Exploring the Effects of Referring General Surgeon's Views on Breast Reconstruction Utilization
Heath Stacey, MD, Michelle Spