Breast Reconstruction Rates Research Articles

533 Patient Counselling and Socioeconomic Deprivation – Two Factors That Profoundly Influence Immediate Breast Reconstruction Rate After Mastectomy

533 Patient Counselling and Socioeconomic Deprivation – Two Factors That Profoundly Influence Immediate Breast Reconstruction Rate After Mastectomy

P2-16-11: Role of Proper Patient Counselling in Combination with Effect of Socioeconomic Deprivation on the Rate of Immediate Breast Reconstruction after Mastectomy.

Abstract Introduction: current guidelines in the United Kingdom suggest that the possibility of breast reconstruction should be discussed with all patients prior to mastectomy. However, the majority of patients are still treated with mastectomy alone and no reconstruction is carried out. It has also been suggested that women from more deprived areas are less likely to undergo immediate breast reconstruction (IBR). We investigated potential pitfalls in patient counselling and consequent decision making contributing to present IBR rate in combination with the effect of socioeconomic deprivation. Methods: data from 89 consecutive mastectomy patients was prospectively collected in a single centre in Glasgow between August 2010 and March 2011. Each patient was scored for deprivation based on The Scottish Index of Multiple Deprivation. The patients were then divided into two groups: high and low deprivation levels. Consultations about IR and patients’ acceptance of counselling were analysed. For statistical calculations Fischer's exact test was applied. Results: IBR was offered to 41 (46%) patients, but it was not to 42 (47%) (6 were excluded due to incomplete data). 25 patients accepted IBR, and of those 24 (27%) underwent IBR. 16 of 41 patients refused to undergo IBR due to lack of interest (10), not feeling ready for it (2), preference of delayed procedure (2) and fear of delaying adjuvant therapy (2). Of 42 patients whom IBR was not offered, only 10 were documented in the notes, while there was no reference for discussing reconstruction in 32 (36%) cases. Reasons for not even discussing reconstruction were the following: age (15), co-morbidities (18), locally advanced cancer (2), co-morbidities with age (5), and locally advanced cancer with age (2). As regards to socioeconomic deprivation; 44 (49%) patients were from deprived areas and 39 (44%) from affluent areas. 41 patients were offered IBR and of these 23 (26%) were from affluent areas compared to 18 (20%). Of the 42 patients who were not offered IR, 26 (29%) were from deprived while 16 (18%) from affluent areas (p<0.05). Of the 44 deprived patients, 18 were offered IBR but 26 were not. 15 of 25 patients, who accepted IBR, were from affluent areas. The 16 patients who refused IBR had equal distribution of deprivation. Conclusions: while none of the reasons for not offering IBR represent absolute contraindication to IBR, decisions about refusal are based mostly on patients’ subjective intuitions. Further, a greater proportion of the patients who were not offered IBR were from more deprived areas, and it seems that patients from affluent areas are more likely to be offered IBR compared to ones from deprived areas. However, confounding factors such as co-morbidities may contribute to the above. We believe, therefore, that detailed counselling about reconstruction of each patient requiring mastectomy is necessary, which is likely to further increase IBR rate. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-16-11.

P2-16-10: Practice Variations in Post-Mastectomy Breast Reconstruction: What Are the Roles of Clinical Factors, Access Barriers, and Delayed Reconstruction?

Abstract Background: Breast reconstruction rates vary widely by race, income, and location. Proposed explanations have included clinical contraindications to reconstruction, access barriers, and patient or surgeon preference for delayed reconstruction. We sought to determine whether clinical contraindications (planned radiation, comorbidities) or access barriers (distance to care, surgeon) were associated with reconstruction and to estimate the frequency of delayed reconstruction over time. Methods: A retrospective cohort study was conducted among women treated with mastectomy for Stage 0-IIIa breast cancer between 2002 and 2007 at one institution. Demographics, stage, comorbidities, adjuvant therapy plans, and treatments were obtained from the medical record. Multivariable modified Poisson regression analyses were performed, with immediate and any reconstruction (immediate or delayed) as outcomes. Interaction terms were added to examine surgeon effects. Kaplan-Meier survival analysis was performed. Results: Among 539 women, 18.9% had a plan for chemotherapy; 13.7% had a plan for radiation. Comorbidities were: obesity 17.1%, diabetes 11.9%, smoking 16.3%, heart disease 5.6%, immunodeficiency 2.2%. Most patients (59.8%) lived within 50 miles of the hospital. 33.8% had immediate reconstruction; 5.6% had delayed. Patients who had a plan for adjuvant therapy or comorbidity were less likely to have reconstruction. Patients who lived farther from the hospital were slightly more likely to have reconstruction, but this was not statistically significant (p<0.08). None of the associations varied significantly by surgeon. Few patients had reconstruction more than 2 years after mastectomy. Conclusion: Clinical contraindications may explain some breast reconstruction practice variations. Few patients who defer immediate reconstruction, however, ever have delayed reconstruction. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-16-10.

