Immediate reconstruction after breast cancer: A most disturbing study

I realize that being in academic medicine at a tertiary care center often produces the “ivory tower” syndrome, but occasionally it is brought home to me that the way we practice surgery here often differs considerably from how surgery is practiced “in the trenches.” This time around, it was a study about how often surgeons referred women whose breast cancers are large enough to require a mastectomy to treat to plastic surgeons for a discussion of reconstruction options prior to the mastectomy. The answer was: Not nearly often enough. See for yourself:

ANN ARBOR, Mich. — Forty-four percent of surgeons do not refer the majority of their breast cancer patients to a plastic surgeon prior to the initial surgery when the woman is choosing her treatment course, according to a new study by researchers at the University of Michigan Comprehensive Cancer Center.

The finding may help explain the consistently low number of women who pursue breast reconstruction after mastectomy.

The researchers surveyed 365 surgeons, asking them how often they referred patients considering a mastectomy to a plastic surgeon before performing the mastectomy. The surgeons were identified from a population-based database of women in the Detroit and Los Angeles metropolitan areas who had been treated for breast cancer.

The study found 44 percent of the surgeons referred fewer than a quarter of their patients to a plastic surgeon prior to the mastectomy. Only 24 percent of surgeons referred three-quarters or more of their patients for reconstruction.

The study appears March 26 in the online edition of the journal Cancer.

Here’s the abstract, published online, before the print version:

BACKGROUND.
General surgeons’ attitudes toward breast reconstruction may affect referrals to plastic surgeons. The propensity to refer to plastic surgeons prior to surgical treatment decisions for breast cancer varies markedly across general surgeons and is associated with receipt of reconstruction. In this study, the authors used data from a large physician survey to examine factors associated with general surgeons’ propensity to refer breast cancer patients to plastic surgeons prior to mastectomy.

METHODS.
The authors surveyed all attending general surgeons (N = 456 surgeons) from a population-based sample of breast cancer patients who were diagnosed in Detroit and Los Angeles during 2002 (N = 1844 patients), with a surgeon response rate of 80%. The dependent variable was surgeon report of the percentage of their mastectomy patients in the past 2 years who they referred to plastic surgeons prior to initial surgery (referral propensity). Referral propensity was collapsed into 3 categories (<25%, 25-75%, and >75%) and regressed on the following covariates using logistic regression: Surveillance, Epidemiology, and End Results registry; number of years in clinical practice; surgeons’ sex; annual breast surgery volume; and hospital setting.

RESULTS.
Only 24% of surgeons referred >75% of their patients to plastic surgeons prior to surgery (high referral propensity). High referral propensity was associated independently with surgeons who were women (odds ratio [OR], 2.3; P = .03), high clinical breast surgery volume (OR, 4.1; P < .01), and working in cancer centers (OR, 2.4; P = .01). High-referral surgeons and low-referral surgeons also had different beliefs about women's preferences for reconstruction, with the low-referral surgeons perceiving more access barriers (cost, availability of plastic surgeons) and a lower patient priority for reconstruction. CONCLUSIONS.
A large proportion of surgeons do not refer breast cancer patients to plastic surgery at the time of surgical decision-making. Surgeons who have a high referral propensity are more likely to be women, to have a high clinical breast volume, and to work in cancer centers. These data support the importance of comanagement through multidisciplinary care models. Women need more opportunities to discuss reconstructive options to make informed surgical treatment decisions about their breast cancer. Cancer 2007. © 2007 American Cancer Society.

It must be the ivory tower syndrome, because I found the results of this study astounding, and unacceptable. I certainly don’t hold myself up as any sort of glowing example of what a surgeon who treats breast cancer should be, but I do at least try to refer as close to 100% of my patients with breast cancer who require a mastectomy as possible to a plastic surgeon before the mastectomy to discuss reconstruction options. Immediate reconstruction (reconstruction done at the same operation as the mastectomy, in which the cancer surgeon and the plastic surgeon work in tandem to perform the mastectomy and reconstruction) almost always gives a better, more aesthetically pleasing (or at least acceptable) result that matches the remaining breast the best. Sometimes I’m surprised when it is the woman who says that she is not interested in reconstruction and insists on immediately scheduling surgery. In such cases, it turns out that immediate reconstruction is less important to the patient than it is to me, and I must respect that. However, most of the time, this is not the case, and the age of the patient is no reliable indicator over who will consider reconstruction important and who will not. I’ve taken care of 70-year-olds who consider reconstruction very important and 40-year-olds who do not. It’s an individual choice, but the point is that not having reconstruction should be, as much as possible, the patient’s choice, not a default treatment that occurs simply because the surgeon doesn’t refer patients to a plastic surgeon.

One of the more disturbing aspects of this study were the reasons given by some of the surgeons:

Many surgeons believed that patients did not undergo reconstruction because of a lack of patient desire. Specifically, 57% of surgeons believed that reconstruction was not important to patients; 64% believed that patients were not interested; and 39% believed that patients were concerned that reconstruction would take too long. However, nearly half of surgeons (46%) reported that patients were concerned about the cost of the procedure.

