Original ReportRadiation practice patterns among United States radiation oncologists for postmastectomy breast reconstruction and oncoplastic breast reduction
Introduction
According to the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database, an estimated 226,870 women will be diagnosed with breast cancer in the United States in 2012, with more than 17% of these cases resulting in death (SEER).1 With improvements in early detection as well as the effectiveness of treatment options, the rates of cancer deaths have steadily decreased over the past 2 decades (SEER).2 With an increase in survivorship, issues relating to quality of life and reconstructive options have modified the context of disease. Recent analyses have found that since 2005 the rate of mastectomy is increasing across all age groups, particularly for women less than 50 years old and greater than 70 years old3; just between 2009 and 2010, the rates of breast reconstructive procedures increased by 8%.4
Breast tissue expanders (TEs) are a commonly utilized reconstruction technique following mastectomy. This technique can be achieved in either a 1-stage or 2-stage reconstructive process. The 1-stage technique is performed as collaboration between the breast surgeon and plastic surgeon. It involves placement of an expandable tissue expander, which is gradually filled over time with saline through an internal valve. Once ideal size is achieved, the internal valve of the expander may be closed and this expander will stand as the patient’s new permanent implant. In the 2-stage reconstructive process a saline-filled tissue expander is placed at the time of surgery and then gradually filled to achieve a desired size. Once ideal size is achieved, a second surgery is performed, exchanging the saline tissue expander for a permanent implant. The permanent implant can be inserted after all adjuvant treatments have been completed. This 2-stage “intermediate” approach has grown in favor, particularly for early-stage breast cancer patients with an uncertain requirement of postmastectomy radiation therapy.5
If a patient requires radiation therapy following mastectomy, there is much variability among practitioners with respect to radiation technique. Some of the variables specific to radiation are whether or not to keep the TE inflated or deflated during radiation therapy, delivery of a boost dose in the presence of a TE, utilization of bolus, thickness of bolus material used, and frequency of placement of bolus material. These variables may have effects on the desired dose distribution of radiation therapy, postoperative healing, and psychologic recovery of the patient.
We created a short clinical questionnaire focusing on the practice patterns for breast cancer reconstruction and radiation therapy. This survey was sent nationwide to radiation oncologists.
Section snippets
Methods and materials
A 14-question survey was created with question topics ranging from practice type, practice size, TE use, timing of reconstruction surgery, postmastectomy (PM) radiation boost, and bolus. This survey was created via SurveyMonkey (https://www.surveymonkey.com/). The survey was sent via email to over 1000 active email addresses of breast cancer specialists (physicians, physicists, nurses, and technicians) obtained from the American Society for Radiation Oncology member directory, who self-claimed
Results
Of the 1535 emails (collective of physicians, technicians, physicists, and nurses gathered from the member directory of the American Society for Radiation Oncology that self-claimed that they treat breast cancer patients), we received a total of 271 (17.6%) responses from radiation oncologists that fully completed survey responses. Responses were received from physicians throughout the country, establishing a representation from the United States (US) and District of Columbia. Fifty-nine
Discussion
We observed in this analysis that nearly all radiation oncologists participating in the survey (95.9%) treat patients with TEs after mastectomy. This technique dates back to 1982, when Radovan6 proposed a gradual method of tissue expansion to replace skin loss. Since then, this technique has evolved the methods of reconstruction in postmastectomy patients.
The use of tissue expansion in the context of adjunctive therapies has provided an alternative to autogenous reconstruction with acceptable
References (21)
- et al.
Failure rate and cosmesis of immediate tissue expander/implant breast reconstruction after postmastectomy irradiation
Clin Breast Cancer
(2012) - et al.
Current clinical coverage of Radiation Therapy Oncology Group-defined target volumes for postmastectomy radiation therapy
Pract Radiat Oncol
(2012) - et al.
The effect of adjuvant postmastectomy radiotherapy bolus technique on local recurrance
Int J Radiat Oncol Biol Phys
(2011) - et al.
Surgical clips for position verification and correction of non-rigid breast tissue in simultaneously integrated boost (SIB) treatments
Radiother Oncol
(2009) - et al.
Variability of target and normal structure delineation for breast cancer radiotherapy: An RTOG Multi-Institutional and Multiobserver Study
Int J Radiat Oncol Biol Phys
(2009) - et al.
Role of postmastectomy radiation after neoadjuvant chemotherapy in stage II-III breast cancer
Int J Radiat Oncol Biol Phys
(2012) Cancer Facts & Figs
SEER Stat Fact Sheets: Breast
- et al.
Increasing mastectomy rates among all age groups for early stage breast cancer: A 10-year study of surgical choice
Breast J
(2012) American Society of Plastic Surgeons Report of the 2010 Plastic Surgery Statistics
Cited by (31)
Randomized clinical trial of tissue equivalent bolus prescription in postmastectomy radiotherapy stratified by skin involvement status
2023, Clinical and Translational Radiation OncologyThe Effect of Bolus on Local Control for Patients Treated With Mastectomy and Radiation Therapy
2021, International Journal of Radiation Oncology Biology PhysicsCitation Excerpt :An international survey study of bolus use in 2004 reported that North Americans (82%) and Australasians (65%) were more likely to always use bolus than Europeans (31%).6 Surveys from the past decade report that bolus was used routinely for 36% of chest wall and 16% of reconstruction cases in Europe, whereas bolus was used for 55% of chest wall and 52% of reconstruction cases in North America.7-10 This trans-Atlantic difference of opinion is reflected in the difference between the breast atlases of the Radiation Therapy Oncology Group (RTOG), which includes skin in its chest wall clinical target volume (CTV), and the European Society for Therapeutic Radiology and Oncology (ESTRO), which excludes the ventral 5 mm of skin and subcutaneous tissue from the chest wall CTV.11-13
Impact of radiation dose on complications among women with breast cancer who underwent breast reconstruction and post-mastectomy radiotherapy: A multi-institutional validation study
2021, BreastCitation Excerpt :In the current study, boost RT was performed generally in patients with positive or close margins upon institutional preferences. Overall 15.6% of the patients received boost RT, which is a fairly small percentage compared to a US survey in 2014, in which 66.5% of responders answered that they would prescribe boost RT [25]. Recently, Naoum et al. [26] investigated the impact of the addition of chest wall boost RT on breast reconstruction morbidity.
Radiotherapy After Skin-Sparing Mastectomy and Implant-Based Breast Reconstruction
2019, Clinical Breast CancerCitation Excerpt :When used, generally a 0.5-cm bolus is reported to be placed on the RB during the entire treatment. Similarly, Thomas et al39 reported the rate of using bolus in patients with breast reconstruction as approximately 50% in the United States with different schemes such as 0.5 cm every other day, 0.5 cm every day as tolerated, 1 cm every other day, and 1 cm every day as tolerated. It is a fact that bolus use increases the rate of acute skin complications and in patients with IBR it can also impair cosmetic outcomes.
The Impact of Chest Wall Boost on Reconstruction Complications and Local Control in Patients Treated for Breast Cancer
2019, International Journal of Radiation Oncology Biology PhysicsCitation Excerpt :Patients with breast cancer who are undergoing PMRT typically receive radiation doses between 50 and 50.4 Gy in 1.8- to 2-Gy fractions daily, 5 days per week.20 Adding CWB to the mastectomy scar or chest wall for at least a total dose of 60 to 60.4 Gy remains debatable among radiation oncologists.15,16 The rationale for boost is extrapolated from clinical evidence of improved local tumor control with a boost to the lumpectomy cavity in a breast-conserving management setting.21
Conflicts of interest: None.
- 1
Co-first authors.