Decision Shared or Otherwise: The Ongoing Evolution of Local Therapy for Breast Cancer

Abstract

The National Surgical Adjuvant Breast and Bowel Project (NSABP) –B06 trial published over 25 years ago and subsequent trials conclusively showed no difference in survival outcomes between radical mastectomy and breast-conserving surgery (BCS) with radiation. This provided women with breast cancer the option of the less disfiguring, less morbid partial mastectomy. However, over the past 10 years, the proportion of women treated with mastectomy may be increasing despite no scientific data demonstrating its superiority over BCS. Reasons for this trend are unclear but may be related to including increased use of breast MRI, awareness and use of genetic testing, increased patient voice in shared decision and use of mastectomy by high-profile celebrities. In addition there has been an increased-rate prophylactic mastectomy of the unaffected breast. One factor making mastectomy a more palatable option to women and a possible additional driver of increased rates of mastectomy is access to breast reconstruction at the time of or subsequent to mastectomy. In the article accompanying this editorial, Jagsi et al evaluate the rate of reconstruction in women with breast cancer undergoing mastectomy in a modern cohort of privately insured, working-age women. Using MarketScan (Truven Health Analytics, Ann Arbor, MI) a commercial claims-based database, 20,560 women were identified who underwent mastectomy with a breast cancer diagnosis between 1998 and 2007. Among these younger, well-insured women treated with mastectomy, reconstruction increased from 46% in 1998% to 63% in 2007. Reconstruction also correlated with plastic surgeon availability defined by population density of specialists, as well as with geographic region, patient age, and use of bilateral mastectomy. Jagsi et al are to be commended for the highly methodical approach to analyzing these data and for both recognizing and avoiding some of the most dangerous potential biases. However, differences in the cohort over time independent of wider trends in the greater population could have affected the magnitude of the observed change. In 2002, the data set was expanded to include additional health plans, significantly enlarging the cohort available for analysis. The time point of expansion correlates with the increasing reconstruction rates noted in the results. Another factor affecting using these data as indicative of the general population is that this cohort consists mostly of women in noncapitated PPO insurance plans (80%) with over two thirds of patients are within the two highest quartiles in income. Age certainly affects the use of breast reconstruction. Among women over age 65 years (Medicare recipients) reconstruction rates are reported as low as 6% to 16% nationally. In addition, there are personal issues that affect a woman’s choice, and these issues are different for older women. However, there is no evidence demonstrating an increased complication rate in older woman undergoing breast reconstructions, including older women who undergo autologous reconstructions. Older woman should be offered breast reconstruction based on their overall health status and perioperative risk assessment. Treatment also varies by provider. The SEER data cited examining rates of reconstruction in women over 65 reported an average rate of reconstruction for women with Stage 0 to 2 disease of 6%. However, there was significant variability across institutions with reconstruction rates ranging from 0% to 44%, with a few institutions performing a large proportion of the reconstructions. Similarly, patients treated at different National Comprehensive Cancer Network centers nationally were found to have different rates of breast conservation, mastectomy, and mastectomy with reconstruction. This highlights that patient care may be driven by regional culture and provider biases reflected by an institution’s practice, or resource. The type of reconstruction also varies, potentially related to provider bias and interests in the use autologous tissue reconstruction. This occurs most frequently at large or academic centers. While in many cases autologous tissue reconstruction provides superior cosmetic and longer lasting results, autologous reconstructions rates are declining compared with implant reconstruction. Staffing limitations in private practice settings are constrained, often with no trainees or other readily available assistants for the labor-intensive tissue techniques. This trend may also be driven by the low reimbursements rendered for these lengthy and complex procedures. On one survey, many plastic surgeons reported limiting the breast reconstructions performed, citing decrease reimbursement as the reason. Those who continue to perform breast reconstruction are incentivized to perform implant-based reconstruction, with reimbursement as much as six times greater based on intraoperative hourly rates. While physician compensation may be lower, system-wide, autologous tissue reconstruction with either pedicle flaps or free flaps may be more cost effective in the long run than implant-based reconstruction Another key trend is the increased use of contralateral prophylactic mastectomy (CPM) and associated higher rates of implant reconstruction as shown by Jagsi et al. Other studies have duplicated these results with increasing CPM rates and increasing use of implant JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 32 NUMBER 9 MARCH 2