Most Breast Cancer Patients Forgo Reconstruction Surgery Without Regret

Monica Morrow, MD

Although universal insurance coverage for postmastectomy breast reconstruction has been mandated since 1998, a new study has found that the persistently high rates of American women who choose not to undergo reconstruction surgery are due primarily to patient preferences and not a lack of awareness.

The study, published in JAMA Surgery, found that 58.4% of 485 patients surveyed decided not to undergo breast reconstruction surgery, citing such reasons as not wanting to have additional surgery (48.5%), it wasn’t important (33.8%), fear of implants (36.3%), and a concern about possible complications (33.6%).

“There has always been a lot of concern because breast reconstruction rates in the United States have persistently been that only about 30% to 40% of women who get a mastectomy undergo reconstruction,” said Monica Morrow, MD, lead author of the study and chief of Breast Surgery Services at Memorial Sloan Kettering Cancer Center in New York City, in an interview. “This has raised concerns that doctors aren’t offering women reconstruction or talking about reconstruction.”

Instead, investigators found that most women know their options but have a variety of reasons for deciding against reconstruction surgery.

SEER Data Analyzed

The authors used Surveillance, Epidemiology, and End Results (SEER) registries from Los Angeles and Detroit to identify women aged 20 to 79 years diagnosed with ductal carcinoma in situ or invasive breast cancer from June 2005 through February 2007. Eligible women were asked to complete a survey. The analytic sample for the authors’ study included 485 patients who initially reported having a mastectomy and 4 years later reported remaining disease free.

Of the 485 patients, 146 patients underwent reconstruction at the time of mastectomy, 76 patients had their breast reconstruction surgeries later, and 263 patients did not undergo breast reconstruction.

According to the study results, only 18% of the patients who chose not to have breast reconstruction after mastectomy were unaware that reconstruction was an option, whereas 11.8% didn’t have insurance coverage. Women also cited trouble finding a surgeon (5.6%) or that their surgeon did not take their insurance (7.8%) as other reasons.

“The overall message from this study is that there is not a big problem here,” Morrow said. “With 4 years of follow-up, there were very few patients who had not been reconstructed who had any interest in reconstruction. The vast majority of the patients were satisfied with the decision-making process and the information that they received.”

Satisfaction Factors Vary

Although the study found that only 13.3% of women reported being dissatisfied with the decision-making process, it also showed that nonwhite women, older women, women with a lower education level, or women with a major coexisting illness and chemotherapy were all less likely to undergo breast reconstruction surgery.

Ethnic minority groups were less prone to indicate a desire to avoid additional surgery as a reason for forgoing reconstruction (70% for nonblack, non-Latina patients vs 39.7% and 34.1% for black and Latina patients, respectively; P <.001) and less likely to suggest that reconstruction was not important (42.4% for nonblack, non-Latina patients vs 21.6% and 31.3% for black and Latina patients, respectively; P = .04).

The study also showed that more Latina patients were worried about interference with cancer detection or complications of the procedure as well as not being able to take time off from work or family. More black and Latina patients also attributed their decision to the barrier of not having insurance coverage, the authors reported.

Morrow said that these women were also more likely to be dissatisfied with the decision-making process.

“It does suggest that there are potentially some additional barriers in women with lower educational attainment and lower socioeconomic status,” she said.

Communication Needs Surface

But while the authors agreed that there is room for improvement regarding the safety of breast implants and the effect of reconstruction on follow-up surveillance, Morrow said that talking to patients newly diagnosed with breast cancer can be difficult.

“The time surrounding a breast cancer diagnosis is very difficult because people’s minds are all full of many different concerns, and for many people, their major focus is that they have a potentially life-threatening illness,” Morrow explained. “So what they’re focused on in that point in time is what they need to do to get rid of that potentially life-threatening disease.”

Morrow said the survey also showed that there are still a lot of misunderstandings surrounding breast reconstruction surgery.

“We did find evidence that there is misunderstanding that having a reconstruction may interfere with detection of cancer recurrence, and so I think that’s something that can clearly be communicated to people when offering them the option of reconstruction,” she said. “There’s also still a whole lot of residual fear of silicon breast implants, and I think most medical professionals are pretty clear that there’s not a problem, but patients don’t get all their information from medical professionals.”

Morrow suggested that physicians and other healthcare professionals take extra care to inform their patients completely about breast reconstruction surgery and to spend more time with patients who are of lower educational attainment, nonwhite, and potentially those with Medicare, Medicaid, or no insurance at all, because these patients have reported more difficulty with the decision-making process.

“It is important…to take a little extra time to really make sure these patients understand that reconstruction is not in any way harmful to the cancer treatment process,” she said.

Morrow M, Li Y, Alderman AK, et al. Access to breast reconstruction after mastectomy and patient perspectives on reconstruction [published online August 20, 2014]. JAMA Surg. doi:10.1001/jamasurg.2014.548.