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Better education on breast reconstruction may be needed after cancer

By Andrew M. Seaman

NEW YORK (Reuters Health) – When it comes to deciding to have breast reconstruction after surgery for breast cancer, most women are generally satisfied with the decision-making process, a new study suggests.

“Our findings generally were good news - women who wanted reconstruction got it, those who didn’t were generally satisfied with the decision process,” said Dr. Monica Morrow, the study’s lead author from Memorial Sloan Kettering Cancer Center in New York City.

The study findings also revealed misunderstandings on the part of some patients. For example, some women who didn’t undergo breast reconstruction said they worried that the implants would interfere with cancer screenings later on, or that they feared the implants.

“Our study points to specific topics doctors can address with patients - safety of implants, lack of interference with cancer detection by reconstruction that are of concern to patients,” Morrow wrote in an email.

She said that the study also indicates that many patients are focused on their cancer treatment at the time of diagnosis and not interested in reconstruction. That’s fine, she said, as long as they are aware of the possibility of reconstruction later on.

“There is no ‘correct’ rate of reconstruction,” she added.

Morrow and her colleagues write in JAMA Surgery that in the U.S., since passage of the Women’s Health and Cancer Rights Act of 1998, women receive universal coverage for breast reconstruction after they have a breast removed.

Despite the coverage for breast reconstruction, only about 25 to 35 percent of women opt for the procedure, they add.

Some people, who are not patients or breast cancer doctors, have said this rate of reconstruction is low, Morrow said.

To ensure that breast cancer patients understood their options, New York State passed a law in 2010 mandating that surgeons discuss breast reconstruction with them and provide information on insurance and availability.

“The purpose of our study was to understand whether patients felt that they were adequately informed about reconstruction and to understand the reasons they chose not to undergo the procedure,” she added. “Without such understanding, it is not possible to devise strategies to address the problem (if there actually is a problem).”

For the study, she and her colleagues used data from cancer registries in Los Angeles and Detroit on 485 women who had a breast removed and were cancer free for four years.

Overall, 222 women, or about 46 percent, eventually underwent breast reconstruction. About two-thirds of those women had it done at the same time their breast was removed; the other third had breast reconstruction later on.

Only about 13 percent of women said they were dissatisfied with the decision process about whether or not to have breast reconstruction, the authors found.

Black women were about three times more likely to report dissatisfaction, however.

Women who were older, had other health problems and lower education levels were less likely to have breast reconstruction. Women who received chemotherapy as treatment were also less likely to have the surgery.

Women without private health insurance were also less likely to have breast reconstruction, despite universal coverage.

About half of the women who did not get reconstruction said they did not want additional surgery. About a third said reconstruction was not important and about 36 percent said they feared implants.

About 24 percent of women were concerned the implants would interfere with future breast cancer screenings, but the researchers said past studies have not found evidence to support that concern.

“What our study actually says is that laws such as the NY state law are addressing a non-problem,” Morrow said. “Patients are informed about reconstruction, some just chose not to have it.”

She added that women who want to keep their breasts may choose lumpectomy, which removes less tissue than a complete mastectomy, and radiation instead of a total breast removal.

“So, it is not particularly surprising that reconstruction isn’t a priority for all women who chose to undergo mastectomy,” she said.

Also, Morrow said, it’s difficult to educate patients in a time when they get information from many sources that may not be scientifically valid or perpetuate myths, such as implants being unsafe.

She also said that it’s worth knowing that many women in this study decided to have breast reconstruction later on.

“During follow-up it is worth asking patients if they have developed an interest in reconstruction and want to see a plastic surgeon, and patients who choose not to have immediate reconstruction need to know that they haven’t closed the door permanently,” she added.

SOURCE: http://bit.ly/1thODnx JAMA Surgery, online August 20, 2014.

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