Most patients who choose to have breast reconstruction following mastectomy are satisfied with the decision-making process. Reasons for not choosing reconstruction vary by race and include the desire to avoid additional surgery and fear of implants. These and other conclusions of an analysis of women undergoing mastectomies following diagnoses for ductal carcinoma in situ or stage I–III invasive breast cancer were reported in JAMA Surgery by Monicia Morrow, MD, of Memorial Sloan Kettering Cancer Center, New York, and colleagues.
The researchers used Surveillance, Epidemiology, and End Results (SEER) registries from Los Angeles and Detroit to identify a sample of women aged 20 to 79 years. Because the study was limited to women from two metropolitan areas, the results “may not reflect access to reconstruction nationally, particularly in rural areas where plastic surgeons may be less available,” the investigators noted.
Of 3,252 women who were sent the initial survey a median of 9 months after diagnosis, 2,290 completed it. The analysis focused on the 485 who also completed a follow-up survey sent 4 years later to determine the frequency of immediate and delayed reconstruction, patient attitudes toward the procedure, and who had remained disease-free. The median age of these patients was 55.8 years, and 64.3 had stage I or II breast cancer.
Among those 485 patients, 24.8% had immediate and 16.8% had delayed reconstruction. Most of those who delayed treatment reported that they did so to focus on cancer treatment (68.7%) or to accommodate chemotherapy (50.7%) or radiotherapy (26.3%). “Residual demand for reconstruction at 4 years was low, with only 30 of 263 who did not undergo reconstruction still considering the procedure,” the investigators found.
Most women were satisfied with the decision-making process surrounding reconstruction. Only 13.3% of women were dissatisfied with the reconstruction decision-making process, but dissatisfaction was higher among nonwhite patients in the sample (P = .03), the researchers reported.
“The most common patient-reported reasons for not having reconstruction were the desire to avoid additional surgery (48.5%) and the belief that it was not important (33.8%), but 36.3% expressed fear of implants,” according to the study report. “Many women continue to report fear of implants as 1 reason for forgoing reconstruction, despite their proven safety. Nearly one fourth of women who did not undergo reconstruction in our sample reported concern about potential interference with cancer detection as a decision factor despite the clinical evidence not supporting this contention,” the investigators commented.
“Although the optimal rate of breast reconstruction is uncertain, our results suggest that patient demand and clinical and treatment factors largely determined who underwent the procedure,” the authors concluded.
Among patients not having reconstruction, the reasons varied by race. “Black patients were less likely than nonblack, non-Latina patients to undergo reconstruction. In addition, patients without private insurance plans were less likely to undergo reconstruction,” the authors stated.
“Our study suggests that room exists for improved education regarding the safety of breast implants and the effect of reconstruction on follow-up surveillance, information about which could be readily addressed through decision tools,” the investigators concluded. “Finally, development of specific approaches to address patient-level and systems factors with a negative effect on the use of reconstruction among minority women is needed.” ■
Morrow M, et al: JAMA Surg. August 20, 2014 (early release online).