Reconstruction rates differ dramatically by geographic location
Researchers found that 46 percent of patients received reconstruction in 1998 but that figure rose to 63 percent by 2007.
"Breast reconstruction has a big impact on quality of life for breast cancer survivors. 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," says study first author Reshma Jagsi, M.D., D.Phil., associate professor of radiation oncology at the University of Michigan Comprehensive Cancer Center.
The researchers, from academic medical centers and private practice, looked at insurance claims data from a large nationwide employment-based database of medical claims. They identified a total of 20,506 women who had been treated with mastectomy for breast cancer between 1998 and 2007. Results appear in the Journal of Clinical Oncology.
While overall rates of reconstruction increased, women who received radiation therapy were less likely to get reconstruction. This is especially concerning because radiation therapy is increasingly being used after mastectomy as a way to further reduce the risk of the cancer returning in women with more aggressive or advanced disease.
The researchers note that reconstruction is more challenging after radiation, which limits the reconstruction options available for these patients. And often the results are not as good.
"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. 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 says.
"In appropriately selected patients, radiation saves lives and is generally well tolerated. However, radiation does cause a certain degree of damage to normal tissue which complicates and often delays breast reconstruction. Team-based collaborative care between breast surgeons, plastic surgeons and radiation oncologists is critical to help patients experience good outcomes," says senior author Benjamin Smith, M.D., associate professor of radiation oncology at The University of Texas MD Anderson Cancer Center.
The study also revealed dramatic variation in reconstruction based on geographic region, from a low of 18 percent in North Dakota, to a high of 80 percent in Washington, D.C. This was largely associated with the number of plastic surgeons working in each state.
"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. 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 says.
Other findings reported show that the rate of bilateral mastectomy increased six-fold between 1998 and 2007, and that three-quarters of women receiving bilateral mastectomy also have breast reconstruction.
The researchers also note that more women are receiving implants rather than recreating breasts using tissue from other parts of their body, called autologous reconstruction. Autologous techniques tend to deliver better cosmetic results and higher satisfaction, but it's a time-consuming, demanding operation that requires a longer hospital stay and recovery time. The researchers raise concern that current medical reimbursement discourages surgeons from offering autologous reconstruction.
"Overall, our finding of substantial increases in breast reconstruction over time is good news for women with breast cancer and reflects positively on cancer care in the United States. However, we need to keep working to ensure that all women have access to quality breast cancer care," Smith says.
Breast cancer statistics: 235,030 Americans will be diagnosed with breast cancer this year and 40,430 will die from the disease, according to the American Cancer Society
Additional authors: Adeyiza O. Momoh, University of Michigan; Jing Jiang, Sharon H. Giordano, Thomas A. Buchholz, MD Anderson; Steven J. Kronowitz, Baylor College of Medicine; Amy Alderman, The Swan Center for Plastic Surgery
Funding: American Cancer Society grant MRSG-09-145-01-CPHPS; Cancer Prevention and Research Institute of Texas grant RP101207; Tracy Starr Breast Cancer Award
Reference: Journal of Clinical Oncology, doi: 10.1200/JCO.2013.52.2284, published online Feb. 18, 2014
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