Barriers to immediate breast reconstruction in the Canadian universal health care system

Prevalence and Severity of Chronic Pain in Patients Receiving Mastectomy with Alloplastic Immediate Breast Reconstruction: A Survey Study

Introduction: Breast cancer is the most frequently diagnosed cancer worldwide. For those undergoing mastectomy, the choice of alloplastic immediate breast reconstruction (IBR) is increasingly favored. Post-operative chronic pain is an important consideration in this decision, but there is a paucity of data for those undergoing alloplastic IBR. We sought to examine the prevalence, severity, and risk factors for the development of chronic pain in this cohort using validated patient-reported outcome measures. Methods: A cross-sectional survey study was conducted among patients receiving mastectomy with alloplastic IBR. Participants completed 3 surveys querying chronic pain, specifically the Breast Cancer Pain Questionnaire (BCPQ), Brief Pain Inventory (BPI), and BREAST-Q. Participant medical records were reviewed for demographic and surgical variables. Results: A total of 118 patients participated in the study-a response rate of 33.6%. Chronic pain prevalence was high (52.5%), and only 29.0% of these patients had consulted a physician regarding their pain. Among those reporting chronic pain (n = 62), the median severity of pain was 3.1 on an 11-point scale. Chronic pain was associated with radiation (p = .018), bilateral reconstruction (p = .05), worse emotional health (p = .0003), less self (p = .022), and sexual confidence (p = .044). Inter-tool reliability was high, with no significant difference in responses between the 3 surveys. Conclusion: In this cohort, chronic pain is supported as a significant concern among patients who have undergone mastectomy with alloplastic IBR. Given the burden of chronic pain, there is an opportunity to intervene with preventative measures and support for its management.

Enhancing Post-Mastectomy Care: Telehealth's Impact on Breast Reconstruction Accessibility for Breast Cancer Patients

OBJECTIVE

To examine how the recent sharp rise in telemedicine has impacted trends in accessibility of breast reconstruction (BR).

PATIENTS AND METHODS

A retrospective study reviewed patients who underwent a total mastectomy at our institution from 1 August 2016 to 31 January 2022. By comparing cohorts before and during the widespread implementation of telemedicine, we assessed telehealth's impact on healthcare accessibility, measured by distance from patients' residences to our institution.

RESULTS

A total of 359 patients were included in this study. Of those, 176 received total mastectomy prior to the availability of telemedicine, and 183 in the subsequent period. There were similar baseline characteristics among patients undergoing mastectomy, including distance from place of residence to hospital (p = 0.67). The same proportion elected to receive BR between groups (p = 0.22). Those declining BR traveled similar distances as those electing the procedure, both before the era of widespread telemedicine adoption (40.3 and 35.6 miles, p = 0.56) and during the height of telemedicine use (22.3 and 61.3 miles, p = 0.26). When tracking follow-up care, significantly more patients during the pandemic pursued at least one follow-up visit with their original surgical team, indicative of the increased utilization of telehealth services.

CONCLUSIONS

While the rate of BR remained unchanged during the pandemic, our findings reveal significant shifts in healthcare utilization, highly attributed to the surge in telehealth adoption. This suggests a transformative impact on breast cancer care, emphasizing the need for continued exploration of telemedicine's role in enhancing accessibility and patient follow-up in the post-pandemic era.

Denis-Katz H, Webb C, Temple-Oberle C. Breast Reconstruction Perceptions and Access in First Nations Women are Influenced by Colonization

Purpose: This qualitative study explored First Nations (FN) women's perceptions about breast reconstruction (BR) after breast cancer surgery. Method: Participants were recruited through purposive and snowball sampling via Aboriginal health and community organizations, breast and plastic surgeons, an Aboriginal health liaison and an FN elder. Semistructured one-on-one interviews and an FN sharing circle were conducted, transcribed, and analyzed using thematic content analysis. Results: Nine women participated in the interviews. Three (33%) had been offered and had pursued BR, while 6 (67%) were either not offered or had not pursued breast reconstruction. Two of these 6 stated that they were not interested in BR. Four women participated in the sharing circle; 2 had been interviewed prior and 2 were new participants who shared similar themes and experiences to other participants also interviewed. Four key themes were identified: identity, information gaps, financial and transportation barriers, and consequences of colonization. Reasons cited to pursue BR were consistent with non-FN women such as improving self-image, concepts of femininity, and sense of normalcy. All participants reported that accessible, appropriate, and timely and culturally sensitive BR information was lacking. Living on reserve and the attendant expenses related to attending medical appointments was another barrier experienced by women in our study. The devastating impacts of colonization also deeply impacted several women in our study. Conclusion: When offered, FN women were receptive to pursuing BR. FN women have a particular set of obstacles related to consequences of colonization. Culturally sensitive and relevant oral communications grounded in first-hand experiences are desired. The 4 themes identified did influence the rate of BR uptake in the FN women who participated in our study and provided significant and unique obstacles to FN women.

Chronic pain in breast cancer patients post mastectomy with alloplastic reconstruction: A scoping review

INTRODUCTION

Women diagnosed with breast cancer are receiving mastectomy with implant-based reconstruction at an increasing rate. Chronic post-surgical pain can be a major concern for these patients. This review sought to address the knowledge gap on the prevalence, severity and characteristics of chronic pain in this population.

METHODS

A scoping review was conducted using the Arksey and O'Malley framework. Five databases were searched using keywords. Two independent reviewers performed selection and data extraction of studies that met inclusion criteria.

RESULTS

Seventeen studies were included in this review. Ten studies reported prevalence of chronic pain which ranged from 7.3%-90.9% with pooled prevalence of 26.3%. Nine studies reported severity of chronic pain using various scales and methodology; most patients' pain was not severe. Risk factors for chronic pain included axillary dissection, lack of perioperative local anaesthetic, younger age and use of a tissue expander. No studies reported on possible correlation between ethnicity and pain. Eleven different assessment tools were used to measure pain.

