Associations between Breast Reconstruction Surgery vs. Mastectomy without Reconstruction on Postsurgical Radiation Treatment Modalities: a 2004-2018 NCDB Study

Associations between Breast Reconstruction Surgery vs. Mastectomy without Reconstruction on Postsurgical Radiation Treatment Modalities: a 2004-2018 NCDB Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Associations between Breast Reconstruction Surgery vs. Mastectomy without Reconstruction on Postsurgical Radiation Treatment Modalities: a 2004-2018 NCDB Study William Huang, Shriansh Singh, Sean Wallace, Bharat Ranganath This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6466069/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Jul, 2025 Read the published version in European Journal of Plastic Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Background This study compares associations between breast reconstruction surgery (BRS) and types of postmastectomy radiation treatment modalities for breast cancer. Methods Utilizing the NCDB Breast participant use file (PUF) from 2004–2018, we compared the postmastectomy radiation treatment modalities of patients receiving BRS to those who did not. Results Our study suggests that BRS patients had greater odds of pursuing more advanced radiotherapy modalities, IMRT and 3D-CRT, compared to mastectomy without reconstruction (MWR) patients. BRS patients were 3.271 (95% CI 2.704–3.956) times more likely to receive Phase I 3D-CRT vs. 2D-therapy, and 3.421 (95% CI 2.817–4.154) times more likely to receive IMRT vs. 2D-therapy, with relatively equal rates of receiving IMRT compared to 3D-CRT (1.046; 95% CI 0.974–1.123). For Phase II, BRS patients were 1.590 (95% CI 1.490–1.698) times more likely to receive 3D-CRT vs. 2D therapy, 1.533 (95% CI 1.392–1.688) times more likely to receive IMRT vs. 2D therapy, and 1.159 (95% CI 1.111–1.208) times more likely to receive unspecified EBR vs. 2D therapy. Conclusions The choice of radiotherapy modality after breast reconstruction surgery is critical for ensuring optimal treatment efficacy and safety, as it depends on factors like the patient’s goals, anatomy, and preexisting conditions. Advanced techniques like IMRT and 3D therapies have shown increased usage in and potential promise for BRS patients due to their precision in sparing healthy tissues, highlighting the need for further research to improve outcomes for this population. Figures Figure 1 Introduction Breast reconstruction surgery (BRS) has become an increasingly popular procedure across the United States for patients with breast cancer. 1 However, the choice to receive breast reconstruction over mastectomy without reconstruction, (MRS), or other more conservative procedures is still influenced by factors from both the perspectives of the patient and the provider. 1 According to the American Society of Plastic Surgeons (APS) and Annals of Surgical Oncology (ASG), patients have reported a desire to forego BRS and elect for a less invasive procedure due to costs, fears of not regaining sensation in the breast over time, not wanting foreign objects in their bodies such as breast implants, and the perception that a mastectomy without reconstruction would allow lower surgery complications and overall health problems. 1 , 2 While ASG reports that around 75% of surveyed patients who choose to forego BRS are ultimately satisfied with their decision, 25% of patients also reported that their decision to “go flat” was not supported by their physicians. 2 From the perspective of a provider, many factors can come into play as to whether a provider advises a patient to undergo BRS or mastectomy without reconstruction. Common clinical contraindications to BRS include severe cardiopulmonary disease, vascular disease, advanced breast cancer, obesity, age, and prior surgical procedures that have interrupted perfusion to potential flaps. 3 Other complications may also arise from patient comorbidities or past traumas such as surgery, radiotherapy, or biopsy, leading to post-surgery capsular fibrosis or mastectomy skin necrosis. 4 – 6 Furthermore, there is also a possibility that the complications of BRS may impact postsurgical radiotherapy modalities. Common modalities used after breast reconstruction surgery include External Beam (EB), 2D Therapy, 3D Conformal Therapy (3D-CRT), or Intensity Modulated Therapy (IMRT). From a technological standpoint, unspecified External Beam (EB) and 2D therapy are commonly viewed as more outdated versions of treatment, with most treatments being 3D conformal therapy or IMRT to treat breast tumors. 7 Literature has argued that 3D-CRT or IMRT may provide better clinical outcomes, with reports that 3D-CRT is able to provide axillary node coverage and decrease doses to other normal tissues, and IMRT being able to provide superior cosmesis and reduce the risk of skin telangiectasia. 8 , 9 Reports also allude to 3D-CRT having the added benefit of covering the entire breast parenchyma in a way that is limited using 2D therapy, and IMRT providing better organ sparing compared to older techniques. 