Effect of socioeconomic deprivation on the rate of immediate breast reconstruction after mastectomy

Effect of socioeconomic deprivation on the rate of immediate breast reconstruction after mastectomy

Implementation of a Patient-Based Education System Increases the Rate of Breast Reconstruction Following Mastectomy in an Urban Center

Implementation of a Patient-Based Education System Increases the Rate of Breast Reconstruction Following Mastectomy in an Urban Center

Tissue Expander Breast Reconstruction Using Prehydrated Human Acellular Dermis

Human acellular dermal matrices help facilitate immediate tissue expander-implant breast reconstruction by providing support to the inferolateral pole, improving control of implant position, and enhancing early volume expansion. Although several freeze-dried human acellular dermal products have demonstrated reasonable safety and efficacy in immediate tissue expander-implant breast reconstruction, no dedicated studies have evaluated clinical outcomes of prehydrated human acellular dermal matrix (PHADM) in breast reconstruction. The outcomes of 121 consecutive tissue expander reconstructions performed by the senior author using PHADM were evaluated. Mean intraoperative tissue expander fill volume was 256.6 ± 133 mL, 60% of final expander volume. Patients required an average of 3.2 additional expansions prior to tissue expander-to-implant exchange. Mean follow-up period after reconstruction was 44 ± 26.5 weeks. Complications occurred in 20 (16.5%) breasts, including 9 (7.4%) soft-tissue infections, 8 (6.6%) partial mastectomy flap necroses, and 2 (1.7%) seromas. Eleven (9.1%) breasts ultimately required explantation. Patients receiving radiation demonstrated a strong trend toward greater complications (30.8% vs. 13.7%, P = 0.0749). The outcomes and complication rates of PHADM tissue expander breast reconstruction are comparable to those reported with freeze-dried human acellular dermis.

Patient access to breast reconstruction after mastectomy and long-term outcomes.

6021 Background: Little is known about factors associated with current rates of breast reconstruction after mastectomy or longer-term outcomes of different reconstructive options in diverse population-based samples. Methods: We surveyed 2245 women newly diagnosed with breast cancer and reported to the Detroit and Los Angeles SEER registries from 6/05-2/07 and merged these data to SEER. Patients were surveyed again about 4 years after diagnosis (expected n=1520). We report on a preliminary sample of 707 patients. Results: 249 patients (35.2%) had mastectomy as initial therapy. Of those, 110 (44%) received reconstruction (62% immediate, 38% delayed). One-third had autologous tissue and two-thirds had an implant (equally divided between saline and silicone) reconstruction. Less than one-quarter (22.8%) of women who received reconstruction were dissatisfied with the cosmetic results, and 28% felt the outcome did not match expectations. Women who received reconstruction were slightly more satisfied with their breast and body appearance than those who received mastectomy alone, but less satisfied than those who received BCS (5 pt scale score 3.2, 3.0, 3.5 for reconstruction, mastectomy alone, and BCS, respectively, p<.001, controlling for age). Most common reasons for not getting reconstruction were related to patient attitudes about the surgery: Half (52%) reported that they did not want more surgery or that reconstruction was not important and one-third (34%) were concerned about possible complications. Barriers to care were less commonly endorsed: 18% reported that insurance would not cover reconstruction or that they could not find a surgeon who accepted insurance (12%). 37% of those who did not get reconstruction were dissatisfied with the information they received about it. About 15% of women were still considering reconstruction at time of re-survey. Conclusions: While some women were dissatisfied with the results of breast reconstruction, overall, satisfaction with body appearance was slightly higher than for women with mastectomy alone. The majority of women who did not get reconstruction did not want it and few women continue to consider it. However, some financial and informational barriers may persist.