CONCLUSION

Chronic pain following post-mastectomy implant-based breast reconstruction is prevalent, associated with specific risk factors and poorly characterised. There is a need to investigate and evaluate chronic pain in this population using validated breast cancer specific pain assessment tools.

Disparities in Access to Postmastectomy Breast Reconstruction: Does Living in a Specific ZIP Code Determine the Patient's Reconstructive Journey?

BACKGROUND

Postmastectomy breast reconstruction (BR) has been shown to provide long-term quality of life and psychosocial benefits. Despite the policies initiated to improve access to BR, its delivery continues to be inequitable, suggesting that barriers to access have not been fully identified and/or addressed. The purpose of this study was to assess the influence of geographic location, socioeconomic status, and race in access to immediate BR (IBR).

METHODS

An institutional review board-approved observational study was conducted. All patients who underwent breast cancer surgery from 2014 to 2019 were queried from our institutional Breast Cancer Registry. A geographical analysis was conducted using demographic characteristics and patient's ZIP codes. Euclidean distance from patient home ZIP code to UPMC Magee Women's Hospital was calculated, and χ2, Student t test, Mann-Whitney, and Kruskal-Wallis tests was used to evaluate differences between groups, as appropriate. Statistical significance was set at P < 0.05.

RESULTS

Overall, 5835 patients underwent breast cancer surgery. A total of 56.7% underwent lumpectomy or segmental mastectomy, and 43.3% underwent modified, total, or radical mastectomy. From the latter group, 33.5% patients pursued BR at the time of mastectomy: 28.6% autologous, 48.1% implant-based, 19.4% a combination of autologous and implant-based, and 3.9% unspecified reconstruction. Rates of IBR varied among races: White or European (34.1%), Black or African American (27.7%), and other races (17.8%), P = 0.022. However, no difference was found between type of BR among races (P = 0.38). Moreover, patients who underwent IBR were significantly younger than those who did not pursue reconstruction (P < 0.0001). Patients who underwent reconstruction resided in ZIP codes that had approximately US $2000 more annual income, a higher percentage of White population (8% vs 11% non-White) and lower percentage of Black or African American population (1.8% vs 2.9%) than the patients who did not undergo reconstruction.

CONCLUSIONS

While the use of postmastectomy BR has been steadily rising in the United States, racial and socioeconomic status disparities persist. Further efforts are needed to reduce this gap and expand the benefits of IBR to the entire population without distinction.

Impact of Competition Versus Centralisation of Hospital Care on Process Quality: A Multilevel Analysis of Breast Cancer Surgery in France

BACKGROUND

The implications of competition among hospitals on care quality have been the subject of considerable debate. On one hand, economic theory suggests that when prices are regulated, quality will be increased in competitive markets. On the other hand, hospital mergers have been justified by the need to exploit cost advantages, and by evidence that hospital volume and care quality are related.

METHODS

Based on patient-level data from two years (2005 and 2012) we track changes in market competition and treatment patterns in breast cancer surgery. We focus on technology adoption as a proxy of process quality and examine the likelihood of offering two innovative surgical procedures: immediate breast reconstruction (IBR), after mastectomy and sentinel lymph node biopsy (SLNB). We use an index of competition based on a multinomial logit model of hospital choice which is not subject to endogeneity bias, and estimate its impact on the propensity to receive IBR and SLNB by means of multilevel models taking into account both observable patient and hospital characteristics.

RESULTS

The likelihood of receiving these procedures is significantly higher in hospitals located in more competitive markets. Yet, hospital volume remains a significant indicator of quality, therefore benefits of competition appear to be sensitive to the estimates of the impact of volume on care process. In France, the centralisation policy, with minimum activity thresholds, have contributed to improving breast cancer treatment between 2005 and 2012.

CONCLUSION

Finding the right balance between costs and benefits of market competition versus concentration of hospital care supply is complex. We find that close to monopolistic markets do not encourage innovation and quality in cancer treatment, but highly competitive markets where many hospitals have very low activity volumes are also problematic because hospital quality is positively linked to patient volume.

Identifying the top research priorities in postmastectomy breast cancer reconstruction: a James Lind Alliance priority setting partnership

BACKGROUND

Major improvements in breast cancer treatment in the last decade include advancements in postmastectomy breast reconstruction (PMBR). Unfortunately, the studies in PMBR are primarily researcher or industry led with minimal input from patients and caregivers. The aim of this study is to use the James Lind Alliance (JLA) approach to bring together the patients, caregivers and clinicians in a priority setting partnership to identify the most important unanswered research questions in PMBR.

METHODS

The JLA priority setting methodology involved four key stages: gathering research questions on PMBR from patients, caregivers and clinicians; checking these research questions against existing evidence; interim prioritisation and a final consensus meeting to determine the top 10 unanswered research questions using the modified nominal group methodology.

RESULTS

In stage 1, 3168 research questions were submitted from 713 respondents across Canada, of which 73% of the participants were patients or caregivers. Stage 2 confirmed that there were a total of 48 unique unanswered questions. In stage three, 488 individuals completed the interim prioritisation survey and the top 25 questions were taken to a final consensus meeting. In the final stage, the top 10 unanswered research questions were determined. They cover a breadth of topics including personalised surgical treatment, safety of implants and newer techniques, access to PMBR, breast cancer recurrence and rehabilitation.

INTERPRETATION

Identification of the top 10 unanswered research questions is an important first step to generating relevant and impactful research that will ultimately improve the PMBR experience for patients with breast cancer.

Preconsultation Educational Group Intervention Can Address the Knowledge Gap in Postmastectomy Breast Reconstruction

BACKGROUND

Whether to undergo postmastectomy breast reconstruction (PMBR) is a challenging, preference-sensitive decision. It is therefore paramount to optimize decision quality through ensuring patients' knowledge and aligning treatments with their personal preferences. This study assessed the effects of a preconsultation educational group intervention (PEGI) on patient knowledge, state-trait anxiety, and decisional conflict (patient uncertainty in decision making) during the decision-making process.

