Research- Breast Reconstruction

Consolidating expertise in breast reconstruction research and practice

 With generous support from the Friends of the Mater Foundation (FOTM), Breast & Surgical Oncology at The Poche Centre (BSO) is involved in several clinical trials and research projects relating to quality of life and clinical outcomes for women who have undergone mastectomy and breast reconstruction following breast cancer.  The BSO team is research active and is developing a solid track record in publishing on breast reconstruction issues. We are developing local, national and international collaborations with other breast reconstruction researchers and actively promote our work. The unit has an immediate breast reconstruction rate of 41%, over three times the national average.

Breast reconstruction research

Dr Kathy Flitcroft PhD, who has academic appointments with the Northern Clinical School and the School of Public Health at the University of Sydney, has been coordinating several BSO breast reconstruction projects, funded by the FOTM Foundation, since 2014.

Improving Breast Reconstruction Equity of Access through Stakeholder consultation and Translation into policy and practice (I-BREAST)

This project comprised three components. The first was geo-spatial mapping of where BR was performed using 2013 data from the BreastSurgANZ Quality Audit. This mapping confirmed the concentration of BR services in capital city areas and along the south-eastern coastline. More surprisingly, detailed analysis of this data on a state and territory basis showed the lack of BR availability even within capital city areas, and subsequent analysis of data from the NSW Admitted Patient Data Collection confirmed this finding. Both studies revealed an estimated national and NSW BR rate of 18%, although accurate estimates are difficult to obtain in Australia.

The second component involved 90 in-depth interviews with breast and reconstructive plastic surgeons, health professionals and women with breast cancer over a two-year period. This qualitative data raised many issues surrounding access to, and satisfaction with, BR. As part of the I-BREAST project, three systematic reviews were undertaken. These explored women’s reasons for wishing to have BR,  women’s expectations of BR and decisional regret associated with their choice. I-BREAST interview data was used to document the impact that lack of BR choice can have on women and in two further publications currently under review: one on improving informed choice through designated referral pathways and another using BR as a case study of delivering patient-centred care. The latter paper provided examples of barriers to patient-centred care as well as cases of exemplary care delivered in well-resourced settings. A final two publications will be submitted shortly: the first on demarcation issues between sub-specialties of breast and plastic surgeons and the second on specific BR barriers in non-metropolitan areas of Australia.

The final stage of the I-BREAST project is a roundtable discussion that aims to translate these empirical findings into feasible and acceptable recommendations for policy and practice changes to reduce the unwarranted variation in access to this important component of cancer survivorship. This roundtable event is scheduled for October 2019 and a report of the outcomes will be published and made widely available.

Quality of Life following Immediate, Delayed or no breast reconstruction (QoLID)

This pilotstudyis the first Australian prospective cohort study to look at the impact of the choice of breast reconstruction (immediate, delayed or none) on quality of life measures and clinical outcomes for women undergoing mastectomy and PMRT for breast cancer. It was developed by Dr April Wong, the first surgical post-fellowship trainee supported by the FOTM, in collaboration with the team at BSO and other academic quality of life leaders. It is a longitudinal observational study that follows women for five years following their mastectomy. Waikato Hospital in New Zealand joined the pilot study as a second site in August 2014.  Analysis of the three month data was presented by Dr Wong at the ANZ Breast Cancer Trials Group meeting in Perth in 2015. Recruitment to this study is now completed at both sites, with 92 women participating. Analysis of the data is ongoing.

Breast reconstruction and radiotherapy for breast cancer

This study was a retrospective observational clinical trial of women with breast cancer who had mastectomy, immediate breast reconstruction and post-mastectomy radiotherapy (PMRT). This clinical trial, led by A/Prof Meagan Brennan and Prof Andrew Spillane, examined the impact of PMRT on a range of outcomes including quality of life, satisfaction with breast surgery results, psychological distress, post-decisional regret and body image. Data were also collected on clinical and oncological outcomes.  Abstract

Other projects

In addition, the BSO was a collaborating centre for An International Field Study of the Reliability and Validity of an EORTC Breast Reconstruction Questionnaire to Assess Quality of Life in all types of Breast Reconstruction – Phase IV. This was a major international study, run by the European Organisation for Research and Treatment of Cancer (EORTC), to validate a quality of life instrument specifically related to breast reconstruction. The BSO was one of the lead contributors to this study.

 Breast reconstruction publications

Publications from these research studies will reinforce the BSO’s growing expertise in this area.  Since 2014, we have published 22 articles specifically on breast reconstruction, with another three under review:

Published:

1)     Wong A, Snook K, Brennan M, Flitcroft K, Tucker M, Hiercz D, Spillane A. Increasing breast reconstruction rates by offering more women a choice. ANZ Journal of Surgery 2014; 84: 31-36. Abstract

2)     Brennan ME, Spillane A, Flitcroft K, Snook K, Wong A. Platinum multidisciplinary breast cancer care or platinum breast reconstruction? ANZ Journal of Surgery 2014; 84(9): 604-605. Abstract

3)     Flitcroft K, Spillane A, Brennan M, Snook K, Costa D, Wong A. The importance of choice: A prospective evaluation of factors affecting preference for immediate, delayed or no reconstruction in the context of mastectomy and post-mastectomy radiotherapy for breast cancer [abstract]. Eur J Surg Onc 2014; 41(6): S24. Abstract

4)     Brennan ME, Flitcroft K, Warrier S, Snook K, Spillane AJ. Immediate expander/implant breast reconstruction followed by post-mastectomy radiotherapy for breast cancer: Aesthetic, surgical, satisfaction and quality of life outcomes in women with high-risk breast cancer. The Breast 2016; 30: 59-65. Abstract

