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Why Some Breast Cancer Patients Forgo Implants

Not All Women Follow Mastectomy With Breast Reconstruction

By Charlene Laino
WebMD Health News

Reviewed By Laura J. Martin, MD

April 30, 2010 -- Fewer than one in three women eligible for breast reconstruction surgery following mastectomy for breast cancer undergo the procedure, according to a small snapshot from four counties in California.

But doctors in other areas of the country tell WebMD that more than 90% of patients opt for reconstruction.

Still, the California study offers insights into which women might be less likely to get implants after mastectomy.

The study showed that older women, non-white women, women who do not have insurance, and women who are not treated at a teaching facility where a plastic surgeon is more likely to be on hand are less likely to undergo reconstruction.

The study was presented at the annual meeting of the American Society of Breast Surgeons (ASBS) in Las Vegas.

About 40% of Early Breast Cancer Patients Undergo Mastectomy

Although studies have shown that women with early-stage breast cancer who undergo breast-conserving surgery and radiation live just as long as women who have a mastectomy, about 40% of women still choose mastectomy, says study leader Laura Kruper, MD, a breast cancer surgeon at City of Hope Medical Center in Duarte, Calif.

"Once they choose mastectomy, there are clear psychological benefits to reconstruction," she says.

So the researchers used California's government-funded health care database for women treated for breast cancer in four counties from 2003 to 2007 to look into what factors influence their decisions to have implants.

Older Women, Non-Whites Less Likely to Have Breast Implants

Results showed that the number of mastectomies performed increased slightly between 2003 and 2007, and the reconstruction rate rose substantially, from 21% to 29%.

Further analysis showed:

  • Women under age 40 had the highest rates of immediate reconstruction compared with any other age group. Compared with them, women 40 to 59 were 48% less likely, women 60 to 79 were 68% less likely, and women over age 80 were 93% less likely to have reconstruction.
  • African-American women were less than half as likely as white women to undergo reconstruction, and Asian women had one-third the reconstruction rate of white women.
  • Women with private insurance were nearly eight times more likely to have reconstruction than women with Medi-Cal insurance, California's Medicaid program.
  • Women treated at teaching hospitals were twice as likely to undergo reconstruction as women treated at other institutions.

Economics, Hospital May Influence Choice to Have Breast Implants

Kruper says many non-teaching hospitals may not have plastic surgeons on staff to perform reconstructive surgery, particularly if women want it months after mastectomy.

So-called "delayed reconstruction" was offered only at a limited number of hospitals in the four-county area, and its availability rose only slightly over the course of the five-year study, she says.

Economics may be another important factor, Kruper says. "The shortage of plastic surgeons willing to accept Medi-Cal's lower reconstruction reimbursement rates likely limits the ability of these patients to undergo reconstruction when desired," she says.

One of the major drawbacks of the study is that women were not asked whether they voluntarily forwent breast implants or whether it wasn't offered.

Patient Preference Influences Breast Implants

ASBS spokeswoman Deanna J. Attai, MD, of the Center for Breast Care Inc., in Burbank, Calif., says that in some areas, particularly rural regions, it may be difficult to find plastic surgeons trained in reconstructive surgery.

But, she says, "sometimes it's patient preference. I am continually surprised at the number of women, younger women, who feel it is just not important to them. It really is an individual issue," she tells WebMD.

John Corbitt Jr., MD, a private practitioner in Palm Beach County, Fla., was completely surprised at the study's findings.

"In my practice, closer to 90% or 95% of women opt for reconstruction," he says.

Nipple-Sparing Mastectomies Seem Safe

At the meeting, Corbitt presented a study of nipple-sparing mastectomies. The procedure is just what its name implies: intricate surgery to preserve the nipple and the areola after mastectomy.

"For years, the nipple was removed because there were worries the breast tissue it contained had breast cells with the potential to become cancerous," he says.

Once considered experimental, nipple-sparing mastectomy has become common enough that the ACSM is starting a registry to ensure women who have it fare as well as women who don't, Attai says.

In Corbitt's small study, one of 228 procedures resulted in a recurrence of cancer in the nipple. "So we simply went in and removed it, and the patient had no cancer.

"Even if a patient does develop a cancer, it is a simple tumor that can be removed," Corbitt tells WebMD.

"Reconstruction of the nipple is good, but it is nothing like the real package" he says.

Women who are interested in such a procedure should know it is done at the same time as reconstruction with a silicone implant. Only about 5% of all centers offering mastectomy have surgeons trained in the procedure, Corbitt says.

As for cost, it is typically covered by insurance, he says, and about the same price as any mastectomy with reconstruction.

SOURCES: American Society of Breast Surgeons annual meeting, Las Vegas, April 28-May 2, 2010.

Laura Kruper, MD, City of Hope Medical Center, Duarte, Calif.

Deanna J. Attai, MD, Center for Breast Care Inc., Burbank, Calif.

John Corbitt, Jr., MD, Palm Beach County, Fla.

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