METHODS

This phase 3 randomized controlled trial assessed effects of a PEGI in women without active breast cancer undergoing delayed PMBR, or prophylactic mastectomy with immediate PMBR. Both groups underwent routine education before consultation. In addition, the intervention group underwent a PEGI composed of presentations from a plastic surgeon and nurse, a value clarification exercise, and shared experiences from PMBR patients before the consultation with the plastic surgeon. Before and 1-week after consultation, outcome measures were assessed using the Decisional Conflict Scale, State-Trait Anxiety Inventory, and the BREAST-Q.

RESULTS

Of the 219 women deemed eligible, a total of 156 women were recruited and randomized. Treatment fidelity was 96% and retention was 88%. At baseline, there were no significant differences in terms of demographic or clinical status, knowledge, state-trait anxiety, and decisional conflict. Patient knowledge about PMBR improved in both groups; however, the degree of knowledge attainment was significantly greater in the PEGI group (24.5% improvement in the intervention group compared with 13.5% in the routine education group, P < 0.001). The reduction in decisional conflict from baseline to follow-up was greater in the intervention group compared with the routine education; however, the difference only approached significance (P = 0.09).

CONCLUSIONS

The provision of a preconsultation educational group intervention has been shown to significantly close the knowledge gap on PMBR in patients seeking delayed breast reconstruction or prophylactic mastectomy with immediate breast reconstruction compared with routine education alone.

Early Postoperative Complications From National Surgical Quality Improvement Program: A Closer Examination of Timing and Technique of Breast Reconstruction

BACKGROUND

Despite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality.

STUDY DESIGN

The NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications.

RESULTS

Of 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01).

CONCLUSIONS

Immediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.

A comprehensive literature review of patient-reported outcome measures (PROMs) among common breast reconstruction options: What types of breast reconstruction score well?

PURPOSE

Breast cancer continues to be the most prevalent cancer affecting women. Many reconstructive options exist after oncologic resection. Breast reconstruction can have a lasting impact on many areas of the patient's life, and therefore, a high consideration for patient satisfaction is crucial. Patient-reported outcome measures (PROMs) provide an important tool in the evaluation of different surgical methodologies. The aim of this comprehensive systematic review is to look at various surgical modalities in breast reconstruction as they relate to patient satisfaction.

METHODS

A PubMed PRISMA search was performed. Criteria for inclusion included nipple-sparing or skin-sparing mastectomy with autologous or implant-based reconstruction, level 2 volume displacement or volume replacement oncoplastic surgery, and measurement of patient-reported outcomes using the BREAST-Q or other validated PROMs. From the data set, weighted proportions were generated and analyzed using the Kruskal-Wallis rank sum test and a post hoc Dunn's test.

RESULTS

After obtaining 254 full text copies, 43 articles met inclusion criteria and were included. Analysis of BREAST-Q data showed oncoplastic breast surgery was significantly preferred over mastectomy regardless of the type of reconstruction. Nipple-sparing was significantly preferred over skin-sparing mastectomy, autologous reconstruction was significantly preferred over implant-based reconstruction, and prepectoral implant placement was preferred over subpectoral implant placement. Validated PROMs other than BREAST-Q showed similar trends in all but type of mastectomy.

CONCLUSIONS

In this comprehensive systematic review, oncoplastic surgery showed the most favorable PROMs when compared to other reconstructive modalities. Autologous was preferred over implant-based reconstruction, and prepectoral was preferred over subpectoral implant placement.

Breast reconstruction in South Western Sydney

BACKGROUND

The rates of breast reconstruction in Australian patients of culturally and linguistically diverse (CALD) backgrounds are currently unknown. This retrospective study determined the rate of breast reconstruction in women who had mastectomy as treatment for breast cancer at public hospitals in South Western Sydney Local Health District (SWSLHD) - a culturally diverse health district in New South Wales, Australia - and compared the rate of reconstruction in the CALD and non-CALD populations.

METHODS

The demographic and clinical data of all female patients who had mastectomy with or without reconstruction for treatment of breast cancer at the five public hospitals in SWSLHD between January 2006 and December 2015 were obtained from the clinical information department of each hospital and from electronic medical records.

RESULTS

The average rate of reconstruction in SWSLHD was 9.4% for 2006-2015. Although the reconstruction rate was higher among English-speaking women (9.9%) compared to women from a CALD background (8.6%), the difference was not statistically significant (P = 0.57). The type (autologous versus implant) and timing (immediate versus delayed) of reconstruction did not differ between groups (P = 0.19 and P = 0.22, respectively). The Index of Relative Socio-Economic Disadvantage was not significantly associated with reconstruction (P = 0.74). However, younger patients were more likely to have reconstruction (P < 0.0001) and patients with adjuvant therapy were more likely to have a delayed reconstruction (P = 0.01).

CONCLUSION

This study found a low breast reconstruction rate in public hospitals in SWSLHD. The reconstruction rate did not differ between CALD or English-speaking patients, or between patients from diverse socio-economic backgrounds.

Exploring the Effect of Post-mastectomy complications on 5-year survival

BACKGROUND

Ramifications of postoperative complications on long-term survival after mastectomy are uncertain.

METHODS

Overall complications (Clavien-Dindo Grades I-IIIB) and wound complications were analyzed using the Kaplan-Meier method for impact on 5-year overall (OS) and disease-free survival (DFS).

RESULTS

A total of 378 patients underwent mastectomy alone (157, 41%) or mastectomy with reconstruction (221, 59%) for Stage I-III disease with a median follow-up of 5 years. Postoperative complications occurred in 186 patients (49%), requiring non-surgical (I/II = 83, 22%) or surgical (IIIa/IIIb = 103, 27%) management. Wound complications occurred in 140 patients (37%). Reconstruction was associated with a higher rate of complication (P < 0.001). Postoperative complications after mastectomy (with or without reconstruction) did not significantly affect OS or DFS. Wound complications also showed no significant effect on OS or DFS following mastectomy alone, or mastectomy with reconstruction.