10 , 11 Given these considerations, it is vital to assess the impact of breast surgery and its effects on post-reconstruction and post-mastectomy radiotherapy (PMRT). Therefore, the aim of this study is to investigate different modalities for breast radiation treatment, and whether there are correlations between breast reconstruction surgery vs. mastectomy without reconstruction on the type of post-surgery radiation treatment modality used. Methods Using the American College of Surgeons (ACS) National Cancer Database (NCDB), a retrospective analysis was performed on breast surgery patients from receiving postmastectomy radiation therapy (PMRT) from 2004–2018. The study design and reporting adhere to the STROBE guidelines. Female patients who underwent mastectomy without reconstruction or breast reconstruction surgery were identified using specific procedural and diagnosis codes. This cohort was further filtered to include only patients who received Phase I or Phase II radiation treatments specifically targeting the breast/chest wall lymph node regions, chest/lung, breast (whole), breast (partial), or chest wall. Multivariable logistic regression was performed via SAS to determine the association between surgical procedure type and PMRT use, adjusting for a range of covariates such as socioeconomic factors and clinical characteristics. The patient selection process is summarized in Fig. 1 , which outlines the inclusion and exclusion criteria used to derive the final study cohort. Adjusted odds ratios (aORs) and 95% confidence intervals (Cis) were calculated and specified in Table 3 . In total, 776,468 patients were identified: 368,423 (47.4%) underwent breast reconstruction surgery (BRS), and 408,045 (52.6%) underwent mastectomy without reconstruction. Among these patients, 52,351 met eligibility criteria for Phase I post-surgery radiation treatment to the breast/chest wall lymph node regions, breast, or chest wall regions. Of these Phase I patients, 2,510 (4.8%) patients received 2D therapy, 33,218 (63.4%) received 3D-CRT, and 16,623 (31.8%) received IMRT. For Phase II, 55,980 patients met eligibility criteria of receiving post-surgery radiation treatment to the breast/chest wall lymph node regions, breast, or chest wall regions. Of those Phase II patients, 43,873 (78.4%) patients received 2D therapy, 8,811 (15.7%) received 3D-CRT, and 3,296 (5.9%) received IMRT. Results As shown in Tables 1 and 2 , the average age of patients who received 2D-Therapy, 3D-CRT, and IMRT were relatively equal across both phases I and II (Phase I: 56.76 ± 13.45 vs. 54.29 ± 12.84 vs. 53.77 ± 12.79; Phase II: 55.45 ± 13.04 vs. 55.08 ± 12.99 vs. 54.64 ± 13.04). There were no significant racial differences in terms of radiotherapy usage, with white patients being the highest users of 2D-therapy, 3D-CRT, and IMRT (Phase I: 78.5% vs. 81.7% vs. 78.6%; Phase II: 81.0% vs. 81.8% vs. 77.9%) followed by black patients (Phase I: 15.5% vs. 12.4% vs. 15.5%; Phase II: 13.3% vs 12.7% vs. 15.9%). There were also no significant differences in the insurance status of post-surgery patients who received radiotherapy, with approximately 60% of the patients receiving radiotherapy having private insurance across 2D-therapy, 3D-CRT, and IMRT respectively (Phase I: 58.8% vs. 62.9% vs. 63.4%; Phase II: 59.2% vs. 60.1% vs. 60.5%). In terms of treatment location, there was no significant predisposition for patients to be treated in a particular medical facility based on radiation treatment. Across 2D-Therapy, 3D-CRT, and IMRT-receiving patients, approximately half were treated in large urban areas (Phase I: 49.6% vs. 54.4% vs. 53.3%; Phase II: 49.9% vs. 48.6% vs. 52.2%), and approximately ~ 40% were treated in comprehensive community cancer programs (Phase I: 42.7% vs. 41.8% vs. 41.8%; Phase II: 45.3% vs. 45.0% vs. 42.2%). In terms of patient comorbidities and health status, no significant differences were noted between the evaluated parameters of Charlson-Deyo Score, tumor behavior, and tumor grade. Across all three radiotherapy modalities for Phase I and II, ~ 80% had a CDCC score of 0, ~ 99% had invasive tumors, and approximately ~ 80% of patients had Grade 2 or 3 tumors. Across these eight descriptive variables of patient characteristics and tumor burden, there are no significant differences associated with radiotherapy modality. As shown in Table 3 , the odds ratio of a BRS patient receiving Phase I 3D-CRT vs 2D-therapy is 3.271 (95% CI 2.704–3.956), and 3.421 (95% CI 2.817–4.154) for IMRT vs 2D-therapy. The odds of a BRS patient receiving Phase I IMRT is roughly equal to receiving 3D-CRT, with a 1.046 (95% CI 0.974–1.123) odds ratio. Furthermore, BRS patients were 2.516 (95% CI 2.087–3.033) more likely to receive Phase I unspecified general external beam radiation (EBR) compared to 2D-therapy, but 0.769 (95% CI 0.734–0.807) less likely to receive EBR compared to 3D-CRT, and 0.735 (95% CI 0.691–0.782) less likely to receive EBR compared to IMRT. These results strongly support the notion that BRS patients are more likely to receive Phase I 3D-CRT and IMRT compared to 2D-therapy, suggesting that Phase I 2D-therapy is uniquely underused by BRS patients compared to other existing treatment modalities. For Phase II radiotherapies, BRS patients were 1.590 (95% CI 1.490–1.698) more likely to receive 3D-CRT vs. 2D therapy, and 1.533 (95% CI 1.392–1.688) more likely to receive IMRT vs. 2D therapy. Phase II patients were slightly less likely to receive IMRT vs. 3D-therapy (0.964, 95% CI 0.863–1.076). Finally, patients were 1.159 times more likely to receive unspecified EBR (95% CI 1.111–1.208) compared to 2D therapy, but 0.756 less likely to receive EBR (95% CI 0.685–0.834) compared to 3D-CRT and 0.756 less likely to receive EBR (95% CI 0.685–0.834) compared to IMRT. With smaller differences in odds ratios compared to their Phase I counterparts, these results do not as strongly support the notion that BRS patients are more likely to receive Phase II 3D-CRT and IMRT compared to 2D-therapy and general, unspecified EBR. However, the differences in odds of receiving Phase II 2D-therapy vs. 3D-CRT or IMRT are still more pronounced compared to the difference in odds of receiving Phase II 3D-CRT vs. IMRT. This suggests that Phase II 2D-therapy is less commonly used by BRS patients compared to other existing treatment modalities. Table 3 Association of BRS Compared to Mastectomy without Reconstruction on Post-Surgical Radiation Planning Technique Variable Adjusted Odds Ratio 95% CI p-value Phase I 3D-CRT vs. 2D Therapy 3.271 2.704–3.956 < .0001 IMRT vs. 2D Therapy 3.421 2.817–4.154 < .0001 External Beam NOS vs. 2D Therapy 2.516 2.087–3.033 < .0001 IMRT vs. 3D-CRT 1.046 0.974–1.123 < .0001 External Beam NOS vs. 3D-CRT 0.769 0.734–0.807 < .0001 External Beam NOS vs. IMRT 0.735 0.691–0.782 < .0001 Phase II 3D-CRT vs. 2D Therapy 1.590 1.490–1.698 < .0001 IMRT vs. 2D Therapy 1.533 1.392–1.688 < .0001 External Beam NOS vs. 2D Therapy 1.159 1.111–1.208 < .0001 IMRT vs. 3D-CRT 0.629 0.589–0.671 < .0001 External Beam NOS vs. 3D-CRT 0.728 0.680–0.780 < .0001 External Beam NOS vs. IMRT 0.756 0.685–0.834 < .0001 Discussion Overall, the data show that BRS patients had greater odds of pursuing more advanced radiotherapy modalities, (such as IMRT and 3D-CRT), when compared to MWR patients across both phase I and Phase II breast cancer. This finding was highlighted especially in the Phase I data as BRS patients had 3.271 times the odds of receiving 3D-CRT as opposed to 2D therapy, and 3.421 times the odds of receiving IMRT therapy as opposed to 2D therapy. These data results can be attributed to a multitude of factors. Notably, breast reconstruction alters the pre-existing anatomy of the patient as the reconstructed breast is of a different contour and shape, while no longer containing glandular tissue, fat or ducts. 12 Scar tissue may also form at the mastectomy incision site. These changes make radiotherapy planning more complex, thus incentivizing the use of the more precise 3D therapy. 3D therapy utilizes CT/MRI imaging to develop a 3D model of the breast and the surrounding anatomy. 13 Hence, this model can more specifically pinpoint the location of the tumor bed and regional lymph nodes, (which require radiation), despite the altered anatomy of the reconstructed breast. 13 Alternatively, 2D therapy relies upon more basic forms of imaging anatomical landmarks, which often cannot account for post-surgery anatomical changes. 13 Subsequently, the distribution of radiation may be uneven and surrounding healthy tissue may be exposed to radiation. Because 3D therapy modulates the radiation dose to a specific target area, nearby healthy tissues and the reconstructed breast itself are often spared. 14 Therefore, the risk for complications in reconstructed breasts, (such as tissue fibrosis in autologous reconstruction or capsular contracture in implant reconstruction), is greatly reduced. 15 This attribute is especially important for BRS patients with left-sided tumors because, 2D therapy oftentimes cannot effectively reduce radiation exposure to the heart and lungs, which may increase the risk for long term complications including heart disease and pulmonary fibrosis. 15 Additionally, for BRS patients, one important goal after surgery is to preserve the functionality and appearance of the reconstructed breast. In this respect, 3D and IMRT therapy is superior to older functionalities, like 2D, as their more focused radiation fields are less likely to cause external burns, fibrosis or poor wound healing. 16 Thus, these therapies offer better cosmetic and aesthetic results as well for BRS patients. Essentially, all the aforementioned factors help explain why BRS patients have greater odds in choosing 3D and IMRT post-surgical radiotherapies vs. 2D therapy when compared to MRS patients. There are multiple limitations on the study’s accuracy in reflecting associations between surgical treatments and post-surgical radiotherapy modalities. A small p-value, (< .0001), alone does not entail scientific or clinical significance and so further studies are needed to replicate these data results in larger sample sizes. Other limitations of this study include a lack of more descriptive indicators, (aside from race, insurance status, etc.), that were included in the calculations of the adjusted odds ratios. This aspect allows for the possibility of other indicators, such as income, that could serve as confounding variables. Additionally, for both Phase I and Phase II data, each radiotherapy cohort had relatively similar distributions of patients along the measured socioeconomic variables such race, insurance status, etc. For example, for phase I patients, the percentages of uninsured patients for 2D, 3D and IMRT radiotherapies were 3.63, 3.19 and 2.93% respectively. As such, there was no distinct association between any of the descriptive statistics and the type of radiotherapy modality received. This aspect is important as it reduces the impact of potential confounding variables within the data, thereby relatively preserving the internal validity of the study. Otherwise, variables, like race, can influence the choice of radiotherapy for breast cancer patients. For instance, marginalized populations are less likely to receive optimal treatment and follow-up due to systemic inequities in healthcare delivery. 17 Another example is insurance status as differences in coverage highlight disproportionate access to healthcare, possibly discouraging patients from pursuing more expensive therapy such as IMRT. Conclusion Ultimately, the decision to choose a specific radiotherapy modality, based on prior breast surgery procedures, is very important to both the patient and the provider. This discussion directly pertains to the quality of care that patients receive as it raises important questions about side effects, complications, and treatment efficacy. Different modalities are indicated depending on the patient’s goals of treatment, preexisting conditions, and financial status. Newer techniques, such as IMRT and 3D therapies show promise for BRS patients compared to MRS patients due to their more focused radiation fields, which target only the tumor and lymph nodes of interest. This technique spares healthy tissue, importantly preventing radiation exposure to the heart and lungs. Breast reconstruction surgery, itself, complicates the delivery of radiotherapy, by changing the internal anatomy, contour and shape of the breast region- thereby potentially impacting selection