Breast Reconstruction Has Increased Over Time but Varies Widely by Region

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Analysis of data from 20,560 women undergoing mastectomy for breast cancer found that breast reconstruction use “increased from 46% in 1998 to 63% in 2007 (P< .001), with increased use of implants and decreased use of autologous techniques over time (P < .001),” according to a report published in the Journal of Clinical Oncology. The authors are affiliated with the University of Michigan in Ann Arbor, The University of Texas MD Anderson Cancer Center in Houston, and the Swan Center for Plastic Surgery in Alpharetta, Georgia.

The percentage of women choosing bilateral mastectomy also increased, from 3% in 1998 to 18% in 2007 (P < .001). “Patients receiving bilateral mastectomy were more likely to receive reconstruction [odds ratio [OR] = 2.3, P < .001], and patients receiving radiation were less likely to receive reconstruction [OR = 0.44, P < .001],” the investigators noted. Autologous techniques were more often used in patients who received both reconstruction and radiation (OR = 1.8, P < .001) and less often in patients undergoing bilateral mastectomy (OR = 0.5, P < .001). Delayed reconstruction was performed in 21% of patients.

The study participants were identified through the MarketScan database, a claims-based data set of U.S. patients with employment-based insurance. The median age was 51 years. The women represented regions across the country, with 49% from the south.

Rates of reconstruction varied dramatically by geographic region, from a low of 18% in North Dakota to a high of 80% in Washington, DC. Current findings suggest that geographic disparities found in previous studies are continuing and “are associated with workforce distribution of plastic surgeons. The finding that breast reconstruction rates are associated with access to plastic surgeons is particularly concerning in light of a recent survey that revealed many plastic surgeons to be decreasing their volume of breast reconstruction surgeries owing to decreasing levels of reimbursement,” the researchers wrote.

“Breast reconstruction has been shown to yield important psychosocial and quality of life benefits for patients with breast cancer who have undergone mastectomy,” the authors noted. “Further research and interventions are needed to ensure equitable access to this important component of multidisciplinary treatment of breast cancer.”

Access to Reconstruction

An accompanying editorial pointed out that “over the past 10 years, the proportion of women treated with mastectomy may be increasing despite no scientific data demonstrating its superiority over [breast-conserving surgery]. One factor making mastectomy a more palatable option to women and a possible additional driver of increased rates of mastectomy is access to breast reconstruction at the time of or subsequent to mastectomy,” wrote Lindi H. VanderWalde, MD, and Stephen B. Edge, MD, of Baptist Cancer Center in Memphis.

Acknowledging that “disparities in health care still exist with low rates of reconstructions based on regional or institutional difference, and based on sociodemographic factors of the patient,” Dr. VanderWalde and Dr. Edge concluded:

In contrast, there is a subset of women with early-stage breast cancer amenable to breast conservation that are pursing bilateral mastectomies with reconstruction. Solutions to improving access to breast reconstruction must be found, while at the same time assuring that we fully communicate the realities of the value of surgical choices, minimize what may otherwise be considered overtreatment, and listen to our patients’ preferences. ■

Jagsi R, et al: J Clin Oncol 32:873-875, 2014.

VanderWalde LH, Edge SB. J Clin Oncol 32:919-926, 2014.