ASBS: Disparities and surprises noted in breast reconstruction rates following mastectomy
Although the rate is increasing, a minority of patients currently undergo breast reconstruction surgery- either immediate or delayed-following mastectomy, found a recent study presented at the 11th annual meeting of the American society of breast surgeons (ASBS) in Las Vegas on April 30.

Alicia Holt, MD, of City of Hope National Medical Center in Duarte, Calif. and colleagues noted that there were few studies undertaken to determine factors influencing whether breast cancer patients undergo reconstruction. The researchers sought to observe variables associated with the use of reconstruction in Los Angeles, Orange, San Bernardino and Riverside, Calif.

Holt noted that a surprising finding of the study was the number of young women that choose to forgo breast reconstruction. “Some women just feel as though it’s not important for them and what I’m surprised about is the number of young women who find reconstruction not important for themselves,” she explained. “Likewise, there are some older women who feel like reconstruction is very important for them.”

The researchers determined postmastectomy reconstruction rates utilizing the California Office of Statewide Health Planning and Development database over a five-year period, ranging from 2003 to 2007. International Classification of Disease-9 codes were used to identify patients undergoing reconstruction after mastectomy, and differences in reconstruction rates were examined by calendar year, age, race/ethnicity, insurance status, and hospital characteristics, they wrote.

Holt and colleagues found that the total number of patients undergoing mastectomy with or without reconstruction was 2,936 in 2003, increasing to 3,151 in 2007 and the proportion of patients undergoing any type of reconstruction, both immediate and delayed procedures, rose from 21.4 percent in 2003 to 29.3 percent in 2007.

In terms of immediate reconstruction, women under the age of 40 had the highest proportion compared to older patients. The authors also wrote that patients with private insurance were more likely to undergo immediate reconstruction than patients with Medi-Cal. In addition, teaching hospitals were nearly twice as likely to perform immediate reconstruction compared to nonteaching hospitals and patients undergoing procedures at National Cancer Institute-designated comprehensive cancer centers (NCI-CCC) are more likely to undergo flap reconstruction than implant, compared to patients undergoing procedures at other hospitals. Teaching hospitals were found to be less likely to perform flap reconstruction compared to implant procedures, they wrote.

Within small hospitals that offered delayed reconstruction, the number of these procedures increased from 22 to 35 hospitals over the course of the five-year period.

Moreover, Holt noted that Caucasian women were found to be twice as likely to undergo post postmastectomy reconstruction, when compared to African-American women.

The study concluded that insurance status, race/ethnicity, as well as type of hospital appear to be significant factors limiting the use of reconstruction.

Holt noted that some women who are going on to receive chemotherapy treatments wish to have their treatments taken care of before any surgery, while some wish to have all surgery taken care of before moving on to other treatments. “It’s really an individual issue, which goes back to making sure that it is at least an option for our patients,” she said.

Deanna Attai, MD, chair of the communications committee for the ASBS noted that at her community practice, plastics surgeons are on staff, providing her the luxury of being able to refer the majority of her patients for immediate reconstruction.  “In certain areas of the country, it’s very difficult to find a plastic surgeon that is adequately trained and has the interest in reconstructive surgical procedures,” she said.

Agreeing with Holt, Attai mentioned patient preference.  “Sometimes you would be surprised by the number of women who are not interested in immediate reconstruction despite having a consultation with a plastic surgeon."

“As surgeons, it is important for us to recognize that is this is very important to many of our patients, that we do make the effort to seek out plastic surgeons that we can collaborate with and continue to refer these patients, to at least give them the option,” she concluded.