A recent study titled “Predicting complications in immediate microvascular breast reconstruction: Validity of the Breast Reconstruction Assessment (BRA) surgical risk calculator” shines a light on the challenges of accurately predicting postoperative complications in microvascular breast reconstruction. The study led by Anne C. O’Neill and her research team at the University of Toronto raises concerns regarding the effectiveness of the BRA score, a tool that has been widely used but has not undergone extensive external validation in this specific cohort.
Background of the Study
Breast cancer is the most common cancer among women worldwide, and post-mastectomy breast reconstruction is a vital aspect of their recovery process, both physically and psychologically. Microvascular breast reconstruction is a complex procedure that involves the transfer of tissue to the breast area to recreate the breast mound.
The Breast Reconstruction Assessment (BRA) score is designed to help surgeons estimate the likelihood of postoperative complications in individual patients. Effective risk prediction is key to improving patient outcomes and tailoring patient care to minimize potential risks. However, the validity of the BRA score in predicting complications following immediate microvascular breast reconstruction has been unclear due to a lack of external validation studies.
Main Findings
The University of Toronto’s Division of Plastic and Reconstructive Surgery conducted this study utilizing data from 415 patients who had undergone immediate microvascular breast reconstruction. The researchers meticulously entered each patient’s information into the BRA risk calculator and later compared the predicted rates to the actual observed rates for surgical complications, medical complications, reoperations, and total or partial flap failures.
Upon analysis, the study found that while the BRA score could accurately predict the proportion of patients who experienced surgical complications and reoperations, it significantly overestimated the occurrence of medical complications and flap failures. The C-statistics – a measure of the model’s ability to correctly discriminate between those who experienced complications and those who did not – were between 0.49 and 0.59 for all four prediction models, suggesting weak discriminatory power. Additionally, high Brier scores (0.09-0.44) indicated a poor correlation between predicted and actual probabilities of complications.
Implications for Clinical Practice
These results call into question the reliability of the BRA score for use in immediate microvascular breast reconstruction. The researchers imply that, based on their findings, the BRA score is not a dependable tool for identifying patients at heightened risk for complications in their institution.
Considering that the BRA score is currently used in surgical planning, these findings may have significant implications for clinical practice. They underscore the need for improved risk calculators that are more accurate and tailored to this particular patient group. Predictive tools that provide better discrimination and calibration are necessary to facilitate more personalized care and better-informed consent discussions.
The study raises important questions about the predictive models currently available and the requirement for ongoing research to develop and validate more precise risk assessment tools for breast reconstruction patients. The gravity of these implications is underscored by the fact that breast reconstruction surgeries can have profound effects on the quality of life for breast cancer survivors.
Keywords
1. Microvascular Breast Reconstruction
2. Postoperative Complications
3. Surgical Risk Calculator
4. BRA Score Validity
5. Mastectomy Reconstruction
References
1. O’Neill, A.C., Murphy, A.M., Sebastiampillai, S., Zhong, T., & Hofer, S.O.P. (2019). Predicting complications in immediate microvascular breast reconstruction: Validity of the Breast Reconstruction Assessment (BRA) surgical risk calculator. Journal of Plastic, Reconstructive & Aesthetic Surgery, 72(8), 1285-1291. doi: 10.1016/j.bjps.2019.03.033
2. American Cancer Society. (2021). Breast Cancer Facts & Figures 2020-2021. Atlanta: American Cancer Society, Inc.
3. Zhong, T., McCarthy, C., Min, S., Zhang, J., & Hofer, S.O.P. (2011). Patient Satisfaction and Health-Related Quality of Life After Autologous Tissue Breast Reconstruction: A Prospective Analysis of Early Postoperative Outcomes. Cancer, 117(8), 1705-1713.
4. Platt, J., Baxter, N., Zhong, T. (2011). Breast Reconstruction after Mastectomy for Breast Cancer. Canadian Medical Association Journal, 183(18), 2109-2116.
5. Al-Ghazal, S.K., Fallowfield, L., & Blamey, R.W. (2000). Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. European Journal of Cancer, 36(15), 1938-1943.
DOI: 10.1016/j.bjps.2019.03.033