Wednesday, March 28, 2007

Too Few American Women Receive Breast Reconstruction

A study from the University of Michigan Comprehensive Cancer Center revealed that fewer than 20% of American women who receive breast cancer surgery (mastectomy) undergo breast reconstruction surgery.

The study also noted that 44% of general surgeons DO NOT refer the majority of their breast cancer patients to a plastic surgeon before the patient’s breast cancer surgery.

This second finding may help explain the consistently low number of American women that receive reconstructive breast surgery after their mastectomies. (General surgeons or breast surgeons are the doctors who remove the breast cancer via mastectomies. Plastic surgeons are the doctors that reconstruct a woman’s breast after the cancer surgery. The large majority of women who receive a mastectomy are candidates for breast reconstruction.)

The survey was compiled from the responses of 365 general surgeons in Ann Arbor, Michigan and Los Angeles, California. 44% of these surgeons referred less than a quarter of their patients to a plastic surgeon before the patient’s breast cancer surgery. Only 24 percent of general surgeons referred three-quarters or more of their patients for reconstruction.

The lead author of the study, Amy Alderman, MD, MPH, made an excellent point about the importance of reconstruction in breast cancer management, “We need to help patients through this difficult decision-making process up front, through patient decision aids that include information about reconstruction and multidisciplinary approaches to care, where all surgical options are fully explained."

General surgeons in this study attributed the low rates of breast reconstruction to patients not wanting the procedure:

  • 57% of surgeons said it was not important to patients
  • 64% thought patients were not interested
  • 39% thought patients were concerned that reconstruction takes too long.
  • 50% felt patients were concerned about the cost of reconstruction.

These concerns about the cost of a reconstruction are particularly unfortunate. Patients need to be educated that insurance companies are REQUIRED by a 1998 federal law to pay for breast reconstruction and symmetry surgery (surgery on the opposite breast to make the breasts match after a reconstruction).

Interestingly, the study pointed out that the surgeons most likely to refer their patients to a plastic surgeon tended to be female, with a large volume of breast cancer patients. They were also more likely to work in a cancer center rather than a community hospital or teaching hospital. The study authors suggested that surgeons who do not refer as many patients for reconstruction may be more likely to treat patients with limited resources or to practice in settings with limited access to plastic surgeons.

This study highlights a really disappointing trend in American cancer care. As a plastic surgeon, I can tell you that breast reconstruction is one of the most rewarding surgeries we perform. When you embark on a breast reconstruction, you get to know the patient and their family very well. You allay their concerns and also share their sense of victory as they overcome the cancer and look forward to the rest of their life. It’s amazing to think back (not so long ago- just before 1998) when insurance companies would try to refuse to pay for a breast reconstruction because they considered this cosmetic surgery. Is having two eyes, two feet, two hands vanity? Would they choose to go through life with one eye, one hand, or one foot?

Today, there are so many options for breast reconstruction. During my consults, we go over all of these with each woman and let them choose the one that will fit their goals, lifestyle, and preferences in shape, size, feel, look, recovery period, etc. I do hope that more American women are referred for breast reconstruction- getting on board BEFORE their initial breast cancer surgery lets us coordinate with the general surgeon and make sure that the patient gets the best outcome.

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