Surgeon attitudes may contribute
to low rates of breast reconstruction

Forty-four percent of surgeons do not refer the majority of their breast cancer patients to a plastic surgeon prior to the initial surgery when the woman is choosing her treatment course, according to a new study by researchers at the Comprehensive Cancer Center.

The finding may help explain the consistently low number of women who pursue breast reconstruction after mastectomy.

The researchers surveyed 365 surgeons, asking them how often they referred patients considering a mastectomy to a plastic surgeon before performing the mastectomy. The surgeons were identified from a population-based database of women in the Detroit and Los Angeles metropolitan areas who had been treated for breast cancer.

The study found 44 percent of the surgeons referred fewer than a quarter of their patients to a plastic surgeon prior to the mastectomy. Only 24 percent of surgeons referred three-quarters or more of their patients for reconstruction.

The study appears March 26 in the online edition of the journal Cancer.

"Women may be more inclined to choose mastectomy with a good understanding of the reconstructive options. We need to help patients through this difficult decision-making process up front, through patient decision aids that include information about reconstruction and multidisciplinary approaches to care, where all surgical options are fully explained," says lead study author Dr. Amy Alderman, assistant professor of plastic surgery at the Medical School.

Fewer than 20 percent of women who could have breast reconstruction choose to undergo the procedure. In the current study, the surgeons attributed low rates of reconstruction to patients not wanting the procedure: 57 percent of surgeons said it was not important to patients, 64 percent thought patients were not interested and 39 percent thought patients were concerned that reconstruction takes too long.

In addition, nearly half of the surgeons felt patients were concerned about the cost of reconstruction, despite a 1998 federal law that mandated insurance coverage of breast reconstruction. "Cost should not be an issue," Alderman says.

Surgeons who referred fewer patients to plastic surgery were more likely to identify patient barriers such as inadequate knowledge, cost concerns and availability of plastic surgeons, compared to surgeons who referred the majority of their patients for reconstruction.

The surgeons most likely to refer their patients to a plastic surgeon tended to be female, with a large volume of breast cancer patients. They were also more likely to work in a cancer center rather than a community hospital or teaching hospital.

The researchers suggest surgeons who do not refer as many patients for reconstruction may be more likely to treat patients with limited resources or to practice in settings with limited access to plastic surgeons.

"We, as a profession, need to do a better job at offering multidisciplinary care or improved decision aids so that patients can be fully educated about all of their treatment options," Alderman says. "Co-management really improves the quality of patient care in several ways. In this case, it would better educate patients and allow them to more fully participate in their choices regarding their health care treatment."

In addition to Alderman, U-M study authors were Sarah T. Hawley, research assistant professor of internal medicine; Dr. Jennifer Waljee, a research fellow in the Robert Wood Johnson Clinical Scholars Program and the Department of Surgery, and Dr. Steven J. Katz, professor of internal medicine and of health management and policy. Dr. Monica Morrow, professor of surgical oncology at Fox Chase Cancer Center in Philadelphia, also was a study author.

Funding for the study was from the National Cancer Institute.

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