CONCLUSIONS

Postoperative complications after mastectomy, with or without reconstruction, bear no significant impact on 5-year survival.

How Ineffective Interprofessional Collaboration Affects Delivery of Breast Reconstruction to Breast Cancer Patients: A Qualitative Study

BACKGROUND

Despite the benefits of breast reconstruction (BR), health care professionals do not consistently integrate it as an option in the treatment of breast cancer patients. Interprofessional collaboration (IPC) amongst professionals may facilitate the elaboration of comprehensive oncological treatment plans. As the application of IPC in the delivery of BR has not yet been studied, we undertook a qualitative study to explore the perceptions of physicians and administrators on IPC in breast cancer care and how these impact BR delivery.

METHODS

Interviews were conducted with 30 participants (22 physicians and 8 administrators). Physician interviews focused on their personal beliefs and values regarding BR, while administrator interviews explored their institutional treatment regimens as well as the availability of a BR program. Our thematic analysis was informed by the Canadian Interprofessional Health Collaborative (CIHC) competency framework.

RESULTS

IPC challenges were thought by participants to affect the delivery of BR. At the physician level, a lack of role clarity as well as the absence of an explicitly established leader negatively influence collaboration in BR delivery. In addition, varying views on the usefulness of BR and on the role of plastic surgeons in breast oncological teams discourage positive collaboration, rendering the delivery of BR more difficult.

CONCLUSIONS

The delivery of BR is overall impaired due to a lack of effective IPC. IPC could be improved through clarifying physician roles, establishing clear leadership, and aligning viewpoints on quality oncological care in collaborative teams; ultimately, this may promote equitable BR delivery for breast cancer patients.

Influence of socioeconomic status on immediate breast reconstruction rate, patient information and involvement in surgical decision-making

Background

Immediate breast reconstruction (IBR) rates in breast cancer differ between healthcare regions in Sweden. This is not explained by regional differences in patient age distribution or tumour characteristics, but by differences in patient‐reported information and patient involvement in the decision‐making process. As socioeconomic status may play a significant role in surgical decision‐making, its potential associations with IBR rates were analysed.

Methods

Women who had undergone therapeutic mastectomy for primary breast cancer in Sweden in 2013 were included in the analysis. Tumour and treatment data were retrieved from the Swedish National Breast Cancer Register, and socioeconomic background data from the Central Bureau of Statistics Sweden. Postal questionnaires regarding information about reconstruction and perceived involvement in the preoperative decision‐making process had been sent out in a previous survey.

Results

In addition to regional differences, lower tumour and nodal category, independent factors increasing the likelihood of having IBR for the 3131 women in the study were living without a registered partner, having current employment and high income per household. Patient‐reported perceived preoperative information (odds ratio (OR) 12·73, 95 per cent c.i. 6·03 to 26·89) and the feeling of being involved in the decision‐making process (OR 2·56, 1·14 to 5·76) remained strong independent predictors of IBR despite adjustment for socioeconomic factors. Importantly, responders to the survey represented a relatively young and wealthy population with a lower tumour burden.

Conclusion

Several socioeconomic factors independently influence IBR rates; however, patient‐reported information and involvement in the surgical decision‐making process remain independent predictors for the likelihood of having IBR.

How patient acceptability affects access to breast reconstruction: a qualitative study

OBJECTIVES

There has been limited research on the acceptability of breast reconstruction (BR) to breast cancer patients. We performed interviews to explore breast cancer patients' acceptability of BR.

DESIGN

Qualitative study.

SETTING

Recruitment from six Ontario hospitals across the province (Toronto, Ottawa, Hamilton, London, Thunder Bay and Windsor) as well as key breast cancer organisations between November 2017 and June 2018.

PARTICIPANTS

Women of any age with a diagnosis of breast cancer planning to undergo or having undergone a mastectomy with or without BR.

INTERVENTION

Sixty-minute semi-structured interviews were analysed using qualitative descriptive methodology that draws on inductive thematic analysis.

OUTCOME

In the telephone interviews, participants discussed their experience with breast cancer and accessing BR, focusing on the acceptability of BR as a surgical option post-mastectomy.

RESULTS

Of the 28 participants, 11 had undergone BR at the time of the interview, 5 at the time of mastectomy and 6 at a later date. Four inter-related themes were identified that reflected women's evolving ideas about BR as they progressed through different stages of their disease and treatment. The themes we developed were: (1) cancer survival before BR, (2) the influence of physicians on BR acceptability, (3) patient's shift to BR acceptance and (4) women's need to justify BR. For many women, access to BR surgery became more salient over time, thus adding a temporal element to the existing access framework.

CONCLUSION

In our study, women's access to BR was negatively influenced by the poor acceptability of this surgical procedure. The acceptability of BR was a complex process taking place over time, from the moment of breast cancer diagnosis to BR consideration. BR access may be improved through enhancing patient acceptability of BR. We suggest adapting the current access to care frameworks by further developing the concept of acceptability.

Barriers of Access to Breast Reconstruction: A Systematic Review

BACKGROUND

The purpose of this systematic review was to comprehensively summarize barriers of access to breast reconstruction and evaluate access using the Penchansky and Thomas conceptual framework based on the six dimensions of access to care.

METHODS

The authors performed a systematic review that focused on (1) breast reconstruction, (2) barriers, and (3) breast cancer. Eight databases (i.e., EMBASE, MEDLINE, PsycINFO, CINHAL, ePub MEDLINE, ProQuest, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials) were searched. English peer-reviewed articles published between 1996 and 2016 were included.