Reconstruction not important to patients? That’s certainly true for a minority of patients, but the majority are usually very interested in some form of reconstruction. Oddly enough, though, this belief did not differs significantly between the low, medium, and high referrers, which means that it’s probably not a difference in perception of the importance of breast reconstruction that accounts for the difference between low and high referrer. What did differ was this:

By contrast, there were marked differences across surgeon referral propensity categories in surgeon beliefs related to potential patient access barriers, such as inadequate knowledge (32%, 16%, and 12% for low, moderate, and high referral propensity categories, respectively; P < .001), concerns about cost (58%, 47%, and 22% for low, moderate, and high referral propensity categories, respectively; P < .001), and unavailability of plastic surgeons (30%, 13%, and 8% for low, moderate, and high referral propensity categories, respectively; P < .001). There also were marked differences across propensity referral categories in surgeon beliefs about patient priorities for treatment. In particular, 31%, 13%, and 12% of surgeons in the low, moderate, and high referral propensity categories, respectively (P < .001), believed that patients were too preoccupied with other elements of their cancer therapy to consider reconstruction.

Now we get to the meat of the matter. Even though there was a federal law passed in 1998 mandating that insurance companies cover breast reconstruction procedures, there is still the widespread myth out there among patients that insurance companies do not pay for reconstruction. In fact, they do, although the myth is not entirely without basis in reality, as HMOs and insurance companies often put up barriers to covering reconstructive surgery. Another significant barrier is that, at least in my area, some of the plastic surgeons can affort to cherry pick the very best insurance plans and thus do not belong to many of the common commercial insurance plans that patients carry. Thus, if patients want what I consider to be the best plastic surgeons, they sometimes find themselves in the situation of having to pay out-of-network rates–that is, if their plan allows them to go out of network at all. Thus, part in perception and part in reality, there really are barriers to getting reconstruction done for patients requiring mastectomy, and it is quite possible that the low referrers practice in an area where plastic surgeons aren’t as available or where insurance companies produce more hassle about paying for reconstruction, leading to more of a perception that it’s more trouble and that it’s way down the list of considerations in getting the cancer treated as quickly as possible.

I can see how this can happen, even from my ivory tower. The problem that I run into more than anything else when a patient needs a mastectomy and would like immediate reconstruction is that there are, in essence, no plastic surgeons around who take Medicaid or our state’s charity care. A significant fraction of my practice consists of what is so delightfully termed “medically indigent,” meaning that they have no health insurance and they qualify for charity care. The problem that comes up with these patients is that, not infrequently, we are unable to find a plastic surgeon willing to take them on because plastic surgeons who accept Medicaid or charity care are rare in our area. This leaves these patients in the unfortunate situation that their mastectomy is covered but their reconstruction is, in practice, not.

There are, of course, legitimate medical reasons for not recommending immediate reconstruction. For example, if a patient’s tumor has characteristics that suggest that the patient will need chest wall radiation after mastectomy and that patient, for whatever reason (usually smoking, diabetes, and/or vascular disease) is not a good candidate for a muscle flap using tissue from the abdomen, then immediate reconstruction may not be a good option at all. The reason is that, if a plastic surgeon can’t use a muscle flap, the only option remaining is a tissue expander or an implant, and such foreign objects produce notoriously bad cosmetic results if they are radiated. Similarly, if a patient has such an aggressive tumor that waiting a few weeks for the patient to recover sufficiently from a large operation, like the abdominal flap procedure (known as the TRAM flap) before starting chemotherapy would endanger the patient’s life, then it’s not unreasonable not to do immediate reconstruction.

Of course, none of these legitimate medical contraindications to immediate reconstruction is what seems to be causing the problem of such a low rate of reconstruction after mastectomy. Indeed, the authors conclude:

Our results have important implications for patient care and policy. Prior research suggests that low rates of breast reconstruction reflect unmet need, especially in vulnerable populations. Our findings indicate that there are systematic differences among surgeons with regard to referral to plastic surgeons prior to surgical decisions for patients with breast cancer. Patient decision aids that include information about reconstruction or comanagement of patients through a multidisciplinary approach may improve patient knowledge about all surgical options and aid in this complex decision-making process. Referral to a plastic surgeon prior to initial surgical decision also may influence this decision; for example, women may be more inclined to choose mastectomy with a good understanding of the reconstructive options. However, our results suggest that barriers to comanagement may exist, especially in smaller surgical practices, which may have a more challenging patient mix and limited resources. The acceptance of multidisciplinary breast cancer treatment as a practice model, coupled with advances in breast reconstruction in the past 2 decades, should motivate strategies to enhance the involvement of plastic surgeons in the education and treatment counseling of patients with newly diagnosed breast cancer.

I mostly agree with this, with one grain of salt. It has to be remembered that the lead author of the study is a plastic surgeon, who naturally wants to promote plastic surgery. My other caveat is that a plastic surgeon is probably only necessary in cases where mastectomy is being considered, adding little in cases where breast conserving therapy (lumpectomy) is going to be the treatment. Finally, it must be remembered that these results may not reflect the whole country, as they were obtained from two large urban areas, Detroit and Los Angeles.

What this study boils down to is that there is a definite deficiency in many areas and among many surgeons when it comes to recommending breast reconstruction. Not all of it is due to surgeon attitudes or misunderstanding, but it would appear that too much of it is.