Reconstructive utilisation and outcomes following mastectomy surgery in women with breast cancer treated in England.

Abstract

Breast cancer usually necessitates breast-conserving surgery or mastectomy, which adversely affect appearance and wellbeing. Immediate reconstruction restores the breast mound but its availability and efficacy are uncertain. Two discrete datasets were used to evaluate mastectomies in England: Hospital Episode Statistics to measure overall activity and variation over time and by region and a national prospective audit to evaluate immediate reconstruction decision making, complication rates and patient-reported satisfaction with information, choice and outcomes. The 2005-08 Hospital Episode Statistics analyses identified 20% breast-conserving surgery reoperation rates nationally, frequently involving mastectomy. Rates were higher with in-situ disease present (30% vs 18%) and varied across NHS trusts (10th-90th centiles 12-30%). The 2008-09 national audit examined 18,216 women. The 19% immediate reconstruction rate varied regionally (9-43%), as did 2006-09 Hospital Episode Statistics data (8-32%). A total of 48% of women were offered immediate reconstruction, again varying regionally (24-75%). Offer likelihood fell with increasing age. National immediate reconstruction rates increased from 10% to 23% from 2000 to 2014, but regional variation persisted. Despite high care satisfaction, just 65% of mastectomy patients received the right amount of reconstructive information (90% for immediate reconstruction). Women from deprived areas experienced higher complication rates. Flap-based immediate reconstruction led to greater satisfaction with breast area appearance, emotional and sexual wellbeing and overall outcome than mastectomy; implant-only immediate reconstruction scored no better. Reconstruction is central to improving breast cancer outcomes. The differential outcomes and persistent regional inequalities identified should facilitate decision making, support improved access to all reconstructive options and inform the development of an optimal patient pathway.