Severely obese breast cancer patients should delay breast reconstruction following mastectomy until they have lost considerable weight. That was the conclusion of a study presented at the American Society of Plastic Surgeons (ASPS) “Plastic Surgery 2006” conference.
Such patients have a much higher risk of serious complications than those classified as overweight or even moderately obese by body mass index (BMI) criteria, according to the study, which was led by Elizabeth K. Beahm, MD, Associate Professor of Surgery at the University of Texas M. D. Anderson Cancer Center.
Due to concern over increasing numbers of reports of poor outcomes appearing in the literature, more surgeons are refusing to operate on massively obese breast cancer patients after mastectomy, she noted in an interview.
''Nevertheless, plastic surgeons still seek safer variations of operative techniques to help obese women undergo the established two-stage procedure of mastectomy followed by reconstruction. Just because someone is overweight doesn't mean she should not be entitled to undergo breast reconstruction after mastectomy. Patients want to feel ‘whole’ again.…It can be an important aspect of recovery from cancer.
“But the surgeons also worry about the dangers introduced by severe obesity,” Dr. Beahm continued. “At the same time, we don't want to deprive patients of the benefits of reconstruction because of empiric concerns for their weight.”
Some 58,000 post-mastectomy patients—“of all shapes and sizes”—underwent breast reconstruction in 2005, double the number seen a decade earlier, she noted. Despite “the epidemic of obesity,” however, there still are no national guidelines to help decision-making when breast reconstruction is being considered.
15-Year Retrospective Study of 3,518 Patients
Her team's 15-year (1990–2005) retrospective study of 3,518 breast cancer patients confirmed the results of previous investigations of the risks of any surgery in the obese, finding that patients with a BMI of 35 or greater showed significantly poorer outcomes for all types of breast reconstruction, from implants to flaps.
In morbidly obese patients with a BMI over 40, the complication rate approached 100%—“Interestingly, there were no deaths, even in the most problematic of cases,” Dr. Beahm remarked.
The BMIs in the study patients ranged from 15.2 to 59.9. Complications evaluated by the researchers included fluid collections and infection at both the reconstructive site and the donor site, usually in the abdomen.
The study also assessed the significance of fat necrosis; delayed wound healing; and chronic pain, bulge, and hernia in the abdominal wall. Additionally, the researchers reported on a variety of medical problems, including pulmonary emboli and deep vein thrombosis—to which obese patients are particularly prone—and long hospital stays. Also analyzed was the overall aesthetic outcomes.
Heaviest Women Least Satisfied with Aesthetic Outcome
Significantly, the study found that the heaviest women were the ones least satisfied with the aesthetic outcome of the surgery. Nonobese patients (those with a BMI under 35) served as the control group for comparisons.
“Ideally, we prefer to carry out the two operations as a single two-part procedure—mastectomy with immediate breast reconstruction,” Dr. Beahm said. “Most patients prefer this as well.”
The delay involved in two separate procedures exposes the patients to twice the risks inherent in surgery and general anesthesia. Nevertheless, “when the women being considered for breast reconstruction are massively obese, we urge delay in Stage two of the surgery until patients achieve a healthier body weight…via a tailored diet and exercise program.” The wait could take years, she noted.
Previous research shows that a simple lifestyle change such as adopting a low-fat diet regimen plus a moderate daily workout could have important additional health benefits as well—on the heart, for example. For some very obese women, certain drugs may also be helpful in achieving and maintaining weight loss.
“But we [surgeons] don't direct those interventions,” Dr. Beahm said. ''When the BMI tells us the patient is at great risk due to severe obesity, we explain the facts to her, then refer her to the special trainers. We hope the patient will be back with us soon—leaner, healthier, and ready for breast reconstruction.
''We don't want her to wait until she's actually skinny. Being overweight by itself is not necessarily a risk factor in all patients. It's the morbid condition we're afraid of.
“While it's very difficult to tell a patient she has to wait for breast reconstruction, ‘safety first’ must be our motto. We cannot compromise the oncologic imperative in breast cancer. Each case must be individualized and candidates for reconstruction carefully scrutinized.”
The Texas researchers recommend a prospective study to develop a treatment algorithm for breast reconstruction in cancer patients with a BMI over 35.
“Hardly a week goes by without a patient telling me how happy she is with the results of reconstructive surgery, how strongly she believes the whole procedure has helped her get over her cancer,” said Walter Erhardt, MD, a former President of ASPS, a plastic surgeon in private practice in Albany, GA. “But these women were not massively obese.”
His own experience confirms a main finding of Dr. Beahm's study, he said—that regardless of the actual appearance of their reconstructed breasts, extremely heavy patients have a low level of satisfaction compared with that of patients with less girth. “This really frustrates the plastic surgeon who must deal with the many complexities of obese tissue,” Dr. Erhardt commented.
Perhaps very obese patients have long been displeased with their body image and secretly envision a total makeover instead of just breast reconstruction, he speculated.
“Getting down to a healthier weight and a firmer body does improve their overall self-image and then they tend to express pleasure over their reconstructed breasts. We've seen this happen and it makes us feel better, too.”
Due to concern over increasing numbers of reports of poor outcomes appearing in the literature, more surgeons are refusing to operate on massively obese breast cancer patients after mastectomy…., “Nevertheless, plastic surgeons still seek safer variations of operative techniques to help obese women undergo the established two-stage procedure of mastectomy followed by reconstruction. Just because someone is overweight doesn't mean she should not be entitled to undergo breast reconstruction after mastectomy.”
Howard T. Wang, MD, Assistant Professor of Surgery at the University of Texas Health Sciences Center at San Antonio, agrees: “It would be ideal if the patient could improve her health prior to surgery,” he said. ''Nor is obesity per se a contraindication for reconstruction.
''Americans in general have gotten heavier in the last few decades. It's extreme obesity—BMI over 40—that's dangerous; I also believe that limiting surgery in this group is a reasonable suggestion. Additionally, one needs to study medical factors such as diabetes in this population and determine how these contribute to morbidity when surgery comes into the picture.
“Still' he continued, being very thin is a problem, too. Such women have a difficult time having enough fat tissue available for reconstruction.”