RESULTS

The authors' search retrieved 4282 unique articles. Two independent reviewers screened texts, selecting 99 articles for inclusion. All studies were observational and qualitative in nature. The availability of breast reconstruction was highest in teaching hospitals, private hospitals, and national cancer institutions. Accessibility affected access, with lower likelihood of breast reconstruction in rural geographic locations. Affordability also impacted access; high costs of the procedure or poor reimbursement by insurance companies negatively influenced access to breast reconstruction. Acceptability of the procedure was not universal, with unfavorable physician attitudes toward breast reconstruction and specific patient and tumor characteristics correlating with lower rates of breast reconstruction. Lastly, lack of patient awareness of breast reconstruction reduced the receipt of breast reconstruction.

CONCLUSIONS

Using the access-to-care framework by Penchansky and Thomas, the authors found that barriers to breast reconstruction existed in all six domains and interplayed at many levels. The authors' systematic review analyzed this complex relationship and suggested multiprong interventions aimed at targeting breast reconstruction barriers, with the goal of promoting equitable access to breast reconstruction for all breast cancer patients.

Relation between socioeconomic variables and surgical, systemic and radiation treatment in a cohort of patients with breast cancer in an urban Canadian centre

Background

Studies have shown an association between socioeconomic status and breast cancer treatment. We examined the relation between socioeconomic status and the treatment of breast cancer (surgical, systemic and radiation) in a universal health care system.

Methods

Data from a single urban Canadian centre were collected for consecutive patients who received a diagnosis of breast cancer from January 2010 to December 2011. Variables included patient and disease factors, surgery type, systemic and radiation treatment, and breast reconstruction. Socioeconomic variables were obtained from 2006 Canadian census data. We used multivariable logistic regression to identify predictors of breast cancer treatment.

Results

A total of 721 patients were treated for breast cancer during the study period. Socioeconomic variables were not related to type of breast surgery for breast cancer. Age less than 50 years, having a first-degree relative with breast cancer and income status were predictors of breast reconstruction. Employment status was a consistent predictor of systemic and radiation treatment.

Conclusion

Employment consistently predicted systemic and radiation treatment, and age and income were predictors of breast reconstruction in a universal health care system. Further research is required to determine precisely how socioeconomic factors affect care and to minimize possible disparities in delivery of health care services.

Feasibility of Implementing a Breast Reconstruction Database

Objective

To assess whether implementing a breast reconstruction database would be feasible in terms of time commitment, cost, and overall benefits in a tertiary-care hospital.

Methods

A survey was sent to 40 Canadian plastic surgeons who have a practice focused on breast reconstruction. The survey assessed demographics, practice characteristics, database use, and opinions on database construction. Univariate descriptive analyses were performed on all variables.

Results

Thirty-one surgeons responded to the survey (77.5%). Most were from Ontario (29.1%) and worked in an academic center (83.9%). Of all, 45.3% of surgeons performed more than 50 breast reconstructions yearly. Six (19.4%) surgeons utilized databases that were all started for quality improvement and research purposes. Databases included variables such as demographics, type of reconstruction, complications, surgeons involved, and type of implants. Data are input by research assistants (50%) for approximately 4.2 hours per month at a cost below 200$CAD per month. Databases are funded by research grants (50%), hospital funds (33.3%), and/or division funds (16.7%). Of the surgeons without databases, 60% have considered starting a database. Barriers include being too busy (72%) and impressions of the cost being too high (32%). Surgeons commonly felt that a database would be beneficial at their practice (80%), provincially (77.4%), and nationally (67.7%).

Conclusions

Plastic surgeons are open to the idea of constructing a breast reconstruction database and that the costs and time required are lower than expected. Grants or integration with existing databases should be pursued on a provincial level first prior to pursuing a national database.

Variations in outcomes by residential location for women with breast cancer: a systematic review

OBJECTIVES

To systematically assess the evidence for variations in outcomes at each step along the breast cancer continuum of care for Australian women by residential location.

DESIGN

Systematic review.

METHODS

Systematic searches of peer-reviewed articles in English published from 1 January 1990 to 24 November 2017 using PubMed, EMBASE, CINAHL and Informit databases. Inclusion criteria were: population was adult female patients with breast cancer; Australian setting; outcome measure was survival, patient or tumour characteristics, screening rates or frequencies, clinical management, patterns of initial care or post-treatment follow-up with analysis by residential location or studies involving non-metropolitan women only. Included studies were critically appraised using a modified Newcastle-Ottawa Scale.

RESULTS

Seventy-four quantitative studies met the inclusion criteria. Around 59% were considered high quality, 34% moderate and 7% low. No eligible studies examining treatment choices or post-treatment follow-up were identified. Non-metropolitan women consistently had poorer survival, with most of this differential being attributed to more advanced disease at diagnosis, treatment-related factors and socioeconomic disadvantage. Compared with metropolitan women, non-metropolitan women were more likely to live in disadvantaged areas and had differing clinical management and patterns of care. However, findings regarding geographical variations in tumour characteristics or diagnostic outcomes were inconsistent.

CONCLUSIONS

A general pattern of poorer survival and variations in clinical management for Australian female patients with breast cancer from non-metropolitan areas was evident. However, the wide variability in data sources, measures, study quality, time periods and geographical classification made direct comparisons across studies challenging. The review highlighted the need to promote standardisation of geographical classifications and increased comparability of data systems. It also identified key gaps in the existing literature including a lack of studies on advanced breast cancer, geographical variations in treatment choices from the perspective of patients and post-treatment follow-up.

Trends in breast reconstruction practices in a specialized breast tertiary referral centre

BACKGROUND

Breast reconstruction is an important component of multidisciplinary breast cancer management. The practice of breast reconstruction after mastectomy has evolved significantly in the past decade as a result of both increasing mastectomy rates and advances in reconstructive strategy. These changes have significantly influenced the contemporary surgical management of breast cancer. The aim of this study was to examine trends in breast reconstruction after mastectomy in an Irish population.

METHODS

Data were reviewed from a database of all patients who had mastectomy with or without breast reconstruction at Galway University Hospital, a tertiary breast cancer referral centre, between 2004 and 2014. Trends in breast reconstruction after mastectomy were explored with respect to patient demographics, clinicopathological features, and neoadjuvant and adjuvant therapy.

