Supplementary Online Content

Transcription

1 Supplementary Online Content Abt NB, Flores JM, Baltodano PA, et al. Neoadjuvant chemotherapy and short-term in patients undergoing mastectomy with and without breast reconstruction. JAMA Surg. Published online August 13, doi: /jamasurg etable 1. Descriptions of CPT Codes for Mastectomy and Breast Reconstruction etable 2. General and Preoperative Patient Characteristics, Including Breakdown of Composite Co Variables and Preoperative Laboratory Chemistries etable 3. Percentages of Patients by Neoadjuvant Chemotherapy Status Who Experienced Morbidity for Mastectomy and Immediate Breast Reconstruction Subgroups etable 4. Predictors of Overall 30-Day Postoperative Morbidity in 59,623 Mastectomy Patients etable 5. Predictors of Overall 30-Day Postoperative Morbidity in 16,742 Immediate Breast Reconstruction Patients This supplementary material has been provided by the authors to give readers additional information about their work.

2 etable 1. Descriptions of CPT Codes for Mastectomy and Breast Reconstruction CPT Code Number Description Mastectomy Mastectomy, partial Mastectomy, partial, with axillary lymphadenectomy Mastectomy, simple, complete Mastectomy, subcutaneous Mastectomy, radical, including pectoral muscles, axillary lymph nodes Mastectomy, radical, including pectoral muscles, axillary, and internal mammary lymph nodes Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy) Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy Mastectomy, simple, complete Mastectomy, subcutaneous Mastectomy, radical, including pectoral muscles, axillary lymph nodes Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation) Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation) Breast Reconstruction Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion

3 19361 Breast reconstruction with latissimus dorsi flap, without prosthetic implant Breast reconstruction with free flap Breast reconstruction with other technique Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis (supercharging) Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site

4 etable 2. General and Preoperative Patient Characteristics, Including Breakdown of Composite Co Variables and Preoperative Laboratory Chemistries No Neoadjuvant Chemotherapy Neoadjuvant chemotherapy Overall (N = 74,262) (N = 3,696) (N = 77,958) General Variables Age, mean (SD)** 58.9 (13.4) 52.3 (12.1) 58.6 (13.4) BMI, mean (SD)** 28.5 (7.1) 28.9 (7.1) 28.5 (7.1) WRVU, mean (SD)** 13.3 (4.0) 15.6 (3.4) 13.4 (4.0) Operation Time, mean (SD)** (102.3) (103.4) (102.6) Smoking, n (%) 10,173 (13.7%) 562 (15.2%) 10,735 (13.8%) Inpatient status, n (%)** 33,172 (44.7%) 2,231 (60.4%) 35,403 (45.41%) Alcohol intake in previous 2 weeks, n (%) * Open wound (with or without infection), n (%) ** Steroid use for chronic condition, n (%) ** 1,026 (1.4%) 32 (0.9%) 1,058 (1.4%) 625 (0.8%) 84 (2.3%) 709 (0.9%) 936 (1.3%) 141 (3.8%) 1077 (1.4%) Pregnancy, n (%) 87 (0.1%) 5 (0.1%) 92 (0.1%) Operation within previous 30 days, n (%) ** 3,355 (4.8%) 66 (1.9%) 3,421 (4.7%) Cardiovascular variables, n (%) Dyspnea at rest* 226 (0.30%) 14 (0.38%) 240 (0.31%) Dyspnea on moderate exertion* Congestive heart failure in previous 30 days* 4,963 (6.68%) 283 (7.66%) 5,246 (6.73%) 133 (0.2%) 12 (0.3%) 145 (0.2%) Angina in previous 30 days* 172 (0.2%) 2 (0.1%) 174 (0.2%) Myocardial infarction in previous 6 months Previous percutaneous coronary intervention** 77 (0.1%) 3 (0.1%) 80 (0.1%) 1,595 (2.2%) 41 (1.1%) 1,636 (2.1%)

