Research Article ISSN 2639-8478

Cancer Science & Research

Mastectomy Wound Infections Increase with Advanced Age

Tammy Ju MD1*, Cecilia Rossi BS2, Andrew Sparks MS1, Claire Edwards MD3, Anita McSwain MD MPH1
and Christine Teal MD1
The George Washington University Hospital, Washington, D.C.,
1

USA. Correspondence:
*

Tammy Ju, 2150 Pennsylvania Ave, Suite 6B, Washington DC

The George Washington University School of Medicine and
2 20037, USA, Tel: 202-741-3365; E-mail: tammyju@gwu.edu.
Health Sciences, Washington, D.C., USA.
Received: 21 November 2018; Accepted: 18 December 2018
Virginia Hospital Center, Arlington, VA, USA.
3

Citation: Tammy Ju MD, Cecilia Rossi BS, Andrew Sparks MS, et al. Mastectomy Wound Infections Increase with Advanced Age.
Cancer Sci Res. 2018; 1(4); 1-6.

ABSTRACT
Objectives: The purpose of this study is to determine if there is an increased risk of complications following
mastectomies associated with advanced age.

Materials and Methods: The ACS-NSQIP database was queried from 2010 to 2015 using a CPT code for mastectomy
and complications were identified as defined by the database. Univariate analyses were performed using a binary
outcome variable (complication present or not) by age decade. Multivariable logistic regression analysis was
performed using decade 6 (age 60-69) as the reference group. P-value<0.05 was considered statistically significant.

Results: 4,854 patients met inclusion criteria, ages 18 to 90+. Univariate analyses for the presence of a
postoperative complication by age decade showed no statistical difference except for wound infections (p<0.01).
On multivariable analysis, the odds of having a postoperative complication is 1.4 times higher in obese patients
(p<0.01,95%CI:1.1-1.8) and 1.4 times higher in smokers (p<0.01,95%CI:1.1-1.9). Complications are 3.5 times
higher in patients who are not of fully independent functional status (p<0.0001,95%CI:2.3-5.8) and 5.9 times
higher for dialysis patients (p<0.001,95%CI:2.3-15). Non-fully independent functional status also increased risk
for mortality (p<0.05,OR=8.7,95%CI:1.5-49.6). Patients ages 90 or older were 3.4 times more likely to have a
wound infection (p<0.05,95%CI:1.3-9.0).

Conclusion: There is no increased overall risk of a postoperative complication within 30 days of mastectomy due
to the age of the patient. However, patients 90 years of age or older are at higher risk for wound infections. Our
study suggests elderly breast cancer patients should not be excluded from undergoing a mastectomy solely based
on their age.

Keywords complications related to breast cancer surgery are also not well
Advanced age, Post-mastectomy complications, Wound infection. elucidated at these age extremes.

Background As elderly breast cancer patients are often undertreated,

Due to the rapid aging population in the U.S. it is anticipated there mastectomy is sometimes avoided because the risk of postoperative
will be a 67% increase in cancer incidence by 2030 for patients over complications may outweigh the benefit. Some studies have shown
the age of 65, compared to an 11% increase in cancer incidence that while elderly patients undergo breast conservation therapy
in patients under 65 [1,2]. Breast cancer is not only the most more often than mastectomy, it is not clear that less aggressive
common cancer among women, but elderly breast cancer patients treatment results in comparable survival [4,5]. Recent studies have
are known to have increased mortality and are largely undertreated investigated complications for the elderly breast cancer patient and
for their cancer compared to their younger counterparts [3-6]. Due have found overall complications to be low (approximately 4%) and
to the paucity of data related to elderly breast cancer patients, similar to those in younger patients [4,7]. However, these studies
Cancer Sci Res, 2018 Volume 1 | Issue 4 | 1 of 6
have not investigated mastectomy alone and often group breast complications compared by age decade using decade 6 (ages 60-69)
conserving surgery with patients treated with mastectomy with as the reference group. Comorbidities of interest were controlled
reconstruction, which has been known to increase complications for and entered into the multivariable model if the univariate test
[8,9]. Furthermore, there is no consensus on the age cut off of an produced a p-value less than 0.1 (α = 0.1). A p-value <0.05 was
older woman, with some studies citing 70 or 80 years of age as considered statistically significant. All statistical analysis was
defining geriatric breast cancer patients [4,7]. performed using SAS version 9.3 (Cary, NC).

Given the anticipated increase in the older breast cancer population Results
in the near future, and lack of data investigating the postoperative There were 4,854 patients who met inclusion criteria. Age range
risk of complications in this population, our study aims to identify was 18 to over 90. On univariate analyses, there was a significant
the short-term outcomes after mastectomy using a large national association between age decade and female gender (p=0.05*), BMI
surgical database to examine whether there is an increased risk of (p <0.0001), diabetes (p <0.0001), smoker (p <0.0001), dyspnea (p
complications in elderly patients. <0.0001), non-independent functional status (p <0.0001), COPD
(p <0.0001), HTN (p <0.0001), dialysis (p=0.08*), and ASA class
Materials and Methods other than 1 (p <0.0001) (Table 1).
Following IRB exemption, a retrospective analysis was performed
from 2010 - 2015 using the American College of Surgeon’s On univariate analysis, there was no statistically significant
National Surgical Quality Improvement Program Participant User difference found between age decade and presence of a complication
File (ACS-NSQIP PUF) database. Adult patients age 18 or older (p=0.69) or with 30-day mortality (p=0.23). However, there was
were identified who underwent mastectomy using CPT code 19303 a difference between wound infection across decades (p<0.01)
with or without sentinel lymph node biopsy (SLNB, CPT code (Table 2). No other complications had a significant difference
38525) for a primary diagnosis of invasive breast cancer defined individually on univariate analysis. On multivariable logistic
by ICD-9 code. Patients were excluded from this study if they had regression analysis, there was no statistically significant difference
disseminated cancer, bleeding disorders, underwent reconstruction, between age decade and presence of a postoperative complication
or underwent emergency surgery. Further information regarding (p = 0.98) and no difference between age decade and 30-day
the ACS-NSQIP database can be found at: https://www.facs.org/ mortality (p = 0.66) (Table 3, Table 4).
quality-programs/acs-nsqip.
The odds of having a postoperative complication was 1.42 times
Preoperative patient variables and 30-day morbidity and higher in patients with obesity (p<0.01, 95% CI: 1.12-1.8) and
mortality were investigated across age quintiles. Preoperative 1.4 times higher in current smokers (p<0.01, 95% CI: 1.1-1.9).
patient variables were defined using the ACS-NSQIP definitions The odds of having complications was 3.5 times higher in patients
which include gender, BMI, diabetes, smoking status, dyspnea, who are not of a fully independent functional status compared to
functional status, history of chronic obstructive pulmonary disease those who are fully functional (p <0.0001, 95% CI: 2.3-5.3) and
(COPD), hypertension (HTN), dialysis, American Society of 5.9 times higher in those on dialysis (p<0.001, 95% CI: 2.3-15)
Anesthesiologists (ASA) classification, and steroid use. Outcomes (Table 3). Female gender had a protective effect with regards to
of interest defined as “postoperative complications” include 30-day mortality (p<0.05, OR = 0.07 95% CI 0.01-0.62) while
wound infection, superficial wound infection, wound dehiscence, not being of fully independent functional status increased risk for
deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding 30-day mortality (p<0.05, OR = 8.7, 95% CI: 1.5-49.6) (Table
requiring transfusion, return to the operating room (OR), myocardial 4). Patients age 90 or older were 3.4 times more likely to have a
infarction (MI), cardiac arrest, stroke, urinary tract infection wound infection (p<0.05 95% CI: 1.3-9.0) (Table 5).
(UTI), renal insufficiency, fail to wean from the ventilator, deep
organ space infection, pneumonia (PNA), reintubation, sepsis, and Discussion
septic shock. A binary score was compiled for presence of any of Due to the paucity of data and limited randomized control
these complications. Complications were then stratified by age trials looking at age extremes, the risk of complications after
decade (decade 2 = age 18-29, 3 = 30-39, 4 = 40-49, etc) using mastectomy for elderly patients is unclear. This is one of the few
patients within decade 6 (ages 60-69) as the reference group due studies addressing risk of complications specifically after simple
to the largest amount of patients in that age range, to determine the mastectomy in elderly breast cancer patients. Post-mastectomy
association between age and risk of postoperative complication. complications continue to have a low overall morbidity and
mortality for patients of all ages in our dataset. Our study shows
Univariate analyses using chi-squared tests were then performed that age is not an independent risk factor for complications after
using age decade by comorbidities and demographic data. mastectomy, whereas comorbid conditions such as obesity,
Univariate analyses using chi-squared tests were performed using smoking, dialysis, and non-independent functional status are
the binary outcome variable (complication present or not) by age significant predictors of 30-day morbidity and mortality [10,11].
decade. The 30-day mortality was also investigated independently However, patients over the age of 90 are at an increased risk for
using a chi-squared test by age decade. A multivariable logistic wound infections, even after adjusting for comorbid conditions.
regression analysis was performed on incidence of postoperative
Cancer Sci Res, 2018 Volume 1 | Issue 4 | 2 of 6
 Age 18-29 (2) 30-39 (3) 40-49 (4) 50-59 (5) 60-69 (6) 70-79 (7) 80-89 (8) 90+ (9) All p-value
Decade N=20 N=172 N=638 N=1049 N=1271 N=1014 N=599 N=91 N=4854 * = sig. at α=0.1
Variable N (%)
Female Gender 18 (90) 169 (98.3) 627 (98.3) 1030 (98.2) 1245 (98) 999 (98.5) 594 (99.2) 87 (95.6) 4769 (98.3) 0.05*
Underweight <18.5 1 (5) 5 (2.9) 16 (2.5) 22 (2.1) 17 (1.3) 30 (3) 30 (5) 8 (8.8) 129 (2.7)
Normal 18.5–24.9 8 (40) 73 (42.4) 253 (39.7) 308 (29.4) 340 (26.8) 289 (28.5) 230 (38.4) 46 (50.6) 1547 (31.9)
BMI Overweight <0.0001*
5 (25) 42 (24.4) 162 (25.4) 299 (28.5) 364 (28.6) 331 (32.6) 181 (30.2) 28 (30.8) 1412 (29.1)
25.0–29.9
Obese >/= 30 6 (30) 52 (30.2) 207 (32.45) 420 (40) 550 (43.3) 364 (35.9) 158 (26.4) 9 (9.9) 1766 (36.4)
Diabetes 0 (0) 5 (2.9) 22 (3.5) 100 (9.5) 197 (15.5) 201 (19.8) 91 (15.2) 8 (8.8) 624 (12.9) <0.0001*
Smoker 5 (25) 41 (23.8) 132 (20.7) 187 (17.8) 187 (14. 7) 84 (8.3) 16 (2.7) 3 (3.3) 655 (13.5) <0.0001*
Dyspnea 0 (0) 5 (2.9) 29 (4.6) 69 (6.6) 125 (9.8) 129 (12.7) 67 (11.2) 11 (12.1) 435 (9) <0.0001*
Not fully independent
0 (0) 0 (0) 5 (0.78) 18 (1.7) 20 (1.6) 25 (2.5) 48 (8) 25 (27.5) 141 (2.9) <0.0001*
functional status
COPD 0 (0) 0 (0) 1 (0.16) 24 (2.3) 54 (4.3) 49 (4.8) 33 (5.5) 2 (2.2) 163 (3.4) <0.0001*
Hypertension 1 (5) 11 (6.4) 120 (18.8) 372 (35.5) 709 (55.8) 674 (66.5) 428 (71.5) 67 (73.6) 2382 (49.1) <0.0001*
Dialysis 0 (0) 0 (0) 3 (0.47) 3 (0.29) 10 (0.79) 0 (0) 4 (0.67) 0 (0) 20 (0.41) 0.08*
ASA class >1 18 (90) 137 (79.7) 561 (87.9) 999 (95.2) 1231 (96.9) 1000 (98.6) 589 (98.3) 91 (100) 4626 (95.3) <0.0001*
Steroid use 0 (0) 2 (1.2) 9 (1.4) 15 (1.4) 27 (2.1) 18 (1.8) 11 (1.8) 3 (3.3) 85 (1.8) 0.78
Table 1: Pre-operative patient characteristics by age decade.
BMI: Body Mass Index, COPD: Chronic Obstructive Pulmonary Disease, ASA: American Society of Anesthesiologists.

Age 18-29 (2) 30-39 (3) 40-49 (4) 50-59 (5) 60-69 (6) 70-79 (7) 80-89 (8) 90+ (9) All p-value
Decade N=20 N=172 N=638 N=1049 N=1271 N=1014 N=599 N=91 N=4854 * = sig. at α=0.05

Variable N (%)
Any post-op
1 (5) 13 (7.6) 54 (8.5) 98 (9.3) 124 (9.8) 91 (9) 57 (9.5) 13 (14.3) 451 (9.3) 0.69
complication
30 Day mortality 0 (0) 0 (0) 1 (0.16) 1 (0.10) 1 (0.08) 1 (0.10) 4 (0.67) 0 (0) 8 (0.16) 0.23
Wound infection 0 (0) 2 (1.2) 4 (0.63) 14 (1.3) 16 (1.3) 13 (1.3) 15 (2.5) 9 (9.9) 73 (1.5) <0.01*
Superficial Wound
0 (0) 2 (1.2) 8 (1.3) 28 (2.7) 37 (2.9) 25 (2.5) 15 (2.5) 1 (1.1) 116 (2.4) 0.42
infection
Wound dehiscence 0 (0) 4 (2.3) 2 (0.31) 4 (0.38) 3 (0.24) 3 (0.30) 1 (0.17) 0 (0) 17 (0.35) 0.08
DVT 0 (0) 0 (0) 2 (0.31) 2 (0.19) 2 (0.16) 5 (0.49) 1 (0.17) 0 (0) 12 (0.25) 0.77
PE 0 (0) 0 (0) 0 (0) 1 (0.10) 1 (0.08) 1 (0.10) 1 (0.17) 0 (0) 4 (0.08) 0.93
Bleeding 1 (5) 0 (0) 2 (0.31) 7 (0.67) 4 (0.31) 8 (0.79) 0 (0) 0 (0) 22 (0.45) 0.07
Return to the OR 0 (0) 5 (2.9) 37 (5.8) 53 (5.1) 67 (5.3) 38 (3.8) 18 (3) 3 (3.3) 221 (4.6) 0.14
MI 0 (0) 0 (0) 1 (0.16) 0 (0) 1 (0.08) 2 (0.20) 2 (0.33) 0 (0) 6 (0.12) 0.50
Cardiac arrest 0 (0) 0 (0) 0 (0) 0 (0) 1 (0.08) 1 (0.10) 1 (0.17) 0 (0) 3 (0.06) 0.71
Stroke 0 (0) 0 (0) 1 (0.16) 0 (0) 1 (0.08) 2 (0.20) 2 (0.33) 0 (0) 6 (0.12) 0.50
UTI 0 (0) 0 (0) 0 (0) 0 (0) 3 (0.24) 4 (0.39) 4 (0.67) 0 (0) 11 (0.23) 0.13
Renal insufficiency 0 (0) 0 (0) 0 (0) 1 (0.1) 0 (0) 0 (0) 1 (0.17) 0 (0) 2 (0.04) 0.38
Fail to wean from the
0 (0) 0 (0) 1 (0.16) 0 (0) 1 (0.08) 1 (0.10) 4 (0.67) 0 (0) 7 (0.14) 0.10
ventilator
Deep organ space
0 (0) 0 (0) 3 (0.47) 1 (0.10) 3 (0.24) 2 (0.20) 1 (0.17) 0 (0) 10 (0.21) 0.79
infection
Pneumonia 0 (0) 0 (0) 0 (0) 0 (0) 2 (0.16) 2 (0.20) 4 (0.67) 0 (0) 8 (0.16) 0.13
Reintubation 0 (0) 0 (0) 1 (0.16) 0 (0) 2 (0.16) 2 (0.20) 4 (0.67) 0 (0) 9 (0.19) 0.21
Sepsis 0 (0) 0 (0) 1 (0.16) 2 (0.19) 4 (0.31) 3 (0.30) 1 (0.17) 0 (0) 11 (0.23) 0.98
Septic shock 0 (0) 0 (0) 0 (0) 0 (0) 1 (0.08) 3 (0.30) 2 (0.33) 0 (0) 6 (0.12) 0.31
Table 2: Presence of postoperative complication by age decade.
Note: VIF analysis performed to analyze multicollinearity in multivariable models below. All independent variables are good, no variance inflation
factors >= 1.4.

Cancer Sci Res, 2018 Volume 1 | Issue 4 | 3 of 6

 Variables Adjusted OR (95% CI) p-value (* if significant at α=0.05)
Age Decade (Overall) N/A 0.98
Age Decade 2 0.52 (0.07 – 3.9) 0.53
Age Decade 3 0.81 (0.44 – 1.5) 0.49
Age Decade 4 0.89 (0.64 – 1.3) 0.51
Age Decade 5 0.97 (0.73 – 1.3) 0.81
Age Decade 7 0.97 (0.72 – 1.3) 0.82
Age Decade 8 0.96 (0.68 – 1.4) 0.82
Age Decade 9 1.22 (0.63 – 2.4) 0.56
BMI obese vs normal 1.42 (1.12 – 1.8) <0.01*
BMI overweight vs normal 1.09 (0.84 – 1.4) 0.53
BMI underweight vs normal 1.03 (0.54 – 2.0) 0.93
Smoker 1.4 (1.1 – 1.9) <0.01*
Non-independent functional status 3.5 (2.3 – 5.3) <0.0001*
Dialysis 5.9 (2.3 – 15.0) <0.001*
Table 3: Logistic regression model for presence of postoperative complications by age decade (reference group = decade 6).

Variables Adjusted OR (95% CI) p-value (* if significant at α=0.05)

Age Decade (Overall) N/A 0.66
Age Decade 2 0 (0 – 1000) 0.99
Age Decade 3 0 (0 – 1000) 0.99
Age Decade 4 2.2 (0.13 – 34.7) 0.59
Age Decade 5 1.2 (0.08 – 19.6) 0.89
Age Decade 7 1.3 (0.08 – 20.3) 0.87
Age Decade 8 7.0 (0.72 – 67.1) 0.09
Age Decade 9 0 (0 – 1000) 0.98
Female gender 0.07 (0.01 – 0.62) <0.05*
Non-independent functional status 8.7 (1.5 – 49.6) <0.05*
Table 4: Logistic regression model of 30-day mortality by age decade (reference group = decade 6).

Variables Adjusted OR (95% CI) p-value (* if significant at α=0.05)

Age Decade (Overall) N/A 0.21
Age Decade 2 0 (0 – 1000) 0.98
Age Decade 3 1.1 (0.26 – 5.1) 0.86
Age Decade 4 0.52 (0.17 – 1.6) 0.26
Age Decade 5 1.1 (0.53 – 3.0) 0.80
Age Decade 7 1.04 (0.49 – 2.2) 0.92
Age Decade 8 1.4 (0.65 – 2.9) 0.40
Age Decade 9 3.4 (1.3 – 9.0) <0.05*
Non independent functional status 10.6 (5.7 – 19.6) <0.0001*
Dialysis 8.4 (2.3 – 31.0) <0.01*
Table 5: Logistic regression model of wound infection by age decade (reference group = decade 6).
According to the U.S. census, the median age continues to rise may omit multimodal treatment due to reasons such as not being
with those age 65 and older increasing from 35 million in 2000 fit for surgery, intolerance to chemotherapy or radiation, or poor
to nearly 50 million in 2016 [1]. It is anticipated that by 2030, overall life expectancy [3]. Previous studies have reported mixed
the geriatric population will be near 70 million, with a similar results citing age as a predictor of complications while more recent
trend of increasing cancer incidence [12]. Studies have shown that studies have shown otherwise [4,5,12]. A recent study using the
with regards to breast cancer, not only is the incidence higher in ACS-NSQIP database by Pettke et al. investigated short-term
elderly women but elderly women are generally undertreated with morbidity for patients greater than 80 years of age compared
recent trends showing older patients undergoing less invasive or to those less than 80 years and found higher rates of mortality
no surgery [3-5,7]. Studies have suggested that elderly patients and complications due to comorbidities. However, this dataset
Cancer Sci Res, 2018 Volume 1 | Issue 4 | 4 of 6
included less invasive procedures such as partial mastectomy With regards to dialysis, it is well established that long term
which inherently carry less morbidity than total mastectomies dialysis is a risk factor for perioperative complications, including
[4,13]. Similarly, another study using the ACS-NSQIP database mortality, among a variety of general surgery procedures such as
by Angarita et al. compared women aged 70 and over to women emergent and non-emergent abdominal surgery, cardiac surgery,
aged 40-69 and found no difference in overall morbidity although and any major general surgery [16,17]. Patients on dialysis also
older women were more likely have complications related to have been found to be at increased risk for wound infection after
cardiac, pulmonary or neurological issues [7]. Again, this study surgery which has been proposed to be due a variety of reasons
pooled partial mastectomy with mastectomy. Our data suggests including increased blood transfusions, central line access, and
that a more aggressive surgical operation such as mastectomy uremia with associated malnutrition [16-18]. Our study also found
if indicated may be performed with no increased risk of overall that dialysis increased the risk of postoperative complications in
short-term complication compared to younger patients, however mastectomy patients.
those at age extremes such as greater than 90 are different.
The ACS-NSQIP database is a nationally validated and risk
Increased BMI, smoking, and diabetes are established risk adjusted database, however our study is not without limitations.
factors for post-surgical complications and specifically for those Due to the retrospective nature of a large database study, we are
undergoing mastectomy for breast cancer [10,11,13]. Our study subject to coding errors and limitations secondary to the database’s
also found increased BMI and smoking status to be predictive of definitions. In addition, we are unable to assess outcomes past 30
increased morbidity across all age quintiles, as well as dialysis. days. Oncologic staging, including tumor characteristics and prior
Functional status has not been previously described to be history of breast cancer could not be accounted for in the database.
predictive of complications in this cohort. Our study found a strong Additionally, chemotherapy and radiation performed could not be
correlation between any non-independent functional status as a assessed as over 75% if the variables were missing. It is known
risk factor for short term postoperative complication and mortality that elderly patients are undertreated for breast cancer, and thus
following mastectomy. Functional status was defined as any non- there may be a selection bias present for those patients being
independent status (such as partially or fully dependent). The treated with mastectomy especially at the extremes of age in our
clinical implications of our study suggest that in addition to these study. However, our study is one of the few to use the ACS-NSQIP
well-established predictors of short-term complications, functional database to specifically look at mastectomy only in age extremes
status should also be included during preoperative assessment of and investigate physiologic status vs chronological status as a
breast cancer patient. Our results show that physiological age is predictor of complications.
more important than chronological age in determining short-term
morbidity and mortality after mastectomy. Other studies have Conclusion
recommended preoperative evaluations such as the comprehensive Our results show that age is not an independent risk factor for
geriatric assessment (CGA) to help predict short term surgical overall risk of a post-mastectomy complication. However, patients
outcomes [14,15]. over the age of 90 are at increased risk for wound infections. Non-
independent functional status is a strong predictor of complications
Our study found that the most common complication was return to in the postoperative period including 30-day mortality. Established
the OR (Table 2) while other studies have cited wound infection risk factors such as increased BMI, smoking, and dialysis continue
complications as the most common after breast surgery [2]. The to be predictive of morbidity. Further studies are needed to
FOCUS study analysis performed in the Netherlands in 2013 by establish the long-term morbidity and oncologic outcomes in these
de Glas et al. looked at postoperative complications for partial patient populations.
mastectomy and mastectomy and found complications of bleeding
were as common as wound infections [13]. On multivariable References
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© 2018 Tammy Ju, et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License

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