RESULTS

Of 1303 patients who underwent mastectomy during interval studied, 706 (54.2 per cent) had breast reconstruction after mastectomy. In 629 patients (89·1 per cent), breast reconstruction was performed in the immediate setting. Reconstruction rates increased over time from 20·5 per cent in 2004 to 44·7 per cent in 2014. Reconstruction was more commonly performed in younger patients and those with benign, in situ and early-stage disease. A negative relationship between radiotherapy and reconstruction was observed. A pedicled flap with or without an implant was the most commonly used reconstructive approach in patients receiving radiotherapy.

CONCLUSION

Breast reconstruction after mastectomy has become the standard of care in the surgical treatment of breast cancer. Recent trends show a transition favouring implant-based approaches.

Factors Influencing the Rate of Post-Mastectomy Breast Reconstruction in a Canadian Teaching Hospital

Background

Post-mastectomy breast reconstruction (PMBR) improves psychosocial well-being, quality of life, and body image. Reconstruction rates vary widely (up to 42% in the United States), but the few Canadian studies available report rates of 3.8% to 7.9%. We sought to evaluate the current state of breast reconstruction in 1 Canadian teaching hospital and factors determining patients' access to reconstruction.

Methods

We performed a retrospective chart review of all patients with breast cancer undergoing mastectomy alone or mastectomy and reconstruction at a Canadian hospital between 2010 and 2013. We calculated rates of breast reconstruction and compared patient characteristics between the 2 groups, and then performed a multiple logistic regression to determine factors increasing the odds of receiving breast reconstruction.

Results

A total of 152 patients underwent 154 total or modified radical mastectomies. We obtained a rate of PMBR of 21%, 14% immediate reconstruction, and 8% delayed. Statistical analysis showed that compared to patients with mastectomy alone, patients who received PMBR were significantly younger, with a larger percentage having bilateral mastectomies, non-invasive breast cancer, and residing further from the hospital. Patients less than 50 years old and those with bilateral mastectomies had significantly greater odds of having a reconstruction.

Conclusions

Our Canadian tertiary care institution has a high volume of breast surgery and an active breast reconstruction team. However, the rate of immediate reconstruction remains low compared to similar centers in the United States. We recommend a united effort to increase awareness regarding PMBR and address common misconceptions hindering patients' access to breast reconstruction.

Level of Evidence

Epidemiologic study, Level III.

Association of Insurance Status with the Use of Immediate Breast Reconstruction in Women with Breast Cancer

Our group sought to determine the influence of health insurance coverage on use of immediate breast reconstruction for working-age women undergoing mastectomy for breast cancer.

Survival Differences in Women with and without Autologous Breast Reconstruction after Mastectomy for Breast Cancer

Background:

Breast reconstruction (BR) is an option for women who are treated with mastectomy; however, there has been concern regarding the oncologic safety of BR. In this study, we evaluated recurrences and mortality in women treated with mastectomy and compared outcomes in those treated with mastectomy alone to those with mastectomy plus transverse rectus adbominis (TRAM) flap BR.

Methods:

The prospective cohort study included women treated with mastectomy at Women’s College Hospital from 1987 to 1997. Women with TRAM flap BR were matched to controls based on age and year of diagnosis, stage, and nodal status. Patients were followed from the date of diagnosis until death or date of last follow-up. Hazard ratios were generated to compare cases and controls for outcome variables using Cox’s proportional hazards models.

Results:

Of 443 women with invasive breast cancer, 85 subjects had TRAM flap BR. Sixty-five of these women were matched to 115 controls. The mean follow-up was 11.2 (0.4–26.3) years. There were no significant differences between those with and without BR with weight, height, or smoking status. Women with TRAM flap were less likely to experience a distant recurrence compared to women without a TRAM flap (relative risk, 0.42; P = 0.0009) and were more likely to be alive (relative risk, 0.54; P = 0.03).

Conclusions:

Women who elect for TRAM flap BR after an invasive breast cancer diagnosis do have lower rates of recurrences and mortality than women treated with mastectomy alone. This cannot be explained by differences in various clinical or lifestyle factors.

The safety of same-day breast reconstructive surgery: An analysis of short-term outcomes

BACKGROUND

We sought to examine the safety of same-day breast reconstructive (BR) surgery.

METHODS

An analysis of the American College of Surgeons, National Surgical Quality Improvement Program (ACS-NSQIP) files was performed. Patients undergoing BR for breast cancer were examined, excluding those with high-risk co-morbidities or concurrent surgery. A propensity score was calculated and a multivariable logistic regression analysis was used to calculate the difference in 30-day complications between those undergoing SDS versus longer hospital stay.

RESULTS

The study consisted of 21,539 patients; 17,449 had implant and 4090 had autologous breast reconstruction. 1195 (5.5%) underwent SDS, whereas 20,344 (94.5%) were admitted at least overnight. On unadjusted analysis, the rate of post-operative complications was nearly three times higher in those admitted compared to those undergoing SDS (6.7% vs. 2.5%; p < 0.001). On propensity score adjusted multivariable regression there was no significant difference in complications amongst those undergoing SDS versus staying in hospital (OR 1.4 (95%CI: 0.9, 2.2)).

CONCLUSIONS

These results suggest that admitting BR patients does not prevent short-term complications and same day BR surgery is safe when co-morbidities are accounted for.

Reoperation costs in attempted breast-conserving surgery: a decision analysis

BACKGROUND

Breast-conserving surgery (bcs) is the preferred surgical approach for most patients with early-stage breast cancer. Frequently, concerns arise about the pathologic margin status, resulting in an average reoperation rate of 23% in Canada. No consensus has been reached about the ideal reoperation rate, although 10% has been suggested as a target. Upon undergoing reoperation, many patients choose mastectomy and breast reconstruction, which add to the morbidity and cost of patient care. We attempted to identify the cost of reoperation after bcs, and the effect that a reduction in the reoperation rate could have on the B.C. health care system.

