implants or the patient's own tissue makes only small differences.
The result, from the multi-center, prospective Michigan Breast Reconstruction Outcome Survey, adds carefully gathered scientific evidence to the mounting argument for reconstruction operations for breast cancer patients. Published in the October issue of Plastic & Reconstructive Surgery, it also contradicts past findings that one approach or another is superior.
"We seem to have found a way to cushion the emotional blow of losing a breast, now that technology and surgical technique have advanced to the point where we can create a new breast that is natural looking," says author and study leader Edwin Wilkins, M.D., M.S., associate professor in the U-M Section of Plastic and Reconstructive Surgery. "The largest effect seemed to occur in those who came out of mastectomy surgery with a new breast already in place, but even patients who waited experienced a substantial positive upswing."
The study surveyed 250 mastectomy patients at 12 medical centers in the U.S. and Canada. The surveys were done twice: days before and a year after their reconstructive surgery by one of 23 surgeons. Most of the women - 184 - had breasts made from their own tissue, using one of two variations of an operation called TRAM reconstruction. The rest had artificial tissue expanders or implants filled with saline or silicone. Two thirds, or 161 patients, had reconstruction during mastectomy surgery.
The two hour-long take-home surveys evaluated the women's emotional well-being, vitality, general mental health, social functioning, functional and social well-being, and body image. After reconstruction, they were also asked about their satisfaction with their surgery. The results were compared among the groups that chose different reconstruction approaches and timing.
"The results showed once again that breast reconstruction is meeting its goals of improving patients' well-being and promoting their recovery," Wilkins says. "Our findings appear to justify recent efforts by legislators and policy makers to widen the availability of reconstruction after mastectomy."
On the whole, the authors say, the result shows that any kind of reconstruction helps women recover emotionally and psychologically from their illness. But they note that the timing of that reconstruction does make a difference, especially in the size of the psychological improvement.
"Patients who were surveyed before their simultaneous mastectomy-reconstruction operation had much lower scores, most likely because they were more recently diagnosed," Wilkins says. "Meanwhile, those undergoing delayed reconstruction had relatively higher preoperative scores, because they had completed their cancer treatment and had had several months or years to cope with their experience."
Though they started from mostly lower psychological scores the immediate reconstruction patients made a bigger jump in most scores by the time they reached a year post-surgery than the other group. The one exception was body image, which did not change much in immediate reconstruction patients - probably because the women had never had to live without a breast.
The survey results did show some measurable differences between reconstruction approaches in particular well-being and body image outcomes.
For example, women who delayed reconstruction and lived without a breast for a while experienced a greater jump in body image if their reconstruction used their own tissue rather than an implant. Wilkins suggests this may be due to the more natural feel of a TRAM breast.
But those who got an implant months after their mastectomy reported a greater rise in vitality and social well-being than TRAM reconstruction patients, perhaps reflecting the sometimes long recovery from TRAM surgery.
"For women undergoing mastectomy, what may matter most is whether or not they received immediate reconstruction, rather than which method of reconstruction they choose," Wilkins explains. "In delayed reconstruction, procedure choice appears to have a greater effect."
Both kinds of TRAM surgery examined in the study involve the transfer of skin, fat and muscle from the abdomen to the site of the new breast. Free TRAM disconnects the rectus abdominus muscle, while pedicle TRAM keeps one end of the muscle attached and swivels it upward.
The MBROS project began in 1996 at the U-M and institutions in three other states and Canada. It is funded by the U.S. Army's Medical Research and Materiel Command, and by the Center for Practice Management and Outcomes Research at the Veterans Affairs hospital in Ann Arbor.
Patients are being followed for at least two years post-reconstruction, so Wilkins and his fellow researchers are preparing to analyze data that will show longer term psychological effects. Other aspects of the study are looking at functional results, complication rates, aesthetic results and cost. Funding limitations precluded having a comparison group of unreconstructed patients.
"We're hoping to give patients, providers and payors the information they all need to make decisions about reconstruction on a case-by-case basis and on the whole," says Wilkins.
Journal
Plastic & Reconstructive Surgery