of different radiotherapy techniques compared to mastectomy with reconstruction. Future studies should explore how the use of different post-surgery radiotherapy techniques have changed over time across multiple different populations of breast cancer patients. In this respect, special consideration should be directed to BRS patients, to optimize treatment efficacy and safety. By doing so, our understanding of the treatment implications of breast reconstruction surgery will become more nuanced and overall patient outcomes will improve. Declarations Ethics in Publishing Statement: I testify on behalf of all co-authors that our article submitted followed ethical principles in publishing. All authors agree that: This research presents an accurate account of the work performed, all data presented are accurate and methodologies detailed enough to permit others to replicate the work. This manuscript represents entirely original works and or if work and/or words of others have been used, that this has been appropriately cited or quoted and permission has been obtained where necessary. This material has not been published in whole or in part elsewhere. The manuscript is not currently being considered for publication in another journal. That generative AI and AI-assisted technologies have not been utilized in the writing process or if used, disclosed in the manuscript the use of AI and AI-assisted technologies and a statement will appear in the published work. That generative AI and AI-assisted technologies have not been used to create or alter images unless specifically used as part of the research design where such use must be described in a reproducible manner in the methods section. All authors have been personally and actively involved in substantive work leading to the manuscript and will hold themselves jointly and individually responsible for its content. Clinical trial number: not applicable. No Funding was involved in the manuscript. No Conflicts of Interest to report. No External Data Availability sources to report. Human Ethics and Consent to Participate declarations: not applicable. 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Accessed Jan 5, 2025. 10.1002/cncr.33121 Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 16 Jul, 2025 Read the published version in European Journal of Plastic Surgery → Version 1 posted Editorial decision: Revision requested 30 May, 2025 Reviews received at journal 29 May, 2025 Reviewers agreed at journal 02 May, 2025 Reviewers invited by journal 28 Apr, 2025 Editor assigned by journal 28 Apr, 2025 Submission checks completed at journal 28 Apr, 2025 First submitted to journal 16 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBreast reconstruction surgery (BRS) has become an increasingly popular procedure across the United States for patients with breast cancer.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e However, the choice to receive breast reconstruction over mastectomy without reconstruction, (MRS), or other more conservative procedures is still influenced by factors from both the perspectives of the patient and the provider.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e According to the American Society of Plastic Surgeons (APS) and Annals of Surgical Oncology (ASG), patients have reported a desire to forego BRS and elect for a less invasive procedure due to costs, fears of not regaining sensation in the breast over time, not wanting foreign objects in their bodies such as breast implants, and the perception that a mastectomy without reconstruction would allow lower surgery complications and overall health problems.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e While ASG reports that around 75% of surveyed patients who choose to forego BRS are ultimately satisfied with their decision, 25% of patients also reported that their decision to \u0026ldquo;go flat\u0026rdquo; was not supported by their physicians.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFrom the perspective of a provider, many factors can come into play as to whether a provider advises a patient to undergo BRS or mastectomy without reconstruction. Common clinical contraindications to BRS include severe cardiopulmonary disease, vascular disease, advanced breast cancer, obesity, age, and prior surgical procedures that have interrupted perfusion to potential flaps.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Other complications may also arise from patient comorbidities or past traumas such as surgery, radiotherapy, or biopsy, leading to post-surgery capsular fibrosis or mastectomy skin necrosis.\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Furthermore, there is also a possibility that the complications of BRS may impact postsurgical radiotherapy modalities. Common modalities used after breast reconstruction surgery include External Beam (EB), 2D Therapy, 3D Conformal Therapy (3D-CRT), or Intensity Modulated Therapy (IMRT). From a technological standpoint, unspecified External Beam (EB) and 2D therapy are commonly viewed as more outdated versions of treatment, with most treatments being 3D conformal therapy or IMRT to treat breast tumors.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Literature has argued that 3D-CRT or IMRT may provide better clinical outcomes, with reports that 3D-CRT is able to provide axillary node coverage and decrease doses to other normal tissues, and IMRT being able to provide superior cosmesis and reduce the risk of skin telangiectasia.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Reports also allude to 3D-CRT having the added benefit of covering the entire breast parenchyma in a way that is limited using 2D therapy, and IMRT providing better organ sparing compared to older techniques.