Breast reconstruction combined with radiation therapy: long-term risks and factors related to decision making

Mastectomy with immediate breast reconstruction is a surgical procedure that addresses both the need to perform a cancer operation, and the desire of the patient to emerge from anesthesia with a replacement breast. An increasing number of these women with invasive breast cancer will benefit from chest wall and regional nodal radiation, in terms of both a decreased risk in local-regional recurrence and an increased chance of overall survival at 10 years and beyond, based on the most recent 2005 Oxford Overview.Indications for recommending radiation are based primarily on the pathologic assessment of the primary tumor and the axillary lymph nodes. More than a decade ago, only women with 10 or more involved nodes were thought to benefit from this treatment; that recommendation shifted to women with 4 or more involved nodes with the publication of the American Society for Clinical Oncology (ASCO) guidelines in 2001 and more recently to considering postmastectomy radiation (PMRT) in women with 1 to 3 positive nodes.In some scenarios, the need for PMRT is recognized before the patient goes to surgery, and reconstruction can be planned with this in mind, as discussed elsewhere in this issue. In other scenarios, the need for radiation is not realized until the final pathology report is back in the surgeon's hands. If that patient has elected an immediate reconstruction, is the radiation feasible and is it effective? Our published experience at Memorial Sloan Kettering (MSK) Cancer Center suggests the answer to both questions is "yes." However, our results differ dramatically from that of other major centers. Both our experience and that of others is discussed in this article.