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LETTERS Breast Reconstruction after Mastectomy Michael J Halls, BSc, MD, FRCS(C), FACS San Diego, CA In reaction to the Collective Review, by Lee and col- leagues, 1 I would caution any clinical decisions or referral bias based on the reported findings. As a reconstructive plastic surgeon, practicing for the last twenty-five years, I have seen an incredible evolution in breast reconstructive techniques and implants. Lumping together studies as far back as 1987 does not do justice to the current state of the art. Our recent literature is replete with more recent studies of patients’ positive feelings con- cerning their reconstructions. 2 Although discussed briefly by Lee and colleagues, 1 the pa- tient bias is the single most important aspect of these kinds of studies. Those who select reconstruction already have placed themselves in an unmatchable cohort as they have brought personal expectations and experiences into that choice. Pa- tients who decide against reconstruction obviously have a dif- ferent mindset on what is acceptable to their own self-image and sexual identity. These patients are often older as well. Patients should best be educated about, and offered all fea- sible methods of breast cancer management including options for both immediate and delayed reconstruction. The decision as to how to proceed will always remain an intensely personal decision for the patient herself rather than a physician’s choice. On a personal note, the number of women who have lived with a mastectomy deformity and then opted for reconstruction, in my practice, have never wished to return to that deformity. REFERENCES 1. Lee C, Sunu C, Pignone M. Patient-reported outcomes of breast reconstruction after mastectomy: a systematic review. J Am Coll Surg 2009;209:123–133. 2. Hu E, Pusic A, Waljee J, et al. Patient-reported aesthetic satis faction with breast reconstruction during the long-term survivor- ship period. Plast Reconstr surg 2009;124:1–8. Reply Clara Lee, MD, Christine Sunu, BA, Michael Pignone Chapel, NC We would like to thank Dr Halls for his letter.We agree that the decision about breast reconstruction is “an intensely per- sonal decision.” In fact, the decision about breast reconstruc- tion is a perfect example of a “preference sensitive” decision, for which the right choice depends primarily upon the pa- tient’s personal preferences. Such decisions call for shared de- cision making between the patient and her providers. We also agree that bias arising from patient differences fundamentally limits the literature on outcomes of breast reconstruction. Without prospective measurement of pa- tient characteristics prior to surgery, accurate evaluation of postoperative outcomes is a challenge. We question, how- ever, the notion of “an unmatchable cohort,” which could conceivably apply to just about any treatment decision. Rigorous methods exist for minimizing bias in clinical studies of treatment efficacy and could certainly apply to the study of reconstruction outcomes. Regarding the date of studies included in our review, we note that 20 of 33 studies were published in the past 10 years and were no more likely than older studies to find a positive outcome of reconstruction. Recent studies of breast reconstruction, such as the one that Dr Halls cites, do provide insight into outcomes of reconstruction, but not in relation to outcomes of mastectomy. We believe that an opportunity exists to raise the bar on studies of breast reconstruction after mastectomy. Surgeons ought to collaborate to conduct prospective cohort studies of breast reconstruction that include measurement of pre- treatment characteristics and patient preferences. Such studies ideally would use validated patient–reported outcome mea- sures and prioritize the patient’s perspective over that of providers. Postoperative Morbidity with Diversion after Low Anterior Resection in the Era of Neoadjuvant Therapy: A Single Institution Experience Giuseppe Pappalardo, MD, FACS, Domenico Spoletini, MD Rome, Italy The use of a protective stoma in anterior resection and in coloanal anastomoses for rectal cancer was, till now, con- troversial. 1,2 Neoadjuvant therapy is considered a risk factor 790 © 2009 by the American College of Surgeons ISSN 1072-7515/09/$36.00 Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2009.08.016
Transcript of Reply
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reast Reconstructionfter Mastectomy
ichael J Halls, BSc, MD, FRCS(C), FACS
an Diego, CAn reaction to the Collective Review, by Lee and col-eagues,1 I would caution any clinical decisions or referralias based on the reported findings.As a reconstructive plastic surgeon, practicing for the last
wenty-five years, I have seen an incredible evolution inreast reconstructive techniques and implants. Lumpingogether studies as far back as 1987 does not do justice tohe current state of the art. Our recent literature is repleteith more recent studies of patients’ positive feelings con-
erning their reconstructions.2
Although discussed briefly by Lee and colleagues,1 the pa-ient bias is the single most important aspect of these kinds oftudies. Those who select reconstruction already have placedhemselves in an unmatchable cohort as they have broughtersonal expectations and experiences into that choice. Pa-ients who decide against reconstruction obviously have a dif-erent mindset on what is acceptable to their own self-imagend sexual identity. These patients are often older as well.
Patients should best be educated about, and offered all fea-ible methods of breast cancer management including optionsor both immediate and delayed reconstruction. The decisions to how to proceed will always remain an intensely personalecision for the patient herself rather than a physician’s choice.
On a personal note, the number of women who haveived with a mastectomy deformity and then opted foreconstruction, in my practice, have never wished to returno that deformity.
EFERENCES
. Lee C, Sunu C, Pignone M. Patient-reported outcomes of breastreconstruction after mastectomy: a systematic review. J Am CollSurg 2009;209:123–133.
. Hu E, Pusic A, Waljee J, et al. Patient-reported aesthetic satisfaction with breast reconstruction during the long-term survivor-ship period. Plast Reconstr surg 2009;124:1–8.
eply
lara Lee, MD, Christine Sunu, BA,ichael Pignone
hapel, NC t7902009 by the American College of Surgeons
ublished by Elsevier Inc.
e would like to thank Dr Halls for his letter. We agree thathe decision about breast reconstruction is “an intensely per-onal decision.” In fact, the decision about breast reconstruc-ion is a perfect example of a “preference sensitive” decision,or which the right choice depends primarily upon the pa-ient’s personal preferences. Such decisions call for shared de-ision making between the patient and her providers.
We also agree that bias arising from patient differencesundamentally limits the literature on outcomes of breasteconstruction. Without prospective measurement of pa-ient characteristics prior to surgery, accurate evaluation ofostoperative outcomes is a challenge. We question, how-ver, the notion of “an unmatchable cohort,” which couldonceivably apply to just about any treatment decision.igorous methods exist for minimizing bias in clinical
tudies of treatment efficacy and could certainly apply tohe study of reconstruction outcomes.
Regarding the date of studies included in our review, weote that 20 of 33 studies were published in the past 10ears and were no more likely than older studies to find aositive outcome of reconstruction. Recent studies ofreast reconstruction, such as the one that Dr Halls cites,o provide insight into outcomes of reconstruction, butot in relation to outcomes of mastectomy.We believe that an opportunity exists to raise the bar on
tudies of breast reconstruction after mastectomy. Surgeonsught to collaborate to conduct prospective cohort studies ofreast reconstruction that include measurement of pre-reatment characteristics and patient preferences. Such studiesdeally would use validated patient–reported outcome mea-ures and prioritize the patient’s perspective over that ofroviders.
ostoperative Morbidity withiversion after Low Anterior Resection
n the Era of Neoadjuvant Therapy:Single Institution Experience
iuseppe Pappalardo, MD, FACS,omenico Spoletini, MD
ome, Italyhe use of a protective stoma in anterior resection and in
oloanal anastomoses for rectal cancer was, till now, con-
roversial.1,2 Neoadjuvant therapy is considered a risk factorISSN 1072-7515/09/$36.00doi:10.1016/j.jamcollsurg.2009.08.016
