Annelotte van Bommel

110 However, surgical oncologists reported tumor and nodal stage more frequently as contra-indication compared to plastic surgeons. Potential reason could be that in cT4 tumors the skin is involved and should be excised as well as the need for radiotherapy of the chest wall, as well as in patients diagnosed with a T3N2 tumor. A survey among breast surgical oncologists and plastic surgeons in the UK reported that 26% of the surgical oncologists would not offer IBR in patients with stage IV disease. 38 Reasons were related to poor prognosis (31%), concerns about temporary cessation of systemic treatments (21%) and recovery time (17%). 38 In the present study, (neo)-adjuvant therapies were not considered major contra- indications while literature suggests that adjuvant therapies such as chemotherapy and radiotherapy may affect IBR rates significantly. 18,22 The question in our survey enquiring about neo-adjuvant and adjuvant therapies may have been phrased not clearly enough, with respondents assuming that only neo-adjuvant therapies were asked for. Surgical oncologists more often regarded adjuvant chemotherapy a contra-indication for IBR compared to plastic surgeons, presumably because of fear of delay in chemotherapy administration. 28 However, a recent systematic review showed no clinically relevant delay in chemotherapy administration if a patient has undergone IBR, irrespective of type of reconstruction. 39 Of the respondents who reported (neo)-adjuvant therapies as contra-indication, radiotherapy was considered a contra-indication specifically for implant reconstructions. Use of radiotherapy leads to a significantly higher reconstruction failure rate compared to if no radiotherapy is given, 40 reason for plastic surgeons not to perform IBR. 41 Radiotherapy is less detrimental to autologous reconstructions 42 and it is therefore not surprising that in this situation it was considered a less important contra-indication for this type of reconstruction. Another study showed that 19% of surgical oncologists answered they did not refer patients to a plastic surgeon if adjuvant radiotherapy was indicated. 28 Our study had respondents fromnearly all hospitals in the Netherlands, resulting in a large and representative sample of clinicians. Respondent characteristics differed slightly between surgical oncologists and plastic surgeons and may have affected