5 Previous cardiac surgery** 1,275 (1.7%) 31 (0.8%) 1,306 (1.7%) Hypertension requiring medication** History of peripheral vascular disease* 30,917 (41.6%) 1,147 (31.0%) 32,064 (41.1%) 324 (0.4%) 8 (0.2%) 332 (0.4%) Rest pain or gangrene 31 (0.0%) 0 (0.0%) 31 (0.0%) Composite cardiovascular (not including HTN requiring medication)** 3,258 (4.4%) 95 (2.6%) 3,353 (4.3%) Respiratory variables, n (%) Current pneumonia 16 (0.0%) 1 (0.0%) 17 (0.0%) History of severe COPD** 1,917 (2.6%) 50 (1.4%) 1,967 (2.5%) Ventilator-dependent in previous 48 h Composite respiratory ** 8 (0.0%) 0 (0.0%) 8 (0.0%) 1,990 (2.7%) 58 (1.6%) 2048 (2.6%) Hepatobiliary variables, n (%) Ascites in previous 30 days 32 (0.0%) 2 (0.1%) 34 (0.0%) Esophageal varices in previous 6 months Composite hepatobiliary 27 (0.0%) 1 (0.0%) 28 (0.0%) 50 (0.1%) 3 (0.1%) 53 (0.1%) Renal variables, n (%) Acute renal failure 25 (0.0%) 1 (0.0%) 26 (0.0%) Presently on dialysis* 197 (0.3%) 3 (0.1%) 200 (0.3%) Composite renal 212 (0.3%) 4 (0.1%) 216 (0.3%) Neurological variables, n (%) Impaired sensorium in previous 48 h 29 (0.0%) 2 (0.1%) 31 (0.0%) Hemiplegia 297 (0.4%) 9 (0.2%) 306 (0.4%) Paraplegia 111 (0.2%) 2 (0.1%) 113 (0.1%) Quadriplegia 27 (0.0%) 2 (0.1%) 29 (0.0%) Coma lasting >24 h 1 (0.0%) 0 (0.0%) 1 (0.0%)

6 History of transient ischemic attacks** History of CVA with neurological deficit* History of CVA without neurological deficit 1,311 (1.8%) 28 (0.8%) 1,339 (1.7%) 840 (1.1%) 25 (0.7%) 865 (1.1%) 882 (1.2%) 34 (0.9%) 916 (1.2%) Tumor involving CNS* 39 (0.1%) 5 (0.1%) 44 (0.1%) Composite neurological ** 3,011 (4.1%) 93 (2.5%) 3,104 (3.9%) Hemato-oncological variables, n (%) Bleeding disorder** 1209 (1.6%) 100 (2.7%) 1309 (1.7%) Weight loss >10% in previous 6 months** 310 (0.4%) 55 (1.5%) 365 (0.5%) Disseminated cancer** 751 (1.0%) 293 (7.9%) 1,044 (1.3%) Chemotherapy in previous 30 days** Radiotherapy in previous 90 days** Composite hematooncological ** 0 (0.0%) 3,696 (100.0%) 3,696 (4.7%) 238 (0.3%) 103 (2.8%) 341 (0.4%) 2,395 (3.2%) 3,696 (100.0%) 6,091 (7.8%) Preoperative laboratory chemistries, n (%) Serum sodium 135 mmol/l 2,983 (5.4%) 149 (4.7%) 3,132 (5.4%) Serum sodium >145 mmol/l 585 (1.1%) 37 (1.2%) 622 (1.1%) Blood urea nitrogen >14.3 mmol/l** Serum creatinine >106.1 μmol/l** 27,930 (50.6%) 1,106 (34.7%) 29,036 (49.7%) 2,144 (3.8%) 64 (1.9%) 2,208 (3.7%) Total bilirubin >1.9 mg/dl** 2,979 (7.3%) 136 (4.9%) 3,115 (7.2%) Aspartate aminotransferase >40 U/L** Alkaline phosphatase >125 U/L** White-blood-cell count >11,000 cells per μl** 2,293 (5.5%) 257 (9.2%) 2,550 (5.7%) 2,158 (5.1%) 287 (10.1%) 2,445 (5.4%) 2,581 (4.3%) 274 (7.9%) 2,855 (4.5%)

