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Increased use of breast reconstruction after mastectomy varied geographically
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Breast reconstruction after mastectomy has increased among patients with breast cancer, although the increased rates tended to vary according to geographic region, study results showed.
“Any time we see geographic variations in practice patterns, we worry that care is not being appropriately individualized and that patients are not being offered all their options,” Reshma Jagsi, MD, DPhil, associate professor of radiation oncology at the University of Michigan Comprehensive Center, said in a press release. “It’s important to make sure women have all the information they need about breast reconstruction and are aware that it is an option.”
Jagsi and colleagues used the MarketScan database of patients with employment-based insurance to identify 20,560 women in the United States who underwent mastectomy for breast cancer between 1998 and 2007. The median age of the study population was 51 years.
Overall, the rate for reconstruction significantly increased from 46% in 1998 to 63% in 2007 (P˂.001). Most patients in the population underwent reconstruction (56%).
Researchers noted the use of implants increased during this time, although use of autologous tissue techniques decreased from 56% in 1998 to 25% in 2007 (P˂.001).
The rate for bilateral mastectomy increased from 3% in 1998 to 18% in 2007 (P˂.001), and women who underwent bilateral mastectomy were more likely to undergo reconstruction (OR=2.3; P˂.001).
However, women who underwent radiation were less likely to undergo reconstruction (OR=0.44; P˂.001).
“As a growing number of women are eligible for radiation after mastectomy, we have to be aware that this alters those patients’ reconstruction options and outcomes,” Jagsi said. “Patients’ and physicians’ concerns about how best to integrate reconstruction and radiation may be influencing patient decisions. We need to determine the best approach to reconstruction for women who receive radiation.”
Jagsi and colleagues found the rates for reconstruction varied according to geographic location. The lowest rate for reconstruction was in North Dakota (18%), whereas the highest was in Washington, D.C. (80%).
Women who lived in states with a high density of plastic surgeons (≥3.04 surgeons) were more likely to undergo reconstruction (OR=1.4) than women who lived in states with the lowest density of plastic surgeons (˂1.68 surgeons per 100,000 residents). Women also were more likely to undergo reconstruction if they lived in counties with the highest quartile of median household income (OR=1.7; 95% CI, 1.5-1.9).
“Breast reconstruction has a big impact on quality of life for breast cancer survivors,” Jagsi said. “As we are seeing more women survive breast cancer, we need to focus on long-term survivorship issues and ensuring that women have access to this important part of treatment.”
In an accompanying editorial, Lindi H. VanderWalde, MD, and Stephen B. Edge, MD, both of Baptist Cancer Center in Memphis, Tenn., wrote that physician–patient communication is essential to improve patient care.
“As clinicians, we must seek to improve our communication with patients and help them understand the impact of therapy on the risk of future breast cancer events,” they wrote. “Providing information to women in a careful, unbiased manner can be challenging. Physician bias may influence a woman’s decision and physicians may not fully listen to or understand patient preference.”
Paper or electronic decision-support tools may help address these challenges and improve patient satisfaction, VanderWalde and Edge wrote.
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Disclosure: The researchers report consultant/advisory roles with and research funding from AbbVie, Eviti and Varian Medical Systems.
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Amy S. Colwell, MD, FACS
Jagsi and colleagues present an interesting article on the trends and variation in use of breast reconstruction in a large cohort of women undergoing mastectomy in the United States. They report an increase in implant-based reconstruction and bilateral mastectomy, which are trends I see in everyday practice. Importantly, they show overall reconstruction rates that are higher than in previous years, suggesting improved overall access to plastic surgeons. However, the authors confirm a disparity in access to reconstruction, which varied by geography and workforce distribution of plastic surgeons. Thus, there may be a greater need for plastic surgeons performing breast reconstruction in these areas.
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