Are Patients Making High-Quality Decisions about Breast Reconstruction after Mastectomy? [Outcomes Article

Variation in rates of breast reconstruction after mastectomy has raised concerns about the quality of decisions about reconstruction. The authors sought to evaluate patient decision making about reconstruction, using a validated measure of knowledge and preferences related to reconstruction. A cross-sectional survey of early-stage breast cancer survivors from four university medical centers was conducted. The survey included measures of knowledge about specific reconstruction facts, personal goals and concerns, and involvement in decision making. A multivariable linear regression model of characteristics associated with knowledge and a logistic regression model of factors associated with having reconstruction were developed. A total of 84 patients participated (59 percent response rate). Participants answered 37.9 percent of knowledge questions correctly. Higher education (beta, 15 percent; p = 0.003) and having reconstruction (beta, 21 percent; p < 0.0001) were associated with higher knowledge. The goals "use your own tissue to make a breast" (odds ratio, 1.53; 95 percent CI, 1.15, 2.05) and "wake up after mastectomy with reconstruction underway" (odds ratio, 1.66; 95 percent CI, 1.30, 2.12) were associated with reconstruction. The goal "avoid putting foreign material in your body" was associated with no reconstruction (odds ratio, 0.64; 95 percent CI, 0.48, 0.86). Most patients reported they mainly made the decision or made the decision with the doctor equally (93 percent; 95 percent CI, 85 to 97 percent) and that their degree of involvement was about right (85 percent; 95 percent CI, 75 to 91 percent). Women treated with mastectomy in this study were not well-informed about breast reconstruction. Treatments were associated with patients' goals and concerns, however, and patients were highly involved in their decisions. Knowledge deficits suggest that breast cancer patients would benefit from interventions to support their decision making.

Sacramento Area Breast Cancer Epidemiology Study: Use of Postmastectomy Breast Reconstruction along the Rural-to-Urban Continuum

Health care disparities have been documented in rural populations. The authors hypothesized that breast cancer patients in urban counties would have higher rates of postmastectomy breast reconstruction relative to patients in surrounding near-metro and rural counties. The authors used the Surveillance, Epidemiology, and End Results database to identify patients diagnosed with breast cancer and treated with mastectomy in the greater Sacramento area between 2000 and 2006. Counties were categorized as urban, near-metro, or rural. Univariate models evaluated the relationship of rural, near-metro, or urban location with use of breast reconstruction by means of the chi-square test. Multivariate logistic regression models controlling for patient, tumor, and treatment-related factors predicted use of breast reconstruction. The likelihood of undergoing breast reconstruction was reported as odds ratios with 95 percent confidence intervals; significance was set at p≤0.05. Complete information was available for 3552 breast cancer patients treated with mastectomy. Of these, 718 (20.2 percent) underwent breast reconstruction. On univariate analysis, differences in the rates of breast reconstruction were noted among urban, near-metro, and rural areas (p<0.001). On multivariate analysis, patients from rural (odds ratio, 0.51; 95 percent confidence interval, 0.28 to 0.93; p<0.03) and near-metro (odds ratio, 0.73; 95 percent confidence interval, 0.59 to 0.89; p=0.002) areas had a decreased likelihood of undergoing breast reconstruction relative to patients from urban areas. Patients from near-metro and rural areas are less likely to undergo breast reconstruction following mastectomy for breast cancer than their urban counterparts. Differences in use of breast reconstruction detected at a population level should guide future interventions to increase rates of breast reconstruction at the local level.

Underfinancing of 90.3% for Implant Costs of Prostheses and Expanders in DRG Revenues for Uni- and Bilateral Mastectomy with Immediate Breast Reconstruction

Background: From the clinic’s point of view economic patient care requires comparison and adjustment of costs to revenues. To verify cost coverage for implants in mastectomy with immediate breast reconstruction, a comprehensive cost-reimbursement analysis was performed. Methods: Retrospective analysis of the German diagnosis-related group (G-DRG) revenues for implants from the DRG Browser 2007/2009HA and comparison with actual costs for implants in 2009 from the annual clinic report and the database of the controlling department. Calculation of the relative cost coverage for implants in unilateral (DRG J06Z) and bilateral mastectomy (DRG J16Z). Results: In 2009, n = 98 J06Z and n = 18 J16Z were performed. DRG-calculated expenses for implants were € 69.65 for J06Z and € 123.07 for J16Z, i.e. a total of € 9,040.96. Actual costs for all implants were € 121,645.60, mean € 699.11 (€ 404.94–1,171.44). Attributable implant costs for 100% immediate breast reconstruction rate were € 93,679.28. Thus, implants are not cost covering by –90.3% (–82.8 to –94.7%). Subsidies for implants from the clinic’s budget range from € 335.29 to € 2,219.81 per case. Conclusions: Immediate breast reconstruction with implants after mastectomy is – even 6 years after introduction of the DRGs – not adequately calculated to be cost covering since the actual implant costs exceed the calculated revenues by far. At present, these implants are subsidized by the clinic at, on average, 90.3%. If economic patient care is mandatory, a maximum of only 1 in 10 patients with mastectomy can be offered immediate breast reconstruction with implants in Germany.