METHODS

A decision tree was constructed to estimate the average cost per patient undergoing initial bcs with two reoperation frequency scenarios: 23% and 10%. The model included the direct medical costs from the perspective of the B.C. health care system for the most common surgical treatment options, including breast reconstruction and postoperative radiation therapy.

RESULTS

Costs ranged from a low of $8,225 per patient with definitive bcs [95% confidence interval (ci): $8,061 to $8,383] to a high of $26,026 for reoperation with mastectomy and delayed reconstruction (95% ci: $23,991 to $28,122). If the reoperation rate could be reduced to 10%, the average saving would be $1,055 per patient undergoing attempted bcs (95% ci: $959 to $1,156). If the lower rate were to be achieved in British Columbia, it would translate into a savings of $1.9 million annually.

SUMMARY

The implementation of initiatives to reduce reoperation after bcs could result in significant savings to the health care system, while potentially improving the quality of patient care.

Contralateral prophylactic mastectomy rate stable at major Canadian breast cancer center

AIM: To examine trends of contralateral prophylactic mastectomy (CPM) rates at a Canadian academic breast cancer center.

METHODS: A single-institution retrospective cohort study was completed. Women of any age who underwent at least a unilateral mastectomy (UM) for primary unilateral breast carcinoma between January 1, 2004 and December 31, 2010 were included. Patients who underwent CPM on the same day as UM were isolated to create two distinct cohorts. Patient and procedure characteristics were compared across groups using R software (version 3.1.0). The percentage of CPMs per year was determined. The Cochrane-Armitage test was used to assess the trend of CPMs over time. A P value of < 0.05 was considered significant.

RESULTS: A total of 811 women met the inclusions/exclusion criteria; 759 (93.6%) underwent UM alone and 52 (6.4%) underwent UM with immediate CPM. The absolute number of procedures (UM and UM + CPM) increased over time, from 83 in 2004 to 147 in 2010 reflecting an increase in mastectomy volume. Annual CPM rates did not increase over time (P = 0.7) and varied between 2.6% to 10.7%. Family history of breast cancer [OR 3.6 (1.8-7.3)] and immediate reconstruction [10.0 (5.2-19.3)] were both significantly associated with CPM. Women who underwent CPM were younger (median age CPM 49 years vs UM 52 years, P < 0.0001) but age less than 50 years was not statistically associated with increased rates of CPM.

CONCLUSION: CPM rates from 2004 to 2010 at a high-volume Canadian breast cancer center did not increase over time, in contrast to trends observed in the United States.

The Impact of Travel Distance on Breast Reconstruction in the United States

BACKGROUND

Inadequate access to breast reconstruction was a motivating factor underlying passage of the Women's Health and Cancer Rights Act. It remains unclear whether all patients interested in breast reconstruction undergo this procedure. The aim of this study was to determine whether geographic disparities are present that limit the rate and method of postmastectomy reconstruction.

METHODS

Travel distance in miles between the patient's residence and the hospital reporting the case was used as a quantitative measure of geographic disparities. The American College of Surgeons National Cancer Database was queried for mastectomy with or without reconstruction performed from 1998 to 2011. Reconstructive procedures were categorized as implant or autologous techniques. Standard statistical tests including linear regression were performed.

RESULTS

Patients who underwent breast reconstruction had to travel farther than those who had mastectomy alone (p < 0.01). A linear correlation was demonstrated between travel distance and reconstruction rates (p < 0.01). The mean distances traveled by patients who underwent reconstruction at community, comprehensive community, or academic programs were 10.3, 19.9, and 26.2 miles, respectively (p < 0.01). Reconstruction rates were significantly greater at academic programs. Patients traveled farther to undergo autologous compared with prosthetic reconstruction.

CONCLUSIONS

Although greater patient awareness and insurance coverage have contributed to increased breast reconstruction rates in the United States, the presence of geographic barriers suggests an unmet need. Academic programs have the greatest reconstruction rates, but are located farther from patients' residences. Increasing the number of plastics surgeons, especially in community centers, would be one method of addressing this inequality.

Geographic Variation Immediate and Delayed Breast Reconstruction Utilization in Ontario, Canada and Plastic Surgeon Availability: A Population-Based Observational Study

BACKGROUND

Utilization of breast reconstruction (BR) is low in many jurisdictions. We studied the geographical and surgical workforce factors that contribute to access and use of BR using a small area analysis approach with a geographical unit of analysis.

METHODS

We linked administrative data from Ontario Canada to calculate the age-standardized rates for immediate BR (IBR) (same time as mastectomy) between 2002 and 2011, and delayed BR (DBR) (within 3 years of mastectomy) for each county. The influence of plastic surgeon access on variation in county rates of BR was examined using Poisson random effects models.

RESULTS

12,663 women underwent mastectomy in Ontario; 2,948 had BR within 3 years (23.3%). Over 50% of the counties had no access to any plastic surgeon. County IBR rates ranged from 0 to 21.5%; plastic surgeon access explained 46% of geographic variation (p<0.0001). IBR rates in counties with very low, low, and moderate access to plastic surgeons were significantly less than counties with high access (relative rate [RR] 0.48 [95% confidence interval (CI) 0.35-0.66], RR 0.61 [CI 0.43-0.87] and RR 0.70 [CI 0.52-0.96], respectively) after adjusting for age and county socioeconomic characteristics. For DBR, while there was less geographic variation, very low access counties demonstrated reduced rates (RR 0.60 [CI 0.47-0.76]).

INTERPRETATION

Geographic access to a plastic surgeon is a major determinant of BR. Targeted interventions for regions without high access to plastic surgeons may improve overall rates and reduce geographic disparities in care, particularly for IBR.

