Breast Reconstruction: Rates Growing, Still Underused

Caroline Helwick

October 27, 2011

October 27, 2011 (San Francisco, California) — Women with breast cancer are undergoing postmastectomy breast reconstruction in larger numbers than ever, but the procedure is still underused and disparities in access persist, according to a large review presented here at the American College of Surgeons (ACS) 97th Clinical Congress.

Other investigators reported long-term durability and good cosmesis over time with the autologous transverse rectus abdominis myocutaneous (TRAM) flap reconstructive procedure.

The 2 presentations earned "Posters of Exceptional Merit" awards.

Immediate Breast Reconstruction Still Underused

Until now, studies evaluating trends in cancer care have suggested that immediate postmastectomy breast reconstruction is underused and that there are racial and socioeconomic disparities in delivery.

"These findings have prompted legislation designed to increase utilization. However, little is known about these trends over the past decade," said Mark Sisco, MD, from the NorthShore University Health System in Evanston, Illinois. "This study sought to look at trends in reconstruction over time, and to see what is happening in terms of these disparities."

To achieve this, Dr. Sisco and colleagues reviewed data from the National Cancer Data Base of the American College of Surgeons and the American Cancer Society. This is a nationwide oncology outcomes database for more than 1500 accredited cancer programs in the United States and Puerto Rico.

Their analysis included 396,434 patients undergoing mastectomy for nonmetastatic invasive breast cancer between 1998 and 2007. They identified 134,479 women who had immediate and early breast reconstruction (within 90 days) between 1998 and 2000 and 105,114 who underwent the procedure between 2005 and 2007.

The analysis showed that the use of breast reconstruction, both autologous and implant-based, almost doubled over time, from 12% in 1998 to 23% in 2007, a trend that was observed in almost all patient subsets.

"This is great. We have come a long way. But a rate of 23% still means that 77% of women are not, as of 2007, having immediate postmastectomy breast reconstruction," Dr. Sisco noted.

There also remained subpopulations of patients who were not having reconstructive procedures at the same rate as others, he added.

After adjusting for tumor characteristics that might affect eligibility for reconstruction, they determined that patients were most likely to have immediate reconstruction if they were younger than age 50 years, non-African American, privately insured, cared for at an academic medical center, or residents of a large metropolitan area (>1 million persons) or had higher census-derived household income ($46,000 or greater).

For this subset, the differences were highly significant compared with other groups (P < .001).

Despite the overall increase in utilization, none of these disparities have significantly narrowed over both time periods, Dr. Sisco reported.

"We are doing better at getting reconstruction to women, which is terrific," he said. "The disproportionate share of the gains [is] among the more affluent patients and those in major medical centers, so in that 'low-hanging fruit' we are getting somewhere. But it is clear that we haven’t done a very good job of narrowing the gap in all patients."

Longevity of TRAM Flaps Examined

In a second study, Chris D. Tzarnas, MD, and colleagues from Temple University School of Medicine, Philadelphia, Pennsylvania, assessed the long-term outcomes of the TRAM flap, which has been increasingly used for reconstructive procedures. The first author and presenter was Wendy Grunberg, DO.

The researchers reviewed the outcomes of 294 patients (mean age, 49 years) who underwent TRAM flap breast reconstruction between 1982 and 1996 (68% had immediate reconstruction) and who were followed for 15 to 29 years. They assessed the durability of the reconstruction, maintenance of symmetry, incidence of procedure-related complications, and long-term outcomes.

A review of the medical records, and personal interviews with some patients, indicated the reconstructions were still intact, and very few women required additional operations. Implant-based reconstructions, on the other hand, often rupture or harden over time, Dr. Tzarnas pointed out.

Three of 294 patients experienced local cancer recurrence in the flap. Seven percent of patients developed fat necrosis or partial flap loss requiring debridement. Only 1.5% had abdominal skin necrosis. There were no total flap losses and no true hernias, Dr. Grunberg reported at the meeting.

"And all the patients reported being satisfied with their reconstruction," she noted. "The cosmetic results were assessed using photographs, and their long-term outcomes were good."

"This is the largest series of patients to date with the longest follow-up period for post-TRAM flap breast reconstruction in the published literature," Dr. Grunberg noted. "This demonstrates that it continues to remain a viable option for postmastectomy breast reconstruction, as long-term outcomes prove the durability of this method."

Dr. Tzarnas added, "The best reconstructions are those that try to replace everything that is removed. And that has been, and I think continues to be, using the TRAM flap. It's good to show that these reconstructions are doing well and holding up long term."

Need for More Awareness Among Both Providers and Patients

Dr. Sisco acknowledged that medical guidelines are a work in progress, but more than'physician education is needed. "Our study really underscores the importance of continuing efforts to improve access to reconstructive surgery, in part by educating both the providers that it's safe for women to have immediate postmastectomy reconstruction but also the patients that breast reconstruction is not considered cosmetic surgery," he said.

Poster discussants Barbara L. Bass, MD, and Leigh A. Neumayer, MD, agreed. "Dr. Sisco's study shows that immediate reconstruction is still relatively uncommon. A lot of women continue to believe this will make it more difficult to detect recurrence. Also, many women don't realize this is really a natural part of the surgery, that reconstruction is an integral part of breast cancer care," said Dr. Bass, from Methodist Hospital in Houston, Texas.

Added Dr. Neumayer, from the University of Utah in Salt Lake City, who has also studied the breast reconstruction trend, "Patients often also look at other breast cancer patients, and if they haven’t had reconstruction and are alive and well, they say they will follow that path. It's awful to see these rates so low."

Regarding the durability of the TRAM flaps, both surgeons viewed the data as very important and encouraging. "This is great long-term follow-up. It's hugely durable," Dr. Neumayer commented. "TRAM is a great adjunct, especially for unilateral reconstruction."

Both surgeons acknowledged, however, that there are other effective reconstruction methods, some of which do not require moving muscle, though the TRAM procedure can be performed in a shorter surgical procedure.

Dr. Tzarnas, Dr. Grunberg, Dr. Sisco, Dr. Bass, and Dr. Neumayer have disclosed no relevant financial relationships.

American College of Surgeons (ACS) 97th Annual Clinical Congress. Abstracts SE100 and SE101. Presented October 25, 2011.

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