7 Platelet count 150,000 cells per μl** International normalized ratio >1.4 1,658 (2.8%) 216 (6.3%) 1,874 (2.9%) 534 (3.2%) 30 (2.8%) 564 (3.2%) Hematocrit <36%** 19,574 (31.9%) 2,643 (76.1%) 22,217 (34.3%) *p<0.05, **p<0.001 Work relative value unit is a scale (0 95) to quantify the amount of work involved in a specific surgery on the basis of preprocedural, intraprocedural, and postprocedural time, technical skill, physical effort, mental effort and judgment, and stress due to potential risk; the scale is the work portion of the Resource-based Relative Value System adopted by US Medicare to quantify the amount of work involved in every medical procedure (score of 0=least complex and 95=most complex). Transfusion of more than four packed red blood cell units within 72 h preoperatively for the years 2008 and 2009, transfusion of at least one unit within 72 h preoperatively for 2010, any number of units transfused intraoperatively for all years, transfusion of more than four units within 72 h postoperatively for 2008 and 2009, or transfusion of at least one unit within 72 h postoperatively for CVA = cerebrovascular accident. > two drinks per day. The percentages of some variables and the composite categories may not total 100% because of limited missing data.

8 etable 3. Percentages of Patients by Neoadjuvant Chemotherapy Status Who Experienced Morbidity for Mastectomy and Immediate Breast Reconstruction Subgroups Neoadjuvant Chemotherapy No Neoadjuvant Chemotherapy Morbidity (-) Morbidity (+) NC Total Morbidity (- ) Morbidity (+) No NC Total All Patients (n=77,958) 3,335 (90.23%) 361 (9.77%) 3,696 65,823 (88.64%) 8,439 (11.36%) 74,262 Mastectomy (n=61,076) 2,609 (90.72%) 267 (9.28%) 2,876 51,628 (88.71%) 6,572 (11.29%) 58,200 All Immediate Breast Reconstruction (n=16,882) 726 (88.54%) 94 (11.46%) ,195 (88.38%) 1,867 (11.62%) 16,062 Tissue Expander (n=11,569) 525 (91.62%) 48 (8.38%) 573 9,875 (89.81%) 1,121 (10.19%) 10,996 Implant (n=2,335) 78 (86.67%) 12 (13.33%) 90 1,990 (88.64%) 255 (11.36%) 2,245 Flap (n=2,978) 123 (78.34%) 34 (21.66%) 157 2,330 (82.59%) 491 (17.41%) 2,821 Abbreviations: NC, neoadjuvant chemotherapy Data displayed as: number (row percentage); Morbidity (-) denotes no was experienced; Morbidity (+) denotes was experienced

9 etable 4. Predictors of Overall 30-Day Postoperative Morbidity in 59,623 Mastectomy Patients Multivariable Regression For Mastectomy Patients Odds Ratio 95% Confidence Interval P value Neoadjuvant chemotherapy <0.001 Age, y <0.001 Body mass index, <0.001 kg/m 2 Smoking, within 1 y Work relative value units <0.001 Inpatient status Operation year <0.001 ASA classification Wound infection Wound classification Clean/Contaminated Contaminated Dirty/Infected <0.001 Composite cardiovascular Composite respiratory Composite renal Composite hematooncological < <0.001

10 Diabetes Steroid use Operation time <0.001 Abbreviations: ASA, American Society of Anesthesiologists ASA Class 4 predicted success perfectly and was dropped from the model

11 etable 5. Predictors of Overall 30-Day Postoperative Morbidity in 16,742 Immediate Breast Reconstruction Patients Multivariable Regression For Immediate Breast Reconstruction Patients Odds Ratio 95% Confidence Interval P value Neoadjuvant chemotherapy Age, y Body mass index <0.001 kg/m 2 Smoking, within 1 y <0.001 Work relative value units Inpatient status <0.001 Operation year ASA classification Wound infection Wound classification Clean/Contaminated Contaminated Dirty/Infected Composite cardiovascular Composite respiratory <0.001

12 Composite renal Composite hematooncological Diabetes Steroid use Operation time <0.001 Abbreviations: ASA, American Society of Anesthesiologists No patients had an ASA class of 4; ASA class 5 predicted failure perfectly and was dropped from the model