Current Status of Breast Reconstruction in Southern China: A 15 Year, Single Institutional Experience of 20,551 Breast Cancer Patients

The study of this study is to assess the current status and trend of the application of breast reconstruction in China.A retrospective review of all patients who had received surgical treatment for breast cancer in the Fudan University Shanghai Cancer Center between January 1999 and June 2014 was performed. The clinicopathological and epidemiological parameters and the follow-up information of each patient were collected.A total of 20,551 patients with 20,974 surgeries were identified. Of those, the rates of patients received mastectomy, breast conserving therapy, and breast reconstruction were 81.2% (17,040 cases), 15.3% (3216 cases), and 3.4% (718 cases), respectively. Skin-sparing mastectomy with autologous breast reconstruction was algate the dominant option for breast reconstruction although a rapid growth in the application of prosthetic reconstructions was observed in recent years. The rates of complications that required reoperation in patients reconstructed with latissimus dorsi myocutaneous flap, pedicled transverse rectus abdominis myocutaneous flap, free flaps, and prosthesis were 1.2%, 8.5%, 11.4%, and 10.5%, respectively, while the revision rates were 0.7%, 6.1 %, 5.3%, and 2.3%, respectively. Multiple regression analysis confirmed that types of surgery did not affect the disease-free survival of breast cancer patients.Skin-sparing mastectomy with breast reconstruction is oncologically safe while achieving satisfactory aesthetic outcomes. Autologous reconstruction remains the most commonly used technique while there is a rapid increase of prosthetic reconstruction in recent years. The low demand for breast aesthetics among Chinese women, defects of healthcare system, and the limited availability of recourses impeded the development of breast reconstruction techniques in China.

Does breast reconstruction after mastectomy for breast cancer affect overall survival? Long-term follow-up of a retrospective population-based cohort

BACKGROUND

This study compared overall and breast cancer-specific survival using long-term follow-up data among women diagnosed with invasive breast cancer undergoing mastectomy or breast reconstruction.

METHODS

Retrospective study using population-based data from Ontario Cancer Registry (1980 to 1990) including women receiving breast reconstruction within 5 years after mastectomy and controls of age- and cancer histology-matched women with mastectomy alone. We compared overall and breast cancer-specific survival using an extended Cox hazards model. Secondary analysis examined conditional survival across early, intermediate, and late follow-up.

RESULTS

Seven hundred fifty-eight matched pairs formed the cohort, with a median follow-up of 23.4 years (interquartile range, 1.1 to 33.0 years). Fewer breast reconstruction patients died overall or from breast cancer compared with controls (overall survival, 44.5 percent versus 56.7 percent, p < 0.0001; breast cancer-specific survival, 31.8 percent versus 42.6 percent, p = 0.0002, respectively). Breast reconstruction was associated with a 17 percent reduced risk of death and a 19 percent reduced risk of breast cancer death, after adjustment (overall survival hazard ratio, 0.83; 95 percent CI, 0.72 to 0.96; breast cancer-specific survival hazard ratio, 0.81; 95 percent CI, 0.68 to 0.99). Among 885 women (58 percent) surviving 20 or more years, there was no difference in risk of death from breast cancer (hazard ratio, 0.59; 95 percent CI, 0.31 to 1.10).

CONCLUSION

In a large cohort with invasive breast cancer followed over 20 years, there is no evidence that breast reconstruction is associated with worse survival outcomes compared with mastectomy alone.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Surgical management for early-stage bilateral breast cancer patients in China

Background

The aim of this study was to investigate the current surgical management strategy for bilateral breast cancer (BBC) patients and to assess the changes in this strategy in China.

Methods

This is a retrospective review of all patients with early-stage BBC who underwent surgical treatment at the Fudan University Shanghai Cancer Center between June 2007 and June 2014.

Results

A total of 15,337 patients with primary breast cancer were identified. Of these patients, 218 (1.5%) suffered from synchronous bilateral breast cancer (sBBC), and 296 (2.0%) suffered from metachronous bilateral breast cancer (mBBC). Patients with a lobular carcinoma component, those with estrogen receptor-positive cancer, and those with an accompanying sclerosing adenosis in the affected breast tended to develop BBC. The rates of bilateral mastectomy, breast conserving therapy, reconstruction, and combined surgeries were 86.2%, 6.4%, 3.7%, and 3.7%, respectively, for patients with sBBC and 81.1%, 4.4%, 3.0%, and 11.5%, respectively, for patients with mBBC. The interval between bilateral cancers, age at first diagnosis of breast cancer, histopathological type, and stage have significant impacts on the choice of surgery for patients with BBC.

Conclusions

Bilateral mastectomy was the dominant surgical management for patients with BBC in China, despite the increased application of breast reconstruction surgery observed in recent years. Bilateral prosthetic breast reconstruction was the ideal choice for patients with sBBC. Chinese surgeons should take responsibility for patient education and inform their patients about their surgical options.

Influence of Patient and Hospital Characteristics on the Performance of Direct Reconstruction after Mastectomy

Aim: International studies have shown that the performance of a direct (or immediate) reconstruction (DR) after mastectomy is associated with patient (e.g., socio-economic status, insurance status, age) and hospital (number of cases, teaching status) characteristics. The present article addresses the question if such relationships also exist in Germany. Material and Methods: The results of a nationwide questionnaire to the patients of certified breast cancer centres were coupled with the clinical features of the patients and the characteristics of the hospital. Predictors for receiving a DR (vs. delayed or no reconstruction) were estimated by means of a logistic multilevel model for a sample of 1165 patients from 105 certified locations. Results: Substantial differences between the treating hospitals were found (intraclass correlation coefficient null model: 0.195) which can in part be explained by the total model (total model: 0.169). Patients with the following features are more likely to receive a DR: younger age, private health insurance, secondary school leaving certificate (vs. primary school leaving certificate), lower stage and acquisition of more information about reconstruction. ASA and partnership status are not statistically significantly related with DR. DR is more likely to be performed in hospitals with higher caseload of patients with primary breast cancer. Teaching status, operations per surgeon and urbanity of the location are not related to receiving a DR. Conclusions: Non-clinical features of the patients and the primary case number are associated with the performance of a DR, this poses questions concerning reasons and the equality of health care.