Understanding breast surgeon referral patterns and their influence on breast reconstruction rates

Preminger, Beth Aviva MD, MPH; Chiang, Austin Lee BS; Kieserman-Smokler, Caroline; El-Tamer, Mahmoud MD; Ascherman, Jeffery MD; Rohde, Christine MD Author Information

Occult malignancy rate associated with thoracodorsal vessel dissection for free flap breast reconstruction

The rate of breast reconstruction following mastectomy is increasing, and currently sits at about 15%. Free flap reconstruction techniques using the thoracodorsal vessels as recipients provide an opportunity for a "second look" at the axillary nodal basin post-mastectomy. The purpose of this study was to determine the occult malignancy rate associated with free flap breast reconstruction. A retrospective chart review was performed to ascertain the occult malignancy rate of women who received a delayed free flap reconstruction at our institution between 1990 and 2001. Any additional therapy as a result of a positive result was also recorded. Free flap breast reconstructions between 1990 and 2001 totalled 322, and of those 136 reconstructions were delayed and met our inclusion criteria. An occult malignancy rate of 3.6% (five patients) was identified for these patients. Four patients received additional therapy as a result of this finding. This study serves to alert reconstructive surgeons to the potential for finding occult tumour during free flap breast reconstruction.

Low breast reconstruction rate owed to few referrals?

Referral practices of general surgeons might partly explain why under 20% of women in the USA who undergo mastectomy for breast cancer also have breast reconstruction, a new study suggests (Cancer published online March 26, 2007; DOI: 10.1002/cncr.22598). 44% of those surveyed referred under 25% of such patients to a plastic surgeon before initial surgery.

Microvascular Breast Reconstruction in the Diabetic Patient

The free transverse rectus abdominis musculocutaneous (TRAM) flap is frequently advocated for autogenous breast reconstruction following mastectomy. The success rate and complications associated with free TRAM flap breast reconstruction are well documented. Risk factors such as cigarette smoking and obesity have been studied. Because of abnormalities in endothelial and red cell function, platelet function, altered blood viscosity, and abnormal intimal repair, diabetes mellitus is generally considered to be a risk factor for free TRAM flap breast reconstruction. The success rate of microvascular TRAM flap breast reconstruction in patients with diabetes mellitus has not been clearly defined. A retrospective review of 893 free TRAM flaps used for breast reconstruction in 763 patients at a single institution was performed. All flaps were performed at M. D. Anderson Cancer Center after January 1, 1985, and before December 31, 1997. Patients were classified as insulin-dependent (type 1) diabetic, non-insulin-dependent (type 2) diabetic, and nondiabetic. Flap and donor-site complications were compared among the three groups. Multivariate statistical analysis was used to examine demographic characteristics, body mass index, comorbid conditions, preoperative radiation therapy, immediate versus delayed reconstruction, and smoking history in patients with type 1 diabetes mellitus, type 2 diabetes mellitus, and nondiabetic patients. The incidence of flap complications did not differ significantly between type 1 diabetics, type 2 diabetics, and nondiabetic patients. The incidence of donor-site complications did not differ significantly between type 1 diabetics, type 2 diabetics, and nondiabetic patients. The present data indicate that type 1 diabetes mellitus and type 2 diabetes mellitus are not relative or absolute contraindications to microvascular TRAM flap breast reconstruction.

The 6Th Annual Toronto Breast Surgery Symposium, March 30, 2006, and the 36Th Annual Symposium On: Aesthetic Plastic Surgery, March 31–April 1, 2006

The 6Th Annual Toronto Breast Surgery Symposium, March 30, 2006, and the 36Th Annual Symposium On: Aesthetic Plastic Surgery, March 31–April 1, 2006

Breast Reconstruction Practices in North America: Current Trends and Future Priorities

The Women's Health and Cancer Rights Act (WHCRA) became federal law on January 1, 1999, mandating health care payer coverage for postmastectomy breast reconstruction. Despite passage of this legislation, breast reconstruction rates in the United States remain low. The Surveillance, Epidemiology and End Results (SEER) database for mastectomy patients in 11 regions across the United States show overall rates for immediate and early delayed reconstruction (performed within 4 months of mastectomy) of 15.4% for 1998 and 18.0% for 2000. Reconstruction rates vary significantly by region as well as by patient age, race, and income. The paper examines potential etiologies for low utilization of breast reconstruction and outlines possible remedies.

