Combining breast and gynecologic surgery not such a good idea

By Dr. Liji Thomas, MDJul 16 2019

A new study from the University of Colorado Cancer Center finds that it is best if women who have to have both preventive gynecologic and breast surgeries have them done separately. The same dictum applies to breast reconstructive procedures following a mastectomy.

Often women who discover they have cancer in one breast want to have the other breast removed as well. When this is done at the same time as the primary surgery, as prudence would seem to dictate, the complication rate is actually higher, up to double the original. Even worse, the patient may not receive additional treatment for her cancer as soon as she should because of the occurrence of such complications. This delay in treatment can worsen the eventual outcome.

Many women who find they are at elevated risk for breast and ovarian cancer choose to have bilateral prophylactic mastectomies (preventive removal of both breasts), and also to have their ovaries removed at the same time. Other women who have one or both breasts removed want a breast reconstruction procedure to be performed simultaneously. Understandably, they often feel this will save them time and trouble. However, this is typically not the best approach, says researcher and breast surgeon Sarah Tevis in her new study report, which was published in The Breast Journal on July 6, 2019.

The current study used data from the National Surgery Quality Improvement Program (NSQIP) database. Researchers looked at more than 77,000 women who had breast surgery between 2011 and 2015.

Among these, 124 had combined surgery on their reproductive organs as well. These tended to be younger women in better health than the overall profile of the group. The researchers wanted to compare outcomes in women who were operated on at one or multiple sites to see which protocol led to fewer post-operative complications and a lower rate of readmissions to hospital.

The study found that patients who had their breasts and ovaries removed at the same time, with or without uterine removal, or who had mastectomy with breast reconstruction, required a significantly longer duration of hospitalization, had more complications, had to be readmitted significantly more often, and required more second surgeries, as compared to women who had two or more separate procedures. This was in spite of the fact that the former group tended to be younger and healthier than those who chose to have combined procedures. Nonetheless, says Tevis, “Their rate of complications was higher.”

In patients with a high risk of breast and ovarian cancer, doctors do recommend the removal of both breasts and of the uterus with the ovaries, to reduce the subsequent gynecologic cancer risk. However, Tevis says, “It's safer and easier to do them separately.”

Besides the increased risk of post-surgical complications, choosing to have combined surgery could delay treatment. It is usually more difficult to set up an operating schedule involving surgeons from three different departments, as in such cases breast surgery must proceed with the help of reconstructive and gynecologic surgeons as well. Moreover, the duration of surgery is much longer, requiring the whole operating day. This may mean that surgery is pushed back, worsening the prognosis.

Another important limitation is that chemotherapy following surgery is typically required following mastectomy for breast cancer. When gynecologic or plastic breast surgery is combined with this, the presence of complications may delay the initiation of chemotherapy, which again reduces the chances of a good outcome for the cancer treatment.

While medical factors may in some cases mandate the combination of these procedures to limit anesthesia exposure to just once, in the vast majority of cases it is better to carry out separate surgeries. Tevis sums up: “A few times, a patient has a medical problem that makes it better, for example, to only have one anesthesia. But outside these rare cases, we recommend separating breast and reconstructive surgery from gynecologic surgery.”