Breast reconstruction in elderly women breast cancer: a review

Introduction: The elderly population is rapidly increasing, and with cancer, particularly breast cancer, being most prevalent in this group, its management is becoming increasingly important. A major aspect of breast cancer treatment and subsequent quality of life is the opportunity for reconstructive surgery post-mastectomy. This is particularly important as survival rates are improving, so a larger proportion of patients are living with the long term consequences of their treatment. Evidence has shown that age itself is not a risk factor for poor surgical outcomes, but concern over this causes surgeons to be wary of offering elderly patients the opportunity of reconstruction. Elderly patients themselves are also less likely to request or accept reconstruction.

Methods: Literature searches using keywords 'breast reconstruction', 'older' and 'elderly' were carried out on Pubmed, Scopus and Google Scholar. Results were limited to English language, and then manually searched to exclude irrelevant articles. Duplicates were removed and a series of articles were reviewed.

Results: Surgery was well tolerated in elderly patients, with complication rates comparable to a younger group. Autogenous tissue produced better outcomes than implant reconstruction. In areas such as social functioning and emotional wellbeing, patients with reconstructive surgery showed better outcomes than those without.

Discussion: The research on this topic is limited and only available in the form of case series. Direct comparison between these series cannot be drawn. The available series lack a clear assessment of the patient's frailty and do not define which patients should be offered breast reconstruction and which ones should be denied. Despite this, the evidence strongly suggests that it would be beneficial to offer elderly patients reconstructive surgery, dependent on their individual risk. A careful pre-operative assessment allows selecting the appropriate candidate on the basis of fitness, particularly when long and complex reconstructive procedures involving microvascular transfer such as DIEP or free TRAM flaps are considered. Reasons why patients decide to decline breast reconstruction may have altered more recently with wider media coverage and information especially on the internet. There are also real issues with availability of highly trained surgical teams capable of performing microsurgical transfer procedures, theatre availability and constraints due the present economic recession. Thus, there are multiple factors that influence breast reconstruction and patients, even in different parts of a single country, may have variations in the algorithm of options offered for breast reconstruction.