Breast reconstruction in older patients: A literature review of the decision-making process

Women not undergoing breast reconstruction after mastectomy tend to be older. This review aims to aid in effective, evidence-based choices regarding breast reconstruction in an older population, appraising the influencing patient factors described in the literature and those directing the reconstructive surgeon. This may refute current misconceptions and ensure surgical decisions are made based on evidence without ageist assumptions. The review forms the basis of an evidence-based algorithm addressing each step of the decision-making process.

A literature search was conducted using PubMed, Medline, Evidence.nhs.uk and the Cochrane database. Search terms initially were breast reconstruction, mastectomy, elderly, older, decision, reasons and rationale. A separate literature search was performed for each of the individual 'steps' in the decision-making process.

Overall, 44 papers were obtained. For each section of the decision-making process, titles and abstracts were screened for relevance. Only English language papers were included.

If reconstruction is oncologically plausible and co-morbidities and frailty formally assessed, older women should be actively informed about breast reconstruction, receive support and engage in 'shared decision-making'. The older patient is less likely to do research independently. Amongst other factors, body image, cancer fears, employment and carer responsibilities play a part in the decision. With adequate preoperative and frailty assessment and early involvement of the geriatrician and anaesthetist, microsurgical reconstruction is safe. Autologous reconstruction has better long-term outcomes than implant-based reconstructions in this age group, correlating with improved survival and longevity of reconstruction. Age alone should not be considered a contraindication to breast reconstruction.