Reply: Breast Surgery in the Time of Global Pandemic: Benefits of Same-Day Surgery for Breast Cancer Patients Undergoing Mastectomy with Immediate Reconstruction during COVID-19.

Sir:

We sincerely appreciate the comments provided by Dr. Jean-Claude Schwartz regarding our publication.[1] The budding topic of same-day surgery for mastectomy has certainly gained immense traction given the pandemic and its impact on hospital resource allocation. We acknowledge that overall, our own experiences, previous research, and Dr. Schwartz’s study[2] uphold the consistent outcomes of reduced readmissions, reoperations, and postoperative complications following same-day surgery for mastectomy.

Our protocol involves a prospective, single-arm, multi-institutional study that primarily seeks to measure complications, pain, satisfaction, and cost subsequent to same-day surgery for mastectomy with reconstruction. (This trial is registered under the name “Same-Day Discharge after Nipple-sparing Mastectomy or Skin-sparing Mastectomy with Breast Reconstruction,” ClinicalTrials.gov identification no. NCT04596683, https://clinicaltrials.gov/ct2/show/NCT04596683.) Inclusion criteria consist of women with breast cancer electing mastectomy with immediate implant-based reconstruction who are amenable to same-day surgery. Exclusion criteria include active smoking and high-risk comorbidities (e.g., cardiac disease, diabetes, and so on). Distinct from Dr. Schwartz’s article, we opted for the validated BREAST-Q survey to collect data on satisfaction and the standardized American Pain Society survey to evaluate postoperative pain. We have enrolled approximately 40 patients treated by various providers within a single hospital system, albeit all operations have been performed within the hospital operating rooms and not in separate ambulatory surgery centers.

Ideally, randomization would have been the gold standard for reporting on a relationship between same-day surgery and improved outcomes. However, without mitigating difference in cost to the patient and influence on satisfaction for those unhappy with treatment allocation, we felt our chosen research design to be more appropriate as an initial study. We have not encountered a study to date that has randomized patients into same-day surgery for mastectomy. Unless evidence demonstrating potential compromise to clinical equipoise is elucidated, this should be the aim for future studies.

While we believe the primary goal of our research is to demonstrate equal if not improved outcomes and satisfaction for women undergoing same-day surgery for mastectomy with reconstruction, a secondary critical component is cost. Dr. Schwartz comments on the financial benefits to same-day surgery, which is very applicable in the time of SARS-Cov-2. In his study, he emphasizes data demonstrating reduced infection rates to infer cost-effectiveness of same-day surgery for mastectomy.[2] While this is a notable assumption, it is not direct evidence. With access to billing information for cohorts that have been either discharged from same-day surgery or admitted following mastectomy, we are conducting a thorough cost analysis of the procedures. In addition, all procedures are performed in the same settings with similar staff and protocols, further reducing potential confounders to our results.

Similar to the evolution of reduced length of stay following the transition from radical to simple mastectomy,[3] the recent advancements in anesthetic protocols and techniques for breast reconstruction serve as the catalyst for change in the standard timing of hospital-level treatment. We completely agree with Dr. Schwartz’s last comment, that admission following mastectomy should eventually be the exception, rather than the standard. Thorough research into the ideal characteristics of patients and resources required to appropriately educate and support same-day surgery for mastectomy is critical. Nonetheless, studies such as Dr. Schwartz’s[2] and ours[1] promote the transition to same-day surgery as a means of improved quality, satisfaction, and cost of reconstruction for breast cancer patients.

DISCLOSURE

Dr. Tousimis receives honoraria for speaking faculty from Medtronic. Idanis M. Perez-Alvarez has no financial interests to declare.