Exploring Breast Reconstruction in Late-stage Breast Cancer Patients

Abstract

Background:

Breast reconstruction after mastectomy improves quality of life for breast cancer patients. As more late-stage patients undergo reconstruction, it is essential to understand how treatment regimens and radiation impact outcomes. This study compared early- and late-stage breast cancer patients, examining comorbidities, reconstructive details, complications, and satisfaction.

Methods:

A total of 989 patients (903 early-stage; 86 late-stage) who underwent breast reconstruction between January 2011 and February 2025 were reviewed. Cancer staging followed the National Cancer Institute definitions: early-stage (I–IIIA) and late-stage (IIIB–IV).

Results:

Late-stage patients had higher rates of diabetes (P = 0.003), neoadjuvant chemotherapy (P < 0.001), and radiation (P < 0.001), whereas early-stage patients more often received adjuvant hormonal therapy (P = 0.006). Hormone receptor profiles differed: late-stage patients were more likely to be human epidermal growth factor receptor 2-positive (P < 0.001), whereas early-stage patients were estrogen receptor-positive (P < 0.001) and progesterone receptor-positive (P = 0.004). Early-stage patients more often underwent 2-stage expander reconstruction (P = 0.002) and implant-based reconstruction (P = 0.039), whereas late-stage patients more frequently had delayed reconstruction (P < 0.001). There were no significant differences in implant, flap, or donor-site complications, or in BREAST-Q satisfaction scores.

Conclusions:

Breast reconstruction is feasible and safe in late-stage breast cancer patients. Despite greater comorbidities and more aggressive disease, late-stage patients achieve complication rates and satisfaction comparable to early-stage patients. Future research should refine protocols to address the specific needs of late-stage patients, emphasizing quality of life and patient-centered outcomes.

Takeaways

Question: This study explored the differences in breast reconstruction between early-stage and late-stage breast cancer patients, analyzing comorbidities, reconstructive details, and outcomes such as complications and patient satisfaction.

Findings: The study showed that although late-stage patients had more comorbidities and underwent aggressive treatments, their reconstruction outcomes were comparable in satisfaction to early-stage patients, with no significant differences in complications or BREAST-Q scores.

Meaning: Despite the challenges of late-stage diagnosis, breast reconstruction can achieve similar satisfaction outcomes compared with early-stage patients.

INTRODUCTION

Breast cancer is a diagnosis burdened with emotional disturbance and medical complexities that presents a particularly challenging journey for patients diagnosed in late stages of the disease. In the realm of cancer treatment, addressing this disease takes precedence, sometimes temporarily overshadowing considerations of quality of life in the face of aggressive therapies.¹ However, as the landscape of oncology evolves, so too does the understanding of holistic patient care, encompassing not only survival but also the restoration of physical and emotional well-being.² Central to this discussion is breast reconstruction, an integral aspect of postmastectomy recovery that offers women an opportunity to restore breast shape and improve physical, sexual, and social well-being following breast cancer treatments.³ Although traditionally associated with early-stage disease, recent strides in treatment modalities have expanded the scope of reconstruction to include patients with late-stage breast cancer (stages III and IV).^1,4,5 Despite the inherent challenges posed by advanced disease progression and aggressive treatment regimens, the potential benefits of reconstruction on patients’ overall well-being should still be considered.^2,6–8

Late-stage breast cancer patients, facing the complexities of metastasis and intensified therapeutic interventions such as chemotherapy and radiation, confront a distinct set of obstacles in their journey toward reconstruction.^1,9 Radiation therapy, a cornerstone of treatment for many late-stage cases, introduces unique challenges, including compromised tissue quality and heightened risk of complications such as wound complications or capsular contraction in implant-based reconstruction.^10–12 Moreover, the shift toward a systemic approach to cancer management underscores the need for a nuanced understanding of the interplay between reconstructive efforts and ongoing oncological care.¹³

Despite the growing recognition of the importance of reconstruction in late-stage breast cancer, a significant gap persists in our understanding of its feasibility, efficacy, and impact on patient outcomes. Furthermore, there is currently no comparison of early- and late-stage breast cancer patients in their reconstruction experiences. This study sought to address this gap by exploring breast reconstruction in late-stage breast cancer patients. Specifically, we aim to examine the types of reconstruction and key outcomes such as complications and patient satisfaction.

