Immediate Breast Reconstruction After Mastectomy More Likely Among Canadian Women With Higher Income Who Are Treated at Teaching Hospitals
In a study reported in the Journal of Clinical Oncology, Zhong et al assessed factors associated with use of immediate breast reconstruction after treatment or prophylaxis for breast cancer among women in the Canadian universal health-care system. Immediate breast reconstruction was more likely in women who were better off financially, traveled longer distances for treatment, and were treated at teaching hospitals or hospitals with multiple available plastic surgeons.
Study Details
This population-based retrospective cohort study included data from 28,176 women who underwent mastectomy, including 25,141 undergoing mastectomy alone and 3,035 undergoing immediate breast reconstruction, between April 2002 and March 2012 in Ontario.
Between 2002–2003 and 2011–2012, the age-adjusted rate of mastectomy alone decreased 13.5% (P < .001), with immediate breast reconstruction increasing by 42.0% (P< .001) and breast-conserving surgery decreasing by 33.0% (P < .001). The proportion of women undergoing immediate breast reconstruction at the time of prophylactic or therapeutic mastectomy increased from 8.9% to 16.0% (P < .001), including a nonsignificant 7.1% increase (P = .5) and a significant 78.6% increase in in situ breast cancer (P < .001). The rate of implant reconstruction increased by 95.9% (P < .001), use of microsurgical reconstruction did not change significantly, and use of pedicled tissue decreased significantly (−67.4%, P < .001).
Factors Associated With Immediate Breast Reconstruction
Patients undergoing mastectomy alone vs immediate breast reconstruction differed significantly with regard to age, laterality, income quintile, rural vs nonrural residence, fiscal year, teaching vs nonteaching hospital, hospital volume of breast cancer surgeries and immediate breast reconstruction procedures, institutional availability of plastic surgeons, distance to surgery institution, and distance to institution with an above average volume of immediate breast reconstruction procedures.
Analysis in a select sample of 15,689 patients who had mastectomy alone and 1,683 who had immediate breast reconstruction between January 2004 and March 2010 showed that immediate breast reconstruction was significantly more common in women with stage I disease and recurrent breast cancer and in nonimmigrant women.
Significant Predictors
On multivariate analysis adjusting for patient, institutional, and geographic characteristics, factors significantly associated with increased likelihood of immediate breast reconstruction were ages 18 to 49 years (odds ratio [OR] = 6.62, P < .001) and 50 to 64 years (OR = 3.39, P < .001) vs 65 to 74 years; middle (OR = 1.28, P = 0.10), second highest (OR = 1.42, P < .001), and highest (OR = 1.71, P <.001) income quintiles vs lowest quintile; surgery at a teaching hospital (OR = 1.84, P = .02); ≥ 2 plastic surgeons available to perform the procedure at the institution (OR = 2.01, P < .001); and distance to surgical treatment (OR = 1.04, P <.001, for every 10 km increase). Diagnosis of invasive breast cancer prior to or on the day of mastectomy (OR = 0.20, P < .001) and immigrant status within 10 years of the procedure (OR = 0.59, P < .001) were associated with reduced likelihood of immediate breast reconstruction.
The investigators concluded, “[Immediate breast reconstruction] is a discretionary surgical service in Ontario that is used only by patients with favorable clinical and demographic characteristics who travel farther to undergo [the procedure] at teaching hospitals that have a greater availability of plastic surgeons who perform [the procedure]. This study highlights that universal coverage of [immediate breast reconstruction] is insufficient and that the barriers and inequities in [its] delivery pose a challenge to the central tenets of Canada’s publicly funded health care system.”
Toni Zhong, MD, of the University Health Network, Toronto, is the corresponding author for the Journal of Clinical Oncology article.
The study was supported by the Canadian Breast Cancer Foundation, GlaxoSmithKline, Canadian Institute of Health Research, American Society of Clinical Oncology, Cancer Care Ontario, and Ontario Ministry of Health and Long-Term Care. The study authors reported no potential conflicts of interest.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
