Postmastectomy Breast Reconstruction Grows in Use; However, Some Women Still May Not Have Equal Access to the Procedure

New findings show an increase in postmastectomy breast reconstruction, and that TRAM flap reconstruction remains intact with a high degree of patient satisfaction

Newswise — SAN FRANCISCO: Until now, studies looking at trends in cancer care have shown that immediate postmastectomy breast reconstruction has been underutilized. But a pair of studies presented today at the 2011 Annual Clinical Congress of the American College of Surgeons indicate that the number of women undergoing breast reconstruction procedures has almost doubled between 1998 and 2007. Furthermore, the first study points to successful results from a surgical technique called TRAM (Transverse Rectus Abdominis Myocutaneous) flap with a minimum of 15 to 29 years of follow-up after the procedure, while the second study identifies which women were most likely to undergo reconstruction procedures.

Breast reconstruction is a surgical procedure that restores shape to the breast after mastectomy. There are two types of breast reconstruction—autologous and implant-based. A TRAM flap operation is an autologous reconstruction that involves taking abdominal tissue and relocating it to the chest to build a natural-looking breast.

As reported on at the Clinical Congress, Chris D. Tzarnas, MD, FACS, senior author and professor of surgery, Temple University School of Medicine, Philadelphia, and his colleagues reviewed the outcomes of 217 women who underwent TRAM flap breast reconstruction between 1982 and 1996. Most of the women, average age 51, underwent the reconstruction procedure immediately following a mastectomy. The point of the study, Dr. Tzarnas explained “was to assess the long-term outcomes. This is the longest follow-up for this type of reconstruction in the literature to date.” After examining medical records and conducting interviews with the patients 15 to 29 years after the procedures, researchers found that the reconstructions were still intact, and very few women required additional operations, unlike implant-based reconstructions, which often rupture or harden over time. More important, from a quality of life perspective, all of the women felt good about themselves after the TRAM procedure.

“The best reconstructions are those that try to replace everything that is removed. And that has been and, I think, continues to be using the TRAM flap,” Dr. Tzarnas said. “It’s good to show that these reconstructions are doing well and holding up long term.”

On another front, researchers from NorthShore University HealthSystem, Evanston, IL, wanted to look at the reasons breast reconstruction procedures have been underutilized in the past. In their analysis, lead researcher Mark Sisco, MD, a clinical assistant professor of surgery at the University of Chicago Pritzker School of Medicine and his team examined data from the National Cancer Data Base (NCDB) of the American College of Surgeons and the American Cancer Society, a nationwide oncology outcomes database for more than 1,500 Commission on Cancer- accredited cancer programs in the United States and Puerto Rico.

Dr. Sisco and his team sought to conduct a follow-up study of one led by Monica Morrow, MD, FACS, and published in the Journal of the American College of Surgeons in January 2001.*

Dr. Sisco and colleagues found that although the use of breast reconstruction, both autologous and implant-based, actually increased from 12 to 23 percent between 1998 and 2007, some populations of women still are not undergoing reconstructive procedures at the same rate as others.

To identify factors influencing the use of immediate and early breast reconstruction (within 90 days post-mastectomy), they evaluated data on 396,434 women who underwent mastectomy for invasive breast cancer between 1998 and 2007. Then, they compared two cohorts of patients: 134,479 women who had a mastectomy between 1998 and 2000 to 105,114 women who had a mastectomy between 2005 and 2007.

After accounting for tumor characteristics, they found that overall, women who were not African American; had private insurance; were cared for in an academic medical center; resided in large metropolitan communities; and lived in higher-income areas were up to twice as likely to undergo breast reconstruction during both time periods. Despite the overall increase in utilization, none of these disparities have significantly narrowed over both time periods.

“We are doing better at getting reconstruction to women, which is terrific, but it’s clear that we haven’t done a very good job of narrowing the gap in patients who have lower socioeconomic status or live in smaller communities,” Dr. Sisco observed.

Medical guidelines for breast reconstruction are a work in progress, he explained. The guidelines have changed over the years and future change is certain. “Our study really underscores the importance of continuing efforts to improve access to reconstructive surgery, in part by educating both the providers that it’s safe for women to have immediate post mastectomy breast reconstruction and the patients that breast reconstruction is not considered cosmetic surgery,” said Dr. Sisco._________

NOTE: Both of these studies on postmastectomy breast reconstruction were designated as “Posters of Exceptional Merit” at the ACS Clinical Congress.

Dr. Tzarnas’ co-authors included Wendie Grunberg, DO; R. Barrett Noone, MD, FACS; Andres Mascaro, MD; Azra Ashraf, MD; and Emilia Diego, MD. Dr. Tzarnas’ study was not funded and the data analyzed was obtained from medical records.

Dr. Sisco’s co-authors included Hongyan Du, MS; Karol A. Gutowski, MD; David H. Song, MD, FACS; David J. Winchester, MD, FACS; Kathy Yao, MD, FACS; Jeremy P. Warner, MD; and Michael A. Howard, MD. The study was supported by data provided by the division of plastic surgery, NorthShore University HealthSystem and by the American College of Surgeons National Cancer Database access site.

*Morrow, M et al. “Factors influencing the use of breast reconstruction postmastectomy: a national cancer databgase study.” J Am Coll Surg. 2011 Jan:1-8.