Breast Reconstruction Rates Low After Mastectomy

Roxanne Nelson

August 20, 2014

Fewer than half the women who had undergone a mastectomy for breast cancer opted to have breast reconstruction, according to a study published online August 20 in JAMA Surgery.

Black women were less likely to undergo reconstruction, as were those without private insurance plans. About one-fifth of study participants who did not undergo reconstruction reported a lack of knowledge about the procedure, and more than one-third expressed a fear of implants. Almost a quarter of women reported they were concerned that reconstruction would interfere with cancer detection.

Similar findings have been reported previously, which suggests that barriers to the idea of breast reconstruction still exist, say Monica Morrow, MD, chief of breast service in the Department of Surgery at the Memorial Sloan Kettering Cancer Center in New York City, and colleagues.

"Our study suggests that room exists for improved education regarding the safety of breast implants and the effect of reconstruction on follow-up surveillance, information about which could be readily addressed through decision tools," the researchers write. "Development of specific approaches to address patient-level and systems factors with a negative effect on the use of reconstruction among minority women is needed."

Previous Findings Similar

The coverage of postmastectomy breast reconstruction by insurers was mandated in the Women's Health and Cancer Rights Act in 1998. However, despite this guaranteed coverage, most breast cancer patients who undergo mastectomy do not opt for reconstruction, the researchers report.

This lack of uptake of reconstruction has been observed before.

One study demonstrated that fewer than 1 in 4 insured women had breast reconstruction immediately after mastectomy. That study also showed that black women were less likely to undergo reconstructive surgery, as were those covered by Medicare or Medicaid, older women, and those treated at rural or nonteaching hospitals.

Another study showed that only about 20% of women opted for reconstruction in California in 2007, and that black women were half as likely to opt for immediate reconstruction as white women. In that study, rates of immediate reconstruction were highest in women younger than 40 years, and rates were higher in patients with private insurance than in those with Medi-Cal.

Multiple Issues Involved

For their study, Dr. Morrow and colleagues evaluated Surveillance, Epidemiology, and End Results (SEER) registries from Los Angeles and Detroit. They identified 3252 women 20 to 79 years of age who were diagnosed with ductal carcinoma in situ or stage I to III invasive breast cancer from 2005 to 2007. These women were asked to complete an initial survey and, 4 years later, a follow-up survey.

The final analysis consisted of 485 women who had undergone mastectomy, completed both surveys, and had not experienced disease recurrence.

The mean age of the cohort was 55.8 years, 42.2% of the women had no more than a high-school education, 64.3% had stage I or II breast cancer, 33.0% received postmastectomy radiotherapy, and 11.6% underwent contralateral prophylactic mastectomy.

Of the 222 women who underwent breast reconstruction, 146 of the procedures were performed at the time of mastectomy and 76 were delayed.

On multivariable regression analysis, black women, those with no more than a high-school education, those without private insurance, those with any major comorbidity, older women, and those residing in Los Angeles County were significantly less likely to undergo reconstruction than their counterparts.

For all racial/ethnic groups, common reasons for not having reconstruction included the desire to avoid additional surgery (48.5%), a fear of breast implants (38.3%), and the feeling that reconstruction was not important (33.8%).

Most women reported that they were satisfied with the decision-making process about whether to undergo reconstruction.

The majority of patients who delayed breast reconstruction reported that the delay was related to treatment, such as the need to focus on therapy (68.7%) or to accommodate chemotherapy (50.7%) or radiotherapy (26.3%).

Most of the women were aware of the option for reconstruction; less than 15% reported not knowing about it at the time of their initial surgery.

In the women who had not undergone the procedure in the 4 years after diagnosis, there was "little residual demand," the researchers note.

The study was supported by grants from the National Cancer Institute (NCI) and a grant from the American Cancer Society. The data collection was supported by the California Department of Public Health and by the NCI SEER program. The authors have disclosed no relevant financial relationships.

JAMA Surg. Published online August 20, 2014. Abstract

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