Wednesday, March 26, 2008

Referrals for breast reconstruction

As a board certified plastic surgeon, I deal with issues surrounding breast reconstruction on a daily basis. But as I speak to most patients at their initial consultation once they have been newly diagnosed with breast cancer, it is clear that most people are unaware of most of the surgical options for treating and hopefully curing breast cancer, let alone the options for reconstruction after mastectomy. The standard primary treatments available to women with breast cancer are either lumpectomy with radiation therapy to the remaining breast (also know as breast conservation therapy) or mastectomy. Studies have shown that survival rates after either treatment are similar.

Interestingly (or sadly as I see it), only a small percentage of women who undergo mastectomy have reconstruction. The 2 studies that I reviewed (one by Monica Morrow, MD and her colleagues published in 2001 in the Journal of the American College of Surgeons, and another by Amy Alderman, MD and her colleagues published in 2007 in the journal Cancer) suggest that in the last 2 decades the rate of postmastectomy reconstruction has increased from about 3.4% in the mid 1980s to about 16% in this decade. Why is the referral rate for breast reconstruction so low?

Unfortunately, misinformation and old attitudes persist. In the early "modern period" of breast reconstruction (1980s), some were concerned that breast reconstruction would limit the ability to detect local recurrences of cancer, or that compromises in the surgical removal of the breast cancer would have to occur to ensure a better reconstructive result. Both of these misconceptions have been disproved.

What these studies revealed is that some surgeons are reluctant to refer women who are "older" for reconstruction (over 50!). I think that this attitude still persists among some general surgeons. I have performed breast reconstruction on many women in their 60s and 70s when they are medically fit and motivated to have reconstruction. There is also a lower tendency for women of lower socioeconomic status to undergo reconstruction. Alderman's study suggested that low referral surgeons cite cost of reconstruction, availability of plastic surgeons, low patient knowledge, and low patient priority for reconstruction as reasons to justify the lower referral rate. Despite the 1998 Women’s Health and Cancer Rights Act (WHCRA), a federal law establishing that insurance companies covering mastectomy must also pay for breast reconstruction, the number of reconstructions done in the USA remains low. I hope to cover the WHCRA in more detail in later posts.

There were some suggestions that high referral surgeons were more often women, with breast surgery making up a higher proportion of their practice, and often associate with a cancer center. My own experiences suggest that this may be a generalization. Most of the surgeons who refer to me are male, but I think the reason they refer as frequently as they do is that I made an effort to educate them and their staff about the surgical options for breast reconstruction after mastectomy. My staff works well with the staff in their office to coordinate surgical schedules so the patient and all physicians are accommodated promptly. Patient education is where it's at - I'll try to cover some strategies for improving decision making for patients in later posts.

I am excited about where this blog is heading....I am anxious to see comments from any one who wishes to share them!


Just One of Many said...

The first surgeon I met with, a female, suggested lumpectomy. Period. The second surgeon I met with, a male, suggested that meeting with a Plastic Surgeon before deciding on a procedure would be helpful. He was right.
I initially thought the options for reconstruction were "yes" or "no". If "yes", then "saline" or "silicone".

Stephen Harris, MD said...

I think that your experience may be more typical than most people would think. It is unfortunate that patients often get limited information regarding breast reconstruction at the time of initial consultation with the breast surgeon. Having information about what reconstructive options are available significantly impacts one's decision to proceed with mastectomy.