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGiven these considerations, it is vital to assess the impact of breast surgery and its effects on post-reconstruction and post-mastectomy radiotherapy (PMRT). Therefore, the aim of this study is to investigate different modalities for breast radiation treatment, and whether there are correlations between breast reconstruction surgery vs. mastectomy without reconstruction on the type of post-surgery radiation treatment modality used.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eUsing the American College of Surgeons (ACS) National Cancer Database (NCDB), a retrospective analysis was performed on breast surgery patients from receiving postmastectomy radiation therapy (PMRT) from 2004\u0026ndash;2018. The study design and reporting adhere to the STROBE guidelines. Female patients who underwent mastectomy without reconstruction or breast reconstruction surgery were identified using specific procedural and diagnosis codes. This cohort was further filtered to include only patients who received Phase I or Phase II radiation treatments specifically targeting the breast/chest wall lymph node regions, chest/lung, breast (whole), breast (partial), or chest wall. Multivariable logistic regression was performed via SAS to determine the association between surgical procedure type and PMRT use, adjusting for a range of covariates such as socioeconomic factors and clinical characteristics. The patient selection process is summarized in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, which outlines the inclusion and exclusion criteria used to derive the final study cohort. Adjusted odds ratios (aORs) and 95% confidence intervals (Cis) were calculated and specified in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eIn total, 776,468 patients were identified: 368,423 (47.4%) underwent breast reconstruction surgery (BRS), and 408,045 (52.6%) underwent mastectomy without reconstruction. Among these patients, 52,351 met eligibility criteria for Phase I post-surgery radiation treatment to the breast/chest wall lymph node regions, breast, or chest wall regions. Of these Phase I patients, 2,510 (4.8%) patients received 2D therapy, 33,218 (63.4%) received 3D-CRT, and 16,623 (31.8%) received IMRT. For Phase II, 55,980 patients met eligibility criteria of receiving post-surgery radiation treatment to the breast/chest wall lymph node regions, breast, or chest wall regions. Of those Phase II patients, 43,873 (78.4%) patients received 2D therapy, 8,811 (15.7%) received 3D-CRT, and 3,296 (5.9%) received IMRT.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAs shown in Tables \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, the average age of patients who received 2D-Therapy, 3D-CRT, and IMRT were relatively equal across both phases I and II (Phase I: 56.76\u0026thinsp;\u0026plusmn;\u0026thinsp;13.45 vs. 54.29\u0026thinsp;\u0026plusmn;\u0026thinsp;12.84 vs. 53.77\u0026thinsp;\u0026plusmn;\u0026thinsp;12.79; Phase II: 55.45\u0026thinsp;\u0026plusmn;\u0026thinsp;13.04 vs. 55.08\u0026thinsp;\u0026plusmn;\u0026thinsp;12.99 vs. 54.64\u0026thinsp;\u0026plusmn;\u0026thinsp;13.04). There were no significant racial differences in terms of radiotherapy usage, with white patients being the highest users of 2D-therapy, 3D-CRT, and IMRT (Phase I: 78.5% vs. 81.7% vs. 78.6%; Phase II: 81.0% vs. 81.8% vs. 77.9%) followed by black patients (Phase I: 15.5% vs. 12.4% vs. 15.5%; Phase II: 13.3% vs 12.7% vs. 15.9%). There were also no significant differences in the insurance status of post-surgery patients who received radiotherapy, with approximately 60% of the patients receiving radiotherapy having private insurance across 2D-therapy, 3D-CRT, and IMRT respectively (Phase I: 58.8% vs. 62.9% vs. 63.4%; Phase II: 59.2% vs. 60.1% vs. 60.5%). In terms of treatment location, there was no significant predisposition for patients to be treated in a particular medical facility based on radiation treatment. Across 2D-Therapy, 3D-CRT, and IMRT-receiving patients, approximately half were treated in large urban areas (Phase I: 49.6% vs. 54.4% vs. 53.3%; Phase II: 49.9% vs. 48.6% vs. 52.2%), and approximately\u0026thinsp;~\u0026thinsp;40% were treated in comprehensive community cancer programs (Phase I: 42.7% vs. 41.8% vs. 41.8%; Phase II: 45.3% vs. 45.0% vs. 42.2%). In terms of patient comorbidities and health status, no significant differences were noted between the evaluated parameters of Charlson-Deyo Score, tumor behavior, and tumor grade. Across all three radiotherapy modalities for Phase I and II, ~\u0026thinsp;80% had a CDCC score of 0, ~\u0026thinsp;99% had invasive tumors, and approximately\u0026thinsp;~\u0026thinsp;80% of patients had Grade 2 or 3 tumors. Across these eight descriptive variables of patient characteristics and tumor burden, there are no significant differences associated with radiotherapy modality.\u003c/p\u003e\n\u003cp\u003eAs shown in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, the odds ratio of a BRS patient receiving Phase I 3D-CRT vs 2D-therapy is 3.271 (95% CI 2.704\u0026ndash;3.956), and 3.421 (95% CI 2.817\u0026ndash;4.154) for IMRT vs 2D-therapy. The odds of a BRS patient receiving Phase I IMRT is roughly equal to receiving 3D-CRT, with a 1.046 (95% CI 0.974\u0026ndash;1.123) odds ratio. Furthermore, BRS patients were 2.516 (95% CI 2.087\u0026ndash;3.033) more likely to receive Phase I unspecified general external beam radiation (EBR) compared to 2D-therapy, but 0.769 (95% CI 0.734\u0026ndash;0.807) less likely to receive EBR compared to 3D-CRT, and 0.735 (95% CI 0.691\u0026ndash;0.782) less likely to receive EBR compared to IMRT. These results strongly support the notion that BRS patients are more likely to receive Phase I 3D-CRT and IMRT compared to 2D-therapy, suggesting that Phase I 2D-therapy is uniquely underused by BRS patients compared to other existing treatment modalities.