Oncologic Outcomes After Neoadjuvant Chemotherapy and Postmastectomy Breast Reconstruction

For women with breast cancer, rates of locoregional recurrence after skin- and nipple-sparing mastectomy are low (approximately 5%) and often exceeded by those for distant metastases.^1,2 As a result, these contemporary mastectomy techniques in conjunction with breast reconstruction have become widely adopted owing to improved patient-reported outcomes related to cosmesis and quality of life.

The NSABP B-18³ and NSABP B-27⁴ clinical trials ushered in a different but equally important paradigm shift in the treatment of breast cancer by demonstrating the safety and efficacy of preoperative systemic therapy. Response to neoadjuvant chemotherapy (NACT) has emerged as an important prognosticator and factor in adjuvant-treatment decisions. Pathologic complete response is associated with survival and may facilitate eligibility for breast conservation and obviate the need for axillary lymphadenectomy.^5,6 But more recently, receipt of NACT has been paradoxically associated with more extensive surgery, specifically higher rates of bilateral mastectomy and postmastectomy reconstruction in women who might otherwise have been candidates for lumpectomy.⁷

In this issue of JAMA Surgery, Wu et al⁸ evaluate breast cancer outcomes associated with these contemporary trends in more than 1200 women who underwent NACT followed by mastectomy at a single institution. At a median follow-up of approximately 5.5 years (67-68 months), the authors found comparable locoregional (3.7% vs 3.4%; P = .83) and distant (17.3% vs 18.6%; P = .68) recurrence rates as well as no significant difference in disease-specific and overall survival between the propensity score-matched cohorts of women undergoing skin- and nipple-sparing mastectomy with immediate breast reconstruction vs total mastectomy without reconstruction. The complex interaction of NACT and reconstruction as it pertains to surgical complications, reconstruction fatigue, costs, and patient satisfaction remains poorly characterized, but this study by Ko and colleagues⁸ provides reassurance that acceptable oncologic outcomes might be preserved in the setting of immediate breast reconstruction following NACT. Thus, post-NACT surgical decisions should be made in the context of other patient and treatment characteristics that predispose women to perioperative complications and suboptimal outcomes (eg, obesity, history of or potential for future radiotherapy, and smoking).^9,10 Socioeconomic factors and degree of perioperative support also are important in facilitating successful, integrated oncologic care and breast reconstruction. In addition, although they may be difficult to discern in the relatively well-resourced patients who typically pursue reconstruction, factors that promote or detract from equitable, patient-centered care should be sought and identified in future work conducted in diverse populations.

Arguably, improvements in systemic therapy for breast cancer will outpace surgical advancements in the coming decades. This important study by Ko et al⁸ suggests the oncologic safety of NACT and immediate breast reconstruction and may further encourage the surgical community to embrace novel advances that allow us to provide high-quality multi-disciplinary breast cancer care without losing the outcomes that are important to patients.