Is there an unmet need for post-mastectomy reconstruction?

Most women who undergo mastectomy following breast cancer do not then undergo breast reconstruction. In light of this, a team of researchers recently conducted a survey to determine if women are satisfied with their choices concerning reconstruction. Specifically, they set out to “examine correlates of breast reconstruction after mastectomy and to determine if a significant unmet need for reconstruction exists.”

The research team included specialists in radiation oncology, plastic surgery, breast surgery, public health, preventative medicine, and general medicine. 

The team sent a survey to a sample of 3252 women aged 20 to 79 years diagnosed as having ductal carcinoma in situ or stages I to III invasive breast cancer. Black and Latina women were oversampled to ensure adequate representation of minorities. Of the women who received the initial survey a median of 9 months after diagnosis, 2290 completed it. Those who remained disease-free were surveyed 4 years later; 1536 completed the follow-up survey. Four hundred and eighty-five women who remained disease free at follow-up underwent analysis.

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Of the 485 patients who reported on the initial survey that they had undergone mastectomy and remained disease free, 24.8% underwent immediate reconstruction and 16.8% underwent delayed reconstruction, for a total of 41.6%. Factors significantly associated with not undergoing reconstruction were black race, lower educational level, increased age, major comorbidity, and having undergone chemotherapy. Only 13.3% of women were dissatisfied with the reconstruction decision-making process, but this dissatisfaction was higher among nonwhite patients (adjusted odds ratio, 2.87 [95% CI, 1.27-6.51]; P = .03).

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The most common reasons for not having breast reconstruction that women reported were the desire to avoid additional surgery (48.5%), fear of implants (33.8%), and the belief that reconstruction was not important (36.3%). Reasons for avoiding reconstruction varied by race, and reported barriers to reconstruction were more common among nonwhite respondents. Residual demand for reconstruction at 4 years was low, with only 30 of 263 patients who did not undergo reconstruction still considering the procedure.

The researchers concluded that reconstruction rates largely reflect patient demand and that most patients are satisfied with the decision-making process about reconstruction. They recommended developing specific approaches to address lingering patient-level and system factors with a negative effect on reconstruction among minority women.

The study was published online by JAMA Surgery on August 20. 

Morrow M, Li Y, Alderman AK, et al. Access to breast reconstruction after mastectomy and patient perspectives on reconstruction decision making. JAMA Surg. 2014 Aug 20. doi: 10.1001/jamasurg.2014.548. [Epub ahead of print]