In a study reported in the Journal of Clinical Oncology, Jagsi et al found that use of breast reconstruction in patients with breast cancer undergoing mastectomy has increased over time but varies according to a number of treatment and demographic characteristics.
The study involved use of the MarketScan database, a claims-based data set of U.S. patients with employment-based insurance, to identify 20,560 women undergoing mastectomy for breast cancer from 1998 to 2007. Time trends were evaluated using the Cochran-Armitage test, and use of reconstruction was correlated with plastic-surgery workforce density and other treatments using multivariable regression.
Increased Reconstruction Use
Patients had a median age of 51 years. Overall, 56% of patients received breast reconstruction. Reconstruction use increased from 46% in 1998 to 63% in 2007 (P < .001), with increased use of implants and decreased use of autologous tissue techniques (from 56% in 1998 to 25% in 2007) over time (P < .001). Receipt of bilateral mastectomy increased from 3% in 1998 to 18% in 2007 (P < .001). Rates of lymph node surgery decreased from 87% to 82% (P = .08), and rates of radiotherapy decreased from 36% to 27% (P < .001).
Factors Affecting Reconstruction Use
A number of factors influenced use of reconstruction. Reconstruction was used by 76% of patients undergoing bilateral mastectomy, and patients undergoing bilateral mastectomy were significantly more likely to receive reconstruction than those undergoing unilateral mastectomy (adjusted odds ratio [OR] = 2.3, P < .001). Patients receiving radiation therapy were less likely to receive reconstruction (41% vs 62%, OR = 0.44, P < .001), as were patients who received lymph node surgery (OR = 0.84, P < .001).
There was a significant interaction between age and receipt of chemotherapy, and older patients were less likely to receive reconstruction, as were patients who received chemotherapy; however, the negative association of reconstruction with chemotherapy was almost entirely restricted to the youngest patient subgroup (< 40 years at diagnosis).
Reconstruction rates ranged from a low of 18% (2 of 11 patients) in North Dakota to a high of 80% (12 of 15 patients) in Washington, DC. Patients living in states with the highest density of plastic surgeons (≥ 3.04 per 100,000 residents) were significantly more likely to receive breast reconstruction vs those in states with the lowest density (< 1.68/100,000, OR = 1.48, P < .001). Patients living in counties with the highest quartile of income were significantly more likely to have reconstruction than those living in counties with the lowest quartile (60% vs 44%, OR = 1.7, P < .001).
Autologous vs Implant Reconstruction
Use of autologous vs implant-based reconstruction was significantly more likely in patients receiving radiation therapy (OR = 1.8, P < .001) and significantly less likely in those enrolled in health maintenance organizations (HMOs) or capitated preferred provider organizations (PPOs; OR = 0.7, P < .001), those undergoing bilateral mastectomy (OR = 0.5, P < .001), and those in the highest income quartile (OR = 0.7, P = .006).
Delayed reconstruction (defined as first claim for reconstruction after, rather than simultaneously with, claim for mastectomy) was performed in 21% of patients undergoing reconstruction. Delayed reconstruction was significantly more likely in patients in HMOs or capitated PPOs (OR = 1.2, P < .001) and significantly less likely in those in the highest income quartile (OR = 0.6, P < .001).
The investigators concluded, “Breast reconstruction has increased over time, but it has wide geographic variability. Receipt of other treatments correlates with the use of and approaches toward reconstruction. Further research and interventions are needed to ensure equitable access to this important component of multidisciplinary treatment of breast cancer.”
Reshma Jagsi, MD, DPhil, of University of Michigan, is the corresponding author for the Journal of Clinical Oncology article.
The study was supported by grants from the American Cancer Society and Cancer Prevention and Research Institute of Texas and by The Tracy Starr Breast Cancer Award. Dr. Jagsi reported a consultant or advisory role with Eviti and receives research funding from AbbVie. Benjamin D. Smith, MD, receives research funding from Varian Medical Systems.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.