\u003c/p\u003e\n\u003cp\u003eFor Phase II radiotherapies, BRS patients were 1.590 (95% CI 1.490\u0026ndash;1.698) more likely to receive 3D-CRT vs. 2D therapy, and 1.533 (95% CI 1.392\u0026ndash;1.688) more likely to receive IMRT vs. 2D therapy. Phase II patients were slightly less likely to receive IMRT vs. 3D-therapy (0.964, 95% CI 0.863\u0026ndash;1.076). Finally, patients were 1.159 times more likely to receive unspecified EBR (95% CI 1.111\u0026ndash;1.208) compared to 2D therapy, but 0.756 less likely to receive EBR (95% CI 0.685\u0026ndash;0.834) compared to 3D-CRT and 0.756 less likely to receive EBR (95% CI 0.685\u0026ndash;0.834) compared to IMRT. With smaller differences in odds ratios compared to their Phase I counterparts, these results do not as strongly support the notion that BRS patients are more likely to receive Phase II 3D-CRT and IMRT compared to 2D-therapy and general, unspecified EBR. However, the differences in odds of receiving Phase II 2D-therapy vs. 3D-CRT or IMRT are still more pronounced compared to the difference in odds of receiving Phase II 3D-CRT vs. IMRT. This suggests that Phase II 2D-therapy is less commonly used by BRS patients compared to other existing treatment modalities.\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociation of BRS Compared to Mastectomy without Reconstruction on Post-Surgical Radiation Planning Technique\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAdjusted Odds Ratio\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ePhase I\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e3D-CRT vs. 2D Therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.271\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.704\u0026ndash;3.956\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIMRT vs. 2D Therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.421\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.817\u0026ndash;4.154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExternal Beam NOS vs. 2D Therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.516\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.087\u0026ndash;3.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIMRT vs. 3D-CRT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.046\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.974\u0026ndash;1.123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExternal Beam NOS vs. 3D-CRT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.769\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.734\u0026ndash;0.807\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExternal Beam NOS vs. IMRT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.735\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.691\u0026ndash;0.782\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ePhase II\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e3D-CRT vs. 2D Therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.590\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.490\u0026ndash;1.698\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIMRT vs. 2D Therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.533\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.392\u0026ndash;1.688\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExternal Beam NOS vs. 2D Therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.111\u0026ndash;1.208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIMRT vs. 3D-CRT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.629\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.589\u0026ndash;0.671\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExternal Beam NOS vs. 3D-CRT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.728\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.680\u0026ndash;0.780\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExternal Beam NOS vs. IMRT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.756\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.685\u0026ndash;0.834\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOverall, the data show that BRS patients had greater odds of pursuing more advanced radiotherapy modalities, (such as IMRT and 3D-CRT), when compared to MWR patients across both phase I and Phase II breast cancer. This finding was highlighted especially in the Phase I data as BRS patients had 3.271 times the odds of receiving 3D-CRT as opposed to 2D therapy, and 3.421 times the odds of receiving IMRT therapy as opposed to 2D therapy. These data results can be attributed to a multitude of factors.\u003c/p\u003e \u003cp\u003eNotably, breast reconstruction alters the pre-existing anatomy of the patient as the reconstructed breast is of a different contour and shape, while no longer containing glandular tissue, fat or ducts.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Scar tissue may also form at the mastectomy incision site. These changes make radiotherapy planning more complex, thus incentivizing the use of the more precise 3D therapy. 3D therapy utilizes CT/MRI imaging to develop a 3D model of the breast and the surrounding anatomy.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Hence, this model can more specifically pinpoint the location of the tumor bed and regional lymph nodes, (which require radiation), despite the altered anatomy of the reconstructed breast.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Alternatively, 2D therapy relies upon more basic forms of imaging anatomical landmarks, which often cannot account for post-surgery anatomical changes.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Subsequently, the distribution of radiation may be uneven and surrounding healthy tissue may be exposed to radiation.\u003c/p\u003e \u003cp\u003eBecause 3D therapy modulates the radiation dose to a specific target area, nearby healthy tissues and the reconstructed breast itself are often spared.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Therefore, the risk for complications in reconstructed breasts, (such as tissue fibrosis in autologous reconstruction or capsular contracture in implant reconstruction), is greatly reduced.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e This attribute is especially important for BRS patients with left-sided tumors because, 2D therapy oftentimes cannot effectively reduce radiation exposure to the heart and lungs, which may increase the risk for long term complications including heart disease and pulmonary fibrosis.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Additionally, for BRS patients, one important goal after surgery is to preserve the functionality and appearance of the reconstructed breast. In this respect, 3D and IMRT therapy is superior to older functionalities, like 2D, as their more focused radiation fields are less likely to cause external burns, fibrosis or poor wound healing.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Thus, these therapies offer better cosmetic and aesthetic results as well for BRS patients. Essentially, all the aforementioned factors help explain why BRS patients have greater odds in choosing 3D and IMRT post-surgical radiotherapies vs. 2D therapy when compared to MRS patients.\u003c/p\u003e \u003cp\u003eThere are multiple limitations on the study\u0026rsquo;s accuracy in reflecting associations between surgical treatments and post-surgical radiotherapy modalities. A small p-value, (\u0026lt;\u0026thinsp;.0001), alone does not entail scientific or clinical significance and so further studies are needed to replicate these data results in larger sample sizes. Other limitations of this study include a lack of more descriptive indicators, (aside from race, insurance status, etc.), that were included in the calculations of the adjusted odds ratios. This aspect allows for the possibility of other indicators, such as income, that could serve as confounding variables.\u003c/p\u003e \u003cp\u003eAdditionally, for both Phase I and Phase II data, each radiotherapy cohort had relatively similar distributions of patients along the measured socioeconomic variables such race, insurance status, etc. For example, for phase I patients, the percentages of uninsured patients for 2D, 3D and IMRT radiotherapies were 3.63, 3.19 and 2.93% respectively. As such, there was no distinct association between any of the descriptive statistics and the type of radiotherapy modality received. This aspect is important as it reduces the impact of potential confounding variables within the data, thereby relatively preserving the internal validity of the study. Otherwise, variables, like race, can influence the choice of radiotherapy for breast cancer patients. For instance, marginalized populations are less likely to receive optimal treatment and follow-up due to systemic inequities in healthcare delivery.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Another example is insurance status as differences in coverage highlight disproportionate access to healthcare, possibly discouraging patients from pursuing more expensive therapy such as IMRT.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eUltimately, the decision to choose a specific radiotherapy modality, based on prior breast surgery procedures, is very important to both the patient and the provider. This discussion directly pertains to the quality of care that patients receive as it raises important questions about side effects, complications, and treatment efficacy. Different modalities are indicated depending on the patient\u0026rsquo;s goals of treatment, preexisting conditions, and financial status. Newer techniques, such as IMRT and 3D therapies show promise for BRS patients compared to MRS patients due to their more focused radiation fields, which target only the tumor and lymph nodes of interest. This technique spares healthy tissue, importantly preventing radiation exposure to the heart and lungs. Breast reconstruction surgery, itself, complicates the delivery of radiotherapy, by changing the internal anatomy, contour and shape of the breast region- thereby potentially impacting selection of different radiotherapy techniques compared to mastectomy with reconstruction. Future studies should explore how the use of different post-surgery radiotherapy techniques have changed over time across multiple different populations of breast cancer patients. In this respect, special consideration should be directed to BRS patients, to optimize treatment efficacy and safety. By doing so, our understanding of the treatment implications of breast reconstruction surgery will become more nuanced and overall patient outcomes will improve.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics in Publishing Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI testify on behalf of all co-authors that our article submitted followed ethical principles in publishing.\u003c/p\u003e\n\u003cp\u003eAll authors agree that:\u003c/p\u003e\n\u003cp\u003eThis research presents an accurate account of the work performed, all data presented are accurate and methodologies detailed enough to permit others to replicate the work.\u003c/p\u003e\n\u003cp\u003eThis manuscript represents entirely original works and or if work and/or words of others have been used, that this has been appropriately cited or quoted and permission has been obtained where necessary.\u003c/p\u003e\n\u003cp\u003eThis material has not been published in whole or in part elsewhere.\u003c/p\u003e\n\u003cp\u003eThe manuscript is not currently being considered for publication in another journal.\u003c/p\u003e\n\u003cp\u003eThat generative AI and AI-assisted technologies have not been utilized in the writing process or if used, disclosed in the manuscript the use of AI and AI-assisted technologies and a statement will appear in the published work.\u003c/p\u003e\n\u003cp\u003eThat generative AI and AI-assisted technologies have not been used to create or alter images unless specifically used as part of the research design where such use must be described in a reproducible manner in the methods section.\u003c/p\u003e\n\u003cp\u003eAll authors have been personally and actively involved in substantive work leading to the manuscript and will hold themselves jointly and individually responsible for its content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e\u0026nbsp;not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNo Funding was involved in the manuscript.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo Conflicts of Interest to report.\u003c/p\u003e\n\u003cp\u003eNo External Data Availability sources to report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations:\u0026nbsp;\u003c/strong\u003enot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMonday O, Survey (2025) Many U.S. women lack basic information on life after mastectomy. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.plasticsurgery.org/news/press-releases/survey-many-us-women-lack-basic-information-on-life-after-mastectomy\u003c/span\u003e\u003cspan address=\"https://www.plasticsurgery.org/news/press-releases/survey-many-us-women-lack-basic-information-on-life-after-mastectomy\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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Accessed Jan 5, 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/cncr.33121\u003c/span\u003e\u003cspan address=\"10.1002/cncr.33121\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-plastic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejps","sideBox":"Learn more about [European Journal of Plastic Surgery](https://link.springer.com/journal/238)","snPcode":"238","submissionUrl":"https://submission.nature.com/new-submission/238/3","title":"European Journal of Plastic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6466069/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6466069/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study compares associations between breast reconstruction surgery (BRS) and types of postmastectomy radiation treatment modalities for breast cancer.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e Utilizing the NCDB Breast participant use file (PUF) from 2004\u0026ndash;2018, we compared the postmastectomy radiation treatment modalities of patients receiving BRS to those who did not.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOur study suggests that BRS patients had greater odds of pursuing more advanced radiotherapy modalities, IMRT and 3D-CRT, compared to mastectomy without reconstruction (MWR) patients. BRS patients were 3.271 (95% CI 2.704\u0026ndash;3.956) times more likely to receive Phase I 3D-CRT vs. 2D-therapy, and 3.421 (95% CI 2.817\u0026ndash;4.154) times more likely to receive IMRT vs. 2D-therapy, with relatively equal rates of receiving IMRT compared to 3D-CRT (1.046; 95% CI 0.974\u0026ndash;1.123). For Phase II, BRS patients were 1.590 (95% CI 1.490\u0026ndash;1.698) times more likely to receive 3D-CRT vs. 2D therapy, 1.533 (95% CI 1.392\u0026ndash;1.688) times more likely to receive IMRT vs. 2D therapy, and 1.159 (95% CI 1.111\u0026ndash;1.208) times more likely to receive unspecified EBR vs. 2D therapy.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe choice of radiotherapy modality after breast reconstruction surgery is critical for ensuring optimal treatment efficacy and safety, as it depends on factors like the patient\u0026rsquo;s goals, anatomy, and preexisting conditions. Advanced techniques like IMRT and 3D therapies have shown increased usage in and potential promise for BRS patients due to their precision in sparing healthy tissues, highlighting the need for further research to improve outcomes for this population.\u003c/p\u003e","manuscriptTitle":"Associations between Breast Reconstruction Surgery vs. Mastectomy without Reconstruction on Postsurgical Radiation Treatment Modalities: a 2004-2018 NCDB Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-08 14:56:44","doi":"10.21203/rs.3.rs-6466069/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-30T10:35:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-29T13:31:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52733108310455607755778134715941350773","date":"2025-05-02T12:48:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-28T18:32:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-28T09:06:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-28T09:04:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Plastic Surgery","date":"2025-04-16T19:11:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-plastic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejps","sideBox":"Learn more about [European Journal of Plastic Surgery](https://link.springer.com/journal/238)","snPcode":"238","submissionUrl":"https://submission.nature.com/new-submission/238/3","title":"European Journal of Plastic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"98721231-e63e-4de1-b08a-f470a502939d","owner":[],"postedDate":"May 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-21T15:59:56+00:00","versionOfRecord":{"articleIdentity":"rs-6466069","link":"https://doi.org/10.1007/s00238-025-02313-6","journal":{"identity":"european-journal-of-plastic-surgery","isVorOnly":false,"title":"European Journal of Plastic Surgery"},"publishedOn":"2025-07-16 15:57:15","publishedOnDateReadable":"July 16th, 2025"},"versionCreatedAt":"2025-05-08 14:56:44","video":"","vorDoi":"10.1007/s00238-025-02313-6","vorDoiUrl":"https://doi.org/10.1007/s00238-025-02313-6","workflowStages":[]},"version":"v1","identity":"rs-6466069","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6466069","identity":"rs-6466069","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}