METHODS

A retrospective chart review was conducted on patients with recorded cancer staging who underwent reconstructive procedures with the 2 senior authors between January 2011 and February 2025. Cancer staging was classified as early-stage (stages I, IIA, IIB, IIIA) and late-stage (IIIB, IIIC, IV), as defined by the National Cancer Institute Dictionary.¹⁴ Counts were done by patient rather than by breast; therefore, all data recorded separately by sidedness (right versus left) were combined into a single variable for each patient. Reconstruction-specific complications were analyzed separately within an implant or autologous-based group. Donor-site complications were also analyzed. Data, including patient demographics, comorbidities, cancer information, reconstructive procedures, and reconstruction timing, were also analyzed. BREAST-Q surveys were sent to all patients undergoing breast reconstruction by the senior authors. All completed responses were included in the study, regardless of the timing of submission. Patient-reported postoperative satisfaction with breasts, psychosocial well-being, physical well-being (chest), and sexual well-being were tabulated and compared between groups. All data were collected retrospectively and managed with REDCap electronic data capture tools.¹⁵ Statistical analysis was completed with SPSS statistical software. The Pearson χ² test was used to compare categorical variables across groups, and an independent samples t test was used to compare continuous variables across groups.¹⁶ P values less than 0.05 were considered statistically significant.

RESULTS

A total of 903 patients with an early-stage breast cancer diagnosis were analyzed against 86 late-stage patients. A significantly higher proportion of late-stage patients had a history of diabetes (P = 0.003). There were no significant differences in age, body mass index, race, hypertension, autoimmune, or smoking status. A significantly higher proportion of late-stage patients underwent neoadjuvant chemotherapy (P < 0.001) and radiation (P < 0.001), whereas a significantly higher proportion of early-stage patients underwent adjuvant hormonal therapy (P = 0.006). Regarding hormone receptor status, a significantly higher proportion of late-stage patients were human epidermal growth factor receptor 2 (HER2)-positive (P < 0.001), whereas a significantly greater proportion of early-stage patients were estrogen receptor-positive (P < 0.001) and progesterone receptor-positive (P = 0.004). (See table, Supplemental Digital Content 1, which displays the demographics and details on breast cancer and its treatment, https://links.lww.com/PRSGO/E556.)

A significantly greater proportion of early-stage patients underwent 2-stage reconstruction with tissue expander (P = 0.002), whereas a significantly greater proportion of late-stage patients underwent delayed reconstruction (P < 0.001). A significantly higher proportion of early-stage patients underwent implant reconstruction (P = 0.039). There were no differences in patients undergoing autologous reconstruction, nor were there differences in the use of deep inferior epigastric perforator (DIEP), profunda artery perforator (PAP), or lumbar artery perforator (LAP) flaps between the early- and late-stage patient populations. More late-stage patients pursued oncoplastic reconstruction (P = 0.013) and were ultimately lost to follow-up (P = 0.022). There were no significant differences between groups for patients who decided to stop reconstruction and pursue nonsurgical options (P = 0.282) (Table 1). These nonsurgical options refer to patients who chose to remain flat, with or without the use of external breast prostheses.

Table 1.

Type of Reconstruction and Timing

	Early, n %	Late, n %	P
Reconstruction category	Implant: 338 (37.4)	Implant: 22 (25.6)	Implant: 0.029
	Flap: 507 (56.2)	Flap: 52 (60.5)	Flap: 0.440
	Oncoplastic: 11 (1.2)	Oncoplastic: 4 (4.7)	Oncoplastic: 0.013
	Flat: 12 (1.2)	Flat: 0 (0.0)	Flat: 0.282
	Lost to follow-up: 36 (4.0)	Lost to follow-up: 8 (9.3)	Lost to follow-up: 0.022
DIEP	401 (44.4)	37 (43.0)	0.224
PAP	73 (8.1)	4 (4.7)	0.256
LAP	28 (3.1)	2 (2.3)	0.689
Reconstruction timing	Immediate: 96 (10.6)	Immediate: 6 (7.0)	Immediate: 0.203
	Delayed-immediate: 362 (40.1)	Delayed-immediate: 31 (36.0)	Delayed-immediate: 0.125
	Delayed: 93 (10.3)	Delayed: 20 (23.3)	Delayed: <0.001

Bold indicates statistically significant values.

Patients were separated into implant and autologous groups to analyze reconstruction-specific complications. Three hundred thirty-eight early-stage patients and 22 late-stage patients underwent implant-based reconstruction. There were no significant differences in implant-related complications (Table 2). A total of 507 early-stage patients and 52 late-stage patients underwent autologous-based reconstruction. There were no significant differences in autologous-related complications (Table 3). There were no significant differences in donor-site complications between these groups (Table 4). Analysis of BREAST-Q survey responses was also completed. The postoperative response rates were 45.7% and 18.6% for early and late stages, respectively. There were no significant differences recorded for postoperative BREAST-Q responses (Tables 5, 6).

Table 2.

Implant Complications

	Early, n (%)	Late, n (%)	P
Hematoma	4 (1.2)	1 (4.5)	0.368
Seroma	2 (0.6)	0 (0.0)	0.662
Wound	4 (1.2)	0 (0.0)	0.536
Infection	12 (3.6)	0 (0.0)	0.282

Table 3.

Flap Complications

	Early, n (%)	Late, n (%)	P
Flap complication	182 (20.2)	20 (23.3)	0.324
Fat necrosis	81 (16.2)	6 (11.5)	0.482
Unspecified redness	28 (5.6)	4 (7.7)	0.437
Infection	32 (6.4)	5 (9.6)	0.289
Hematoma	17 (3.4)	3 (5.8)	0.312
Seroma	37 (7.4)	1 (1.9)	0.176
Wound	104 (20.8)	10 (19.2)	0.975

Table 4.

Donor-site Complications

	Early, n (%)	Late, n (%)	P
Donor-site complication	164 (18.2)	14 (16.3)	0.78
Abdominal fat necrosis	21 (2.3)	3 (3.5)	0.453
Unspecified redness	41 (4.5)	5 (5.8)	0.592
Infection	48 (5.3)	4 (4.7)	0.792
Hematoma	10 (1.1)	0 (0.0)	0.327
Seroma	28 (3.1)	1 (1.2)	0.309
Wound	135 (15.0)	15 (17.4)	0.538

Table 5.

BREAST-Q for Early- and Late-stage Patients Less Than 2 Years Postoperatively on Satisfaction, Psychosocial Well-being, Physical Well-being of the Chest, and Sexual Well-being

	Early	Late	P
Satisfaction with breasts	74.7 ± 20.9	79.2 ± 19.5	0.508
Psychosocial well-being	80.0 ± 21.9	87.1 ± 17.9	0.310
Physical well-being chest	82.4 ± 16.8	89.2 ± 13.2	0.206
Sexual well-being	60.7 ± 25.7	68.3 ± 29.6	0.420

Table 6.

BREAST-Q for Early- and Late-stage Patients Greater Than 2 Years Postoperatively on Satisfaction, Psychosocial Well-being, Physical Well-being of the Chest, and Sexual Well-being

	Early	Late	P
Satisfaction with breasts	71.9 ± 20.5	68.2 ± 28.5	0.703
Psychosocial well-being	78.0 ± 21.5	69.4 ± 33.9	0.396
Physical well-being chest	84.0 ± 16.0	73.6 ± 15.7	0.157
Sexual well-being	61.4 ± 23.6	62.8 ± 29.5	0.911

DISCUSSION

Breast cancer remains a significant health concern for women worldwide, with treatment strategies and outcomes often varying considerably depending on the stage of diagnosis. Although early-stage breast cancer frequently allows for a range of treatment options and improved prognoses, late-stage diagnoses present unique challenges due to potential disease spread and the need for more aggressive interventions. This disparity in disease presentation also influences decisions surrounding breast reconstruction, a crucial aspect of care aimed at improving patients’ quality of life and psychosocial well-being after treatment. This study investigated the differences in patient characteristics, treatment approaches, and reconstructive outcomes between women diagnosed with early-stage versus late-stage breast cancer, seeking to identify factors that may impact reconstructive choices and overall patient experiences.

Although existing literature suggests that younger women with breast cancer often face more aggressive disease and are more likely to carry genetic mutations, our study found no significant difference in age between late-stage and early-stage breast cancer patients.¹⁷ However, late-stage breast cancer patients exhibited a higher prevalence of diabetes, reflecting the complex relationship between diabetes and breast cancer.¹⁸ As expected, a higher proportion of late-stage patients were HER2-positive, whereas early-stage patients tended to be estrogen receptor- and progesterone receptor-positive. Reflecting the advanced nature of their disease, late-stage patients were also significantly more likely to receive neoadjuvant chemotherapy and radiation. Conversely, early-stage patients more frequently underwent adjuvant hormonal therapy, consistent with standard practice for earlier-stage, hormone-sensitive cancers. These findings supported the higher use of chemotherapy and radiation therapy among late-stage patients, as these treatments are standard for HER2-positive cases.¹⁹

In terms of reconstructive approaches, our findings revealed distinct patterns based on the stage of diagnosis. Early-stage patients were significantly more likely to undergo 2-stage reconstruction with tissue expander placement, facilitating a more immediate, though staged, approach to reconstruction. Conversely, late-stage patients were significantly more likely to experience delayed reconstruction, reflecting the prioritization of cancer treatment and the potential need for more extensive surgical procedures in advanced cases. This disparity likely stems from the need for adjuvant therapies, such as radiation, which can complicate immediate reconstructive efforts. One study demonstrated a higher rate of complications in patients with breast reconstruction when compared with patients with mastectomy alone, and these complications, in turn, were a significant risk factor for delay in adjuvant chemotherapy.²⁰ However, a systematic review showed that immediate breast reconstruction does not necessarily delay the start of adjuvant chemotherapy to a clinically relevant extent, suggesting that in general immediate breast reconstruction is a valid option for nonmetastatic breast cancer patients.²¹ Although this may be the case, many of our late-stage patients had metastatic breast cancer, and thus, a more conservative approach was taken.

Although our findings revealed distinct patterns in the timing of breast reconstruction based on disease stage, the choice of reconstructive modality also demonstrated interesting trends. Early-stage patients showed a higher propensity for implant-based reconstruction compared with late-stage patients. Interestingly, there were no significant differences between the 2 groups in the use of autologous reconstruction. Furthermore, there were no differences observed in the specific types of autologous flaps used (DIEP, PAP, or LAP). This suggests that although timing and type of reconstruction may differ based on stage, the overall consideration and application of autologous options remain consistent across both early- and late-stage patients.

Late-stage patients were more likely to be lost to follow-up or opt for oncoplastic reconstruction. However, there were no differences between early- and late-stage patients choosing to go flat after beginning reconstruction or in selecting nonsurgical options. This suggests that late-stage patients are pursuing surgical reconstructive options at a rate similar to that of early-stage patients. Reasons for patients being lost to follow-up included factors such as insurance changes, delays in reconstruction due to feeling unprepared, multiple comorbidities, seeking second opinions, being poor candidates for implants, complications with tissue expanders, death, and prioritizing chemotherapy and other treatments (Fig. 1). Given the mortality of late-stage disease, severity of associated complications, and intensity of treatment, these patients likely experienced a combination of these factors that contributed to their loss to follow-up.

Fig. 1.

Reasons for not pursuing breast reconstruction. TE, tissue expander.

There were no significant differences in autologous reconstruction-related complications or patient-reported outcomes between early- and late-stage patients. Similarly, no significant differences were observed in donor-site complications between the 2 groups. Analysis of BREAST-Q survey responses demonstrated a significantly higher response rate in the early-stage group compared with the late-stage group (45.7% versus 18.6%). Although BREAST-Q surveys were administered uniformly at 3, 6, 12, 18, 24, and 24+ months postoperatively, this discrepancy in response rates introduces the possibility of selection bias. Late-stage patients who completed surveys may represent a healthier or more motivated subset, potentially skewing the findings. Although there were no systematic differences in the timing of survey distribution, the lower response rate among late-stage patients likely reflects increased medical complexity, disease burden, and loss to follow-up. Therefore, although the similarity in BREAST-Q scores across groups is encouraging, these results should be interpreted with caution when generalizing to the broader late-stage population.

Ultimately, the decision to undergo breast reconstruction is highly personal and elective, with many factors, including comorbidities and patient preference, influencing the choice. Notably, some metastatic breast cancer patients may not be suitable candidates for surgery and anesthesia. It is important to acknowledge the limitations of this study, including the relatively small number of late-stage patients and the variability in follow-up duration. Because we aimed to capture all patients who underwent reconstruction with documented cancer staging, no exclusion criteria were applied. As a result, follow-up time varied considerably across the cohort, particularly among late-stage patients who were more likely to be lost to follow-up due to ongoing treatment, comorbidities, or disease progression. “Loss to follow-up” was defined as no clinical contact for more than 1 year after the last reconstruction-related visit. Although all included patients had at least 1 postoperative encounter, the absence of a uniform follow-up period may limit the interpretation of long-term complication rates and patient-reported outcomes.

Additionally, although important confounding variables such as reconstruction timing, radiation therapy, chemotherapy, and comorbidities were examined individually, multivariate regression was not performed, as it was outside the scope of this exploratory study. Immediate and delayed reconstruction are known to differ in complication profiles, and future studies with larger sample sizes should incorporate multivariable modeling to better isolate the independent effects of cancer stage on reconstructive outcomes.

Although limited by the relatively small number of late-stage patients, our findings nonetheless contribute to the growing body of literature on this insufficiently studied topic. Additional studies with larger cohorts are needed to clarify outcomes for patients with advanced disease, but our work highlights the feasibility of reconstruction in this population and underscores its potential role in supporting quality of life.

CONCLUSIONS

Our study contributed to the growing body of evidence supporting the feasibility and safety of breast reconstruction in late-stage breast cancer patients. Despite similar age, higher comorbidity burden, and the aggressive nature of their disease, late-stage patients can achieve reconstruction outcomes that are comparable in satisfaction to those of early-stage patients. Future research should continue to explore care protocols that can accommodate the unique challenges faced by late-stage breast cancer patients, with an emphasis on enhancing quality of life and patient satisfaction. Furthermore, larger studies with more diverse cohorts are needed to validate these findings and explore additional factors influencing reconstructive outcomes in late-stage patients. Ultimately, our findings underscore the importance of a multidisciplinary approach to breast cancer care that addresses the individual needs of each patient, regardless of disease stage, to optimize both survival and quality of life.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.