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Breast Center, University Hospital of Basel, Basel, SwitzerlandUniversity of Basel, Basel, SwitzerlandBreast Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
University of Basel, Basel, SwitzerlandDepartment of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Basel, Switzerland
University of Basel, Basel, SwitzerlandDepartment of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Basel, Switzerland
Breast Center, University Hospital of Basel, Basel, SwitzerlandUniversity of Basel, Basel, SwitzerlandDepartment of Obstetrics and Gynecology, University Hospital of Basel, Basel, Switzerland
Breast Center, University Hospital of Basel, Basel, SwitzerlandUniversity of Basel, Basel, SwitzerlandDepartment of Obstetrics and Gynecology, University Hospital of Basel, Basel, Switzerland
Breast Center, University Hospital of Basel, Basel, SwitzerlandUniversity of Basel, Basel, SwitzerlandDepartment of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Basel, Switzerland
Breast Center, University Hospital of Basel, Basel, SwitzerlandUniversity of Basel, Basel, SwitzerlandDepartment of Obstetrics and Gynecology, University Hospital of Basel, Basel, Switzerland
Corresponding author at: Senior Consultant, Breast Center and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Spitalstrasse 21, 4031 Basel, Switzerland.
Breast Center, University Hospital of Basel, Basel, SwitzerlandUniversity of Basel, Basel, SwitzerlandDepartment of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Basel, Switzerland
Postoperative complications after breast cancer surgery may be associated with decreased quality of life. It remains unclear whether oncoplastic breast-conserving surgery or mastectomy with reconstruction lead to more postoperative complications than conventional breast surgery (CBS). As delayed wound healing (DWH) is one of the most frequent minor complications, we sought to investigate the significance of DWH for patient-reported outcomes after oncoplastic, reconstructive, and CBS.
Methods
Our study is a retrospective cohort study of consecutive patients with stage I-II breast cancer who underwent oncoplastic or CBS performed by three breast surgeons at a single tertiary referral hospital from June 2011 until May 2019. Patient-reported outcomes were evaluated postoperatively using the BREAST-Q questionnaire. Comparisons were made between patients with and without DWH.
Results
A total of 229 patients who met the inclusion criteria and 28 (12%) of them developed DWH, 27/158 (17%) in the oncoplastic breast-conserving surgery and reconstruction group and 1/71 (1%) in the CBS group. The mean time from surgery to BREAST-Q assessment was comparable in both groups (29 months in the DWH vs. 33 months in the normal wound healing group). No statistically significant difference for any BREAST-Q scale was detected between patients with and without DWH. This includes physical (p = 0.183), psychosocial (p = 0.489), sexual well-being (p = 0.895), and satisfaction with breasts (p = 0.068).
Conclusion
Our study confirms that oncoplastic breast-conserving surgery and mastectomy with reconstruction lead to significantly more DWH than CBS. However, neither quality of life nor patient-reported outcomes following state-of-the-art reconstructive or oncoplastic breast-conserving surgery at a specialized center seem to be compromised.
Over the past few decades, there have been major developments in breast cancer surgery with increased focus on esthetic results and associated patient satisfaction. Oncoplastic breast-conserving surgery (OBCS) and mastectomy with breast reconstruction are procedures that combine oncological and plastic techniques that have been shown to improve quality of life (QoL).
As reconstructive techniques encompass volume replacement and volume displacement, so in this study, we refer to oncoplastic breast surgery (OBS) including OBCS techniques and mastectomy with autologous or implant reconstruction.
Higher complication rates following oncoplastic techniques could be explained by the more complex surgical procedures employed to attain optimal cosmetic results.
However, the significance of DWH after OBS and its impact on long-term QoL and patient satisfaction remains unknown. Aside from possible physical sequelae, postoperative complications can be detrimental to the emotional well-being of patients, especially shortly after surgery, but also in the long term.
We sought to investigate the significance of DWH on patient-reported outcomes (PROs) after oncoplastic, reconstructive, and CBS surgery.
We hypothesized that DWH has no negative impact on the high QoL attained by the cosmetically pleasing results of OBS. To test this hypothesis, we compared PROs in patients with and without DWH after CBS and OBS by using the BREAST-Q, as a validated PRO assessment tool.
Consecutive patients with stage I-II breast cancer who were treated by three breast surgeons at a tertiary referral hospital between June 2011 and May 2019 were identified from a prospectively maintained database. Patients were eligible for inclusion if they had undergone either OBS (OBCS or mastectomy with reconstruction) or CBS (CBCS or TM). OBCS methods include oncoplastic reduction mammoplasty (n = 37), circumareolar mastopexy (n = 30), v-mammoplasty (n = 14), hemibatwing (n = 14), and oncoplastic tumorectomy (n = 11). Reconstructive techniques include nipple sparing mastectomy (NSM) with autologous reconstruction with a deep inferior epigastric perforator (DIEP) flap (n = 46) and mastectomy with implant-based reconstruction (n = 5). CBCS was considered as a conventional, breast-conserving tumorectomy (n = 40). TM cases (n = 31) include unilateral and bilateral TM without any further reconstruction. The BREAST-Q was used to prospectively assess postoperative health-related QoL via the outcome collecting software Heartbeat®, which provides a system to measure PROs using the Outcome Sets of the International Consortium for Health Outcome Measurements (ICHOM). Patient, tumor, treatment, and outcome variables were recorded in a dedicated study database (secuTrial®). Comparisons were made between patients with DWH, defined as a wound healing process on the breast or abdomen lasting longer than 21 days
and patients with “normal wound healing”, which lasted shorter than 21 days (NWH).
Statistical analysis
Patient, tumor, treatment, and outcome characteristics of both wound healing groups were compared. We analyzed the following BREAST-Q scales: “physical well-being chest”, “psychosocial well-being”, “sexual well-being”, and “satisfaction with breasts.” Each scale is converted to a continuous scale scoring from zero to 100, with higher values representing greater QoL. Continuous variables were reported by mean, standard deviation (SD), and minimum and maximum values. Mean values were compared using t-test. Categorical variables were summarized by absolute frequencies and percentages. Occurrences were compared using Fisher's exact test for association. A p-value below 0.05 was considered statistically significant. All statistical analyses were conducted with SAS version 9.2.
Results
From June 2011 until May 2019, 229 patients met the inclusion criteria. Twenty-eight patients (12%) experienced DWH, and 201 (88%) did not. In the DWH group, the mean wound healing duration was 88 days (SD 74). Postoperative complications were classified by Clavien-Dindo
and ranged from grades I to IIIb (Table 1). Grade I includes seroma, hematoma, and DWH without the need for special pharmacological treatment or surgical intervention. Grade II includes pharmacologically treatable complications. Grade IIIb includes complications such as skin necrosis, infection, or flap loss that require surgical revision not under general (IIIa) or under general anesthesia (IIIb). Fourteen (50%) patients with DWH underwent NSM with DIEP, 10 (36%) underwent OBCS, 3 (11%) had an implant-based reconstruction, and 1 (4%) had a TM. In the NWH group, 32 (16%) patients had a NSM with DIEP flap reconstruction, 97 (48%) OBCS, 40 (20%) CBCS, 30 (15%) a TM, and 2 (1%) received an implant-based reconstruction. The mean time from surgery to follow-up BREAST-Q assessment was 29 (20) months in the DWH and 33 (23) months in the NWH group (Table 1). The mean BMI was similar in both groups (27 (SD 8) in the DWH group and 25 (SD 5) in the NWH group). In the DWH group 2 (7%) and in the NWH group 9 (5%) had diabetes. A total of 11 patients (39%) in the DWH group were smokers or prior smokers, compared to 86 (43%) in the NWH group. Within the cohort of patients receiving autologous reconstruction (n = 46, 20%), DWH was observed in n = 14 (30%) patients, affecting the breast site only in n = 10 (22%) patients, the donor site only in n = 2 (4%) patients, and the breast and donor site in n = 2 (4%) patients.
Table 1Patient, tumor, and treatment characteristics by wound healing group.
Missing: 2 OBS = oncoplastic breast surgery (including NSM with DIEP, implant-based reconstruction and OBCS) NSM = nipple-sparing mastectomy DIEP = deep inferior epigastric perforator (flap) OBCS = oncoplastic breast-conserving surgery (including V-, B-, hemibatwing and round block mammoplasty as well as oncoplastic tumorectomy) CBS = conventional breast surgery (including CBCS and TM) CBCS = conventional breast-conserving surgery TM = total mastectomy Delayed wound healing = wound healing lasting longer than 21 days
Yes, n (%)
2 (7.1)
9 (4.5)
0.631
No, n (%)
26 (92.9)
190 (94.5)
Mean values were compared using a t-test. Occurrences were compared using a Fisher's exact test for association.
Missing: 6
Missing: 16
Missing: 2OBS = oncoplastic breast surgery (including NSM with DIEP, implant-based reconstruction and OBCS)NSM = nipple-sparing mastectomyDIEP = deep inferior epigastric perforator (flap)OBCS = oncoplastic breast-conserving surgery (including V-, B-, hemibatwing and round block mammoplasty as well as oncoplastic tumorectomy)CBS = conventional breast surgery (including CBCS and TM)CBCS = conventional breast-conserving surgeryTM = total mastectomyDelayed wound healing = wound healing lasting longer than 21 days
For the scale physical well-being chest, mean scores in the DWH group (74 (SD 20)) and in the NWH group (79.71 (SD 19)) were not statistically different (p-value=0.183) (Fig. 1a) (Table 2). The same was true for psychosocial well-being (82.59 (SD 21) vs. 85.18 (SD 18), respectively, p = 0.489) (Fig. 1b) (Table 2), satisfaction with breast (66 (SD 19) vs. 74 (SD 21), respectively, p = 0.068) (Fig. 1c) (Table 2), and sexual well-being (68 (SD 30) vs. 69.25 (SD 25), respectively, p = 0.895) (Fig. 1d) (Table 2). Fig. 2
Mean values were compared using a t-test. Occurrences were compared using a Fisher's exact test for association. Delayed wound healing = wound healing lasting longer than 21 days
BREAST-Q scores from 0 - 100 with higher values representing greater QoL
n
15
135
Mean (SD)
68.33 (29.90)
69.25 (25.08)
0.895
Min - Max
24.00–100.00
0.00–100.00
Mean values were compared using a t-test. Occurrences were compared using a Fisher's exact test for association.Delayed wound healing = wound healing lasting longer than 21 days
BREAST-Q scores from 0 - 100 with higher values representing greater QoL
In this study, we analyzed PROs in 229 consecutive stage I-II breast cancer patients following OBS and CBS. We compared the BREAST-Q scales between patients who developed DWH, and patients who did not. In line with Jagsi et al. and Clough et al.
we found that OBS was associated with a higher rate of DWH compared to CBS. Nonetheless, in our analysis, patient satisfaction was not affected by DWH.
Impact of DWH on QoL
Numerous studies have shown an association between postoperative complications and worse decreased QoL.
Most women recover from psychological distress after postoperative complications following implant or DIEP flap breast reconstruction: a prospective long-term follow-up study.
The impact of complications on function, health, and satisfaction following abdominally based autologous breast reconstruction: a prospective evaluation.
Thus far, there is no study on this subject matter in the literature that specifies DWH as a main postoperative complication and analyzes it individually. In this study, we decided to focus on DWH as it is one of the most important and frequent minor complications in breast surgery.
We focused on long-term QoL after OBS and CBS and found no significant association between DWH and QoL. This is in line with previous studies with long-term follow-up, which suggested that postoperative complications have no significant impact on QoL in the long term.
Most women recover from psychological distress after postoperative complications following implant or DIEP flap breast reconstruction: a prospective long-term follow-up study.
The impact of complications on function, health, and satisfaction following abdominally based autologous breast reconstruction: a prospective evaluation.
Our findings are most likely explained by the fact that women who developed postoperative complications are able to develop coping strategies that allow them to overcome the short-term burden of DWH.
Most women recover from psychological distress after postoperative complications following implant or DIEP flap breast reconstruction: a prospective long-term follow-up study.
The impact of complications on function, health, and satisfaction following abdominally based autologous breast reconstruction: a prospective evaluation.
A retrospective investigation of abdominal visceral fat, body mass index (BMI), and active smoking as risk factors for donor site wound healing complications after free DIEP flap breast reconstructions.
Interestingly, all of these variables were similar in both of our groups, which might suggest no significant impact on DWH. This needs further investigation with greater sample sizes.
Twenty-two patients of the DWH group received adjuvant radiotherapy. Postoperative complications with a significant delay of wound healing could lead to a delay of adjuvant radiotherapy.
We therefore cannot exclude that a probable detrimental effect of DWH on QoL might be compensated by higher PRO scores resulting from better esthetic outcomes of OBS.
The time factor
Another possible explanation for our findings is the relatively long interval from surgery to follow-up (mean time 29.30, (SD 20) months in the DWH group and 32.69, (SD 23) months in the NWH group). Previous studies have shown that postoperative QoL tends to increase over time.
In fact, some studies analyzing PROs after postoperative complications have demonstrated that, in the majority of cases, QoL deterioration reverses over time.
As a result, it is conceivable that an acute event occurring shortly after surgery may not impact QoL in the long term.
A study analyzing QoL after breast cancer surgery with a similar mean time to follow-up as in our study, post-operative complications in general were not associated with overall patient satisfaction.
Limitations of this study include the relatively small sample size, its retrospective nature, and the monocentric design. The small sample size is due to the fact that we included only patients treated by three senior surgeons. This choice was made to increase generalizability of the results as it ensures standardized treatment of very experienced surgeons. Plastic surgeons were, by default, involved in all breast reconstructions and sometimes in more complex OBS or CBCS.
On the other hand, a major strength of this study lies in the inclusion of different types of surgical procedures including mastectomy, breast reconstruction, but also breast conservation procedures. Previous studies have had only included patients who had a mastectomy and breast reconstruction. To the best of our knowledge, our study is the first to analyze the impact of DWH on QoL and to compare different OBS techniques and CBS procedures such as mastectomy and CBCS.
In addition to analyzing the impact of complications on QoL like previous studies in the literature, we centered our focus on DWH as one of the most important minor complications after abdominal and breast surgery.
Therefore, our findings allow for more precise information about the impact of DWH in particular.
Conclusion
Our results suggest that superior PROs and QoL after state-of-the-art OBS at a specialized center are not compromised by an increased rate of DWH. These circumstances may be explained by the excellent esthetic outcome achieved with oncoplastic procedures. Another explanation might be that the effect of wound healing complications on patient satisfaction decreases over time.
In times of personalized health care, patients should be informed of the possible complications related to more extensive surgeries such as oncoplastic procedures with due diligence. If postoperative complications — particularly DWH — occur, intensive and adequate care should be given. Nevertheless, based on the results of our study, patients ought to be reassured that such possible complications may not negatively impact their QoL in the long term.
Declaration of Competing Interest
E.A. Kappos has received research support from the “Freiwillige Akademische Gesellschaft Basel.” W.P. Weber has received research support from Takeda Pharmaceuticals International via Swiss Group for Clinical Cancer Research (SAKK), honoraria from Genomic Health, Inc., USA, and support for conferences and meetings from Sandoz, Genomic Health, Medtronic, Novartis Oncology and Pfizer.
C. Kurzeder has received honoraria from Tesaro, GSK, AstraZeneca, Novartis, PharmaMar, Genomic Health, Roche, Eli Lilly S.A., Pfizer, and Daichi, support for attending meetings and/or travel from GSK, AstraZeneca, and Roche and participation on a data safety monitoring board or advisory board from Tesaro, GSK, AstraZeneca, Novartis, PharmaMar, Genomic Health, Roche, Eli Lilly S.A., Merck MSD, and Pfizer.
J. Lévy has received renumeration for his work from the Department of Plastic, Reconstructive, Aesthetic and Hand Surgery and the Department of Breast Surgery, University Hospital of Basel.
All other authors report no conflict of interest.
Acknowledgments
We thank the quality management team of the University Hospital of Basel for their help and support in the implementation of the outcome collecting software Heartbeat®. We also thank Constantin Sluka and his team of the Clinical Trial Unit Basel for the maintenance of the online clinical data management system secuTrial®.
Funding
This work was funded by the Department of Surgery, University Hospital of Basel. This financial backer had no involvement in study design; the collection, analysis, and interpretation of data; the writing of the report; nor in the decision to submit the article for publication.
Ethical approval
We have obtained ethical approval by the Ethikkommission Nordwest- und Zentraischweiz (EKNZ). Approval number BASEC ID 2016–01525
Most women recover from psychological distress after postoperative complications following implant or DIEP flap breast reconstruction: a prospective long-term follow-up study.
The impact of complications on function, health, and satisfaction following abdominally based autologous breast reconstruction: a prospective evaluation.
A retrospective investigation of abdominal visceral fat, body mass index (BMI), and active smoking as risk factors for donor site wound healing complications after free DIEP flap breast reconstructions.
We read with interest the above article by Zehnpfennig et al.1 While we admire the efforts by Zehnpfennig and colleagues in evaluating the impact of delayed wound healing in patients who underwent breast cancer surgery, we question whether BREAST-Q was the most appropriate tool in this situation. Although the validity and reliability of BREAST-Q have been repeatedly demonstrated, and it is undeniable that delayed wound healing can have an impact on patients’ quality of life (QoL), perhaps it is worth to take a step back to contemplate the fundamental question being asked here - “the impact of delayed wound healing on patient-reported outcomes after breast cancer surgery”.
Mean values were compared using a t-test. Occurrences were compared using a Fisher's exact test for association.
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