5)     Flitcroft K, Brennan M, Costa D, Spillane A. Documenting patterns of access to breast reconstruction in Australia: The National Picture. The Breast 2016; 30: 47-53. Abstract

6)    Flitcroft K, Brennan, ME, Spillane AJ. Difficulties of sourcing Australian health data: The case of breast reconstruction. ANZ Journal of Surgery 2016. 86(7-8): 537-9. Abstract

7)     Oh D, Flitcroft K, Brennan ME, Spillane AJ. Patterns and outcomes of breast reconstruction in older women – a systematic review of the literature.  Eur J Surg Oncol 2016; 42: 604-615. Abstract

8)     Brennan ME, Flitcroft K, Warrier S, Snook K, Spillane AJ. Immediate expander/implant breast reconstruction followed by post-mastectomy radiotherapy for breast cancer: Aesthetic, surgical, satisfaction and quality of life outcomes in women with high-risk breast cancer. The Breast 2016; 30: 59-65. Abstract

9)     Flitcroft K, Brennan M, Costa D, Spillane A. Documenting patterns of access to breast reconstruction in Australia: The National Picture. The Breast 2016; 30: 47-53. Abstract

10)  Flitcroft K, Brennan, ME, Spillane AJ. Difficulties of sourcing Australian health data: The case of breast reconstruction. ANZ Journal of Surgery 2016. 86(7-8): 537-9. Link to journal

11)  Flitcroft K, Brennan ME, Costa D, Wong A, Snook K, Spillane AJ. An evaluation of factors affecting preference for immediate, delayed or no breast reconstruction in women with high risk breast cancer. Psycho-oncology 16 Feb 2016. doi: 10.1002/pon.4087. Abstract

12)  Winters Z, Azfal M, Rumpold G, Holzner B, Oberguggenburger A, Da Costa Vieira R, Hartnup S, Flitcroft K, Bjelic-Radisic V, Panouilleres M, Rydevik-Mani M, King M, Rutherford C. International validation of the EORTC Patient-Reported Outcome Measure (PROM) in breast reconstruction (BRR): Evaluating health related quality of life (HRQL) and clinical effectiveness [abstract]. Eur J Surg Oncol 2016. Abstract
DoI: http://dx.doi.org/10.1016.ejso.2016.02.042

13) Feng Y, Flitcroft K, van Leeuwen MT, Elshaug AG, Spillane A, Pearson S-A. Patterns of immediate breast reconstruction in New South Wales, Australia: A population-based study. ANZ J Surg (accepted 24 June 2019).

14) Oh D, Flitcroft K, Meagan E Brennan, Kylie Snook, Andrew J. Spillane. Outcomes of breast reconstruction in older women: Patterns of uptake and clinical outcomes in a large metropolitan practice. ANZ J Surg May 2019 doi:10.1111/ans.15145

15) Flitcroft KL, Brennan ME, Spillane AJ. The impact on Australian women of lack of choice of breast reconstruction options: A qualitative study. Psycho-oncology 2019; 28(3): 547-52. https://doi.org/10.1002/pon.4974

16) Azimi F, Flitcroft K, Mathieu E, Karantonis R, Snook K, Spillane A. Low level laser treatment is ineffective for capsular contracture. Results of the LaTCon randomised controlled trial. Plast Reconstr Surg 2018; 142: 621e-31e.

17) Oh D, Flitcroft K, Meagan E Brennan, Kylie Snook, Andrew J. Spillane. Patient-reported outcomes of breast reconstruction in older women: Audit of a large metropolitan public/private practice in Sydney, Australia. Psycho-Oncology Sept 2018. DOI:  10.1002/pon.4895

18) Flitcroft K, Brennan M, Spillane A. Decisional regret and choice of breast reconstruction following mastectomy for breast cancer: A systematic review. Psycho-Oncology. 2018; 27:1110–20 DOI: 10.1002/pon.4585

19) Winters ZE, Afzal M, Rutherford C, Holzner B, Rumpold G, da Costa Vieira RA, Hartup S, Flitcroft K, Bjelic-Radisic V, Oberguggenburger A, Panouilleres M, Mani MR, Catanuto G, Douek M, Kokan J, Sinai P, King MT. On behalf of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life group.  International validation of the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ) for women undergoing breast reconstruction: the QLQ-BRECON23. Br J Surg 2018; 105: 209–22. DOI: 10.1002/bjs.10656

20) Flitcroft K, Brennan M, Costa D, Spillane A. Regional variation in immediate breast reconstruction rates in Australia. BJS Open 2017; 1: 114-21. DOI: 0.1002/bjs5.19

21) Flitcroft K, Brennan M, Spillane A. Making decisions about breast reconstruction: A systematic review of patient-reported factors influencing choice. Quality of Life Research 2017; 26(9), 2287-2319. doi:10.1007/s11136-017-1555-z.

22) Flitcroft K, Brennan M, Spillane A. Women’s expectations of breast reconstruction following mastectomy for breast cancer. A systematic review. Supportive Care in Cancer, 2017;25(8):2631-2661.

Breast reconstruction collaborations

In addition to our international collaboration with the EORTC group, we also have strong research links with several groups at The University of Sydney including the School of Public Health, the Northern Clinical School and the Psycho-Oncology Cooperative Research Group that has a focus on quality of life outcomes for cancer patients. The BSO has facilitated links with the Australasian Society of Plastic Surgeons (ASPS), and has written a position statement for Breast Surgeons ANZ (BreastSurgANZ) on recommended investigations prior to breast surgery, which the ASPS supports.