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May 4, 2010 (Las Vegas, Nevada) — The choice to rebuild a breast after a mastectomy might not be as easy to make and implement as one might expect. Only about 20% opted for reconstruction in 2007, despite legislation passed more than a decade ago making breast reconstruction a requisite part of all insurance policies, Alicia Holt, MD, Surgical Fellow at City of Hope Medical Center in Duarte, California, reported here at the American Society of Breast Surgeons (ASBrS) 11th Annual Meeting.

Dr. Holt and her research team analyzed variables associated with reconstruction to determine why so few women opt for breast reconstruction. They looked at postmastectomy reconstruction rates reported by the California Office of Statewide Health Planning and Development Database during the 5-year period from 2003 to 2007.

The total number of patients undergoing mastectomies increased from 2936 in 2003 to 3151 in 2007, said Dr. Holt. The number of patients undergoing reconstruction (immediate or delayed) after the surgery rose from 21.4% in 2003 to 29.3% in 2007.

Dr. Holt reported that women younger than 40 years of age had the highest proportion of immediate reconstruction rates, that African Americans were half as likely as whites to opt for immediate reconstruction (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.38 - 0.62), and that patients with private insurance were more likely than those with Medi-Cal to have immediate reconstruction (OR, 7.12; 95% CI, 6.04 - 8.39, P < .0001). Furthermore, patients at teaching or National Cancer Institute–qualified facilities were more likely to undergo reconstruction than those at other facilities.

Study leader Laura Kruper, MD, breast cancer surgeon and assistant professor at the City of Hope Medical Center, told Medscape General Surgery that the results indicate that it is very important to get information out to patients about reconstruction options, noting that she requires her patients to see a plastic surgeon about reconstruction even if they have opted not to undergo the procedure.

“I think it really helps with psychological healing and moving forward through the cancer to the long term,” Dr. Kruper said. “I always want women to really think about their choices.”

Dr. Holt added that the team found that insurance status, race, and hospital type all appeared to be significant limiting factors in the use of reconstruction, and that it is the responsibility of surgeons and patients to “follow through to get more information” on reconstruction because there are many different options that will appear differently to different people during the decision process.

However, Deanna Attai, MD, director of the Center for Breast Care in Burbank, California, diplomate for the American Board of Surgery, and chair of the Communications Committee for ASBrS, told Medscape General Surgery that there is more to these limitations than first meets the eye.

“There are many community hospitals with excellent plastic surgeons,” she said, pointing out that although the type of hospital at which these procedures is most often performed is significant, this factor should not be overestimated, because there are a variety of limiting factors in smaller community hospitals. For example, it might be difficult in some areas of the country to find trained plastic surgeons to perform reconstruction that accept insurance payments.

“I take out of this that there is a lot of education needed, not only for the public, but also for the surgeons and our oncology colleagues,” Dr. Attai said, observing that often patients delay or forego reconstruction because they believe that they need to progress through chemotherapy as quickly as possible, which might not, in fact, be the case.

Dr. Kruper agreed, stating that “the thing we need to focus on is that public health interventions are not just for patients, but for providers. We have to get information out to people in community settings without plastic surgeons [or] who are not referred. Breast reconstruction is their right,” she said.

The study did not receive commercial support. Dr. Kruper and Dr. Holt have disclosed no relevant financial relationships.

American Society of Breast Surgeons (ASBrS) 11th Annual Meeting: Presented April 30, 2010.

(from Medscape Medical News)

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