Geographic variation in postmastectomy breast reconstruction rates.

Data on postmastectomy breast reconstructive surgery were examined for 52,357 female breast cancers that were treated with mastectomy and diagnosed in geographic areas covered by the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. The proportion of cancers that involved reconstruction varied in these geographic areas in each age group (under age 70 years) by a factor of about four or five, even after adjustment for stage at diagnosis, marital status, and poverty rate of county of residence at diagnosis. Studies are needed to explain the large differences in reconstruction rates by geographic area.

Breast Disease-Related Educational Outcomes at the University of Florida.

The purpose of this study was to assess resident knowledge related to breast disease at the University of Florida. In addition, we surveyed graduates of our surgery program regarding the importance of breast disease in their surgical practice and we determined if the completion of postgraduate courses on breast disease influenced patient outcome measures. In the decade of the 1990s, we compared the American Board of Surgery In-Service Training Examination (ABSITE) scores of residents rotating on the breast service in the 6 months immediately prior to examination (June-January) with those residents who had not rotated on the breast service within the 6 months leading up to the ABSITE examination. We also compared ABSITE scores of surgery residents at the University of Florida at Gainesville (breast service) to surgery residents at the University of Florida at Jacksonville (no breast service). Finally, we surveyed graduates of the general surgery program at the University of Florida at Gainesville (1980-1998) to determine the importance of breast disease in their practices and if the completion of postgraduate courses on breast disease influenced rates of breast conservation and immediate breast reconstruction. Residents who rotated on the breast service in the 6 months prior to the ABSITE had significantly fewer incorrect breast-related ABSITE questions than residents who had not rotated on the breast service. Those graduates who had taken postgraduate courses in breast disease responded that they were more likely to perform breast-conserving surgery. There was also a trend for graduates who had completed postgraduate courses on breast disease to respond that they were more likely to perform immediate breast reconstruction following mastectomy. Limiting breast surgery to a single service does not appear to improve resident accumulation and retention of breast disease-related knowledge. Graduates who complete postgraduate courses related to breast disease are more likely to perform breast-conserving surgery and immediate reconstruction following mastectomy. Since the management of breast disease comprises a significant part of general surgical practice, surgical educators must ensure adequate resident education and evaluation with respect to breast disease.

Breast Reconstruction with Myocutaneous Flaps in Previously Irradiated Patients

Breast reconstructions performed with latissimus dorsi and transverse rectus abdominis myocutaneous (TRAM) flaps in 82 patients with a history of previous chest-wall irradiation were compared with similar reconstructions in 202 nonirradiated patients to determine whether prior irradiation was associated with more frequent complications and to determine the success rate of breast reconstruction using distant flaps in irradiated patients. The mean dose of radiation administered was 5637 cGy. Complications in the reconstructed breast were more frequent in the irradiated patients (39 percent) than in the nonirradiated patients (25 percent; p = 0.03). In the irradiated group, breast complications were more common in reconstructions performed with the latissimus dorsi flap (63 percent) than in those performed with the TRAM flap (33 percent; p = 0.063). Aesthetic outcomes also were slightly poorer in the irradiated patients. Although complications were more common and aesthetic outcomes not as good in previously irradiated patients, we do not consider such irradiation to be a contraindication to breast reconstruction. (Plast. Reconstr. Surg. 93: 460, 1994.)

Breast Reconstruction with Myocutaneous Flaps in Previously Irradiated Patients

Breast reconstructions performed with latissimus dorsi and transverse rectus abdominis myocutaneous (TRAM) flaps in 82 patients with a history of previous chest-wall irradiation were compared with similar reconstructions in 202 nonirradiated patients to determine whether prior irradiation was associated with more frequent complications and to determine the success rate of breast reconstruction using distant flaps in irradiated patients. The mean dose of radiation administered was 5637 cGy. Complications in the reconstructed breast were more frequent in the irradiated patients (39 percent) than in the nonirradiated patients (25 percent; p = 0.03). In the irradiated group, breast complications were more common in reconstructions performed with the latissimus dorsi flap (63 percent) than in those performed with the TRAM flap (33 percent; p = 0.063). Aesthetic outcomes also were slightly poorer in the irradiated patients. Although complications were more common and aesthetic outcomes not as good in previously irradiated patients, we do not consider such irradiation to be a contraindication to breast reconstruction.