Breast Reconstruction in the Setting of Postmastectomy Radiotherapy: Controversies and Disparities

The complex decision of breast reconstruction in the setting of postmastectomy radiotherapy (PMRT) involves an understanding of the indications of PMRT and weighing the risks and benefits of various reconstruction options suitable for each patient. Classic indications for PMRT include patients with at least T3 tumors, 4 or more positive lymph nodes, and/or positive surgical margins. The benefit of PMRT in patients with T1-T2 tumors with 1 to 3 positive lymph nodes, however, remains unclear. Breast reconstruction is known to improve quality of life in breast cancer patients. Reconstruction rates have continued to increase despite the lack of medical consensus in these patients with early cancers and limited nodal burden. A collaborative effort among providers is therefore of utmost importance in selecting an optimal approach of reconstruction in the setting of PMRT to minimize postoperative complications. In this review, we discuss the advantages and disadvantages of each reconstruction method with PMRT and highlight the practice patterns at different types of institutions, especially noting the disparities seen at safety net institutions. By refocusing on this important topic, we hope to encourage a multidisciplinary effort to reduce disparities and find innovative algorithms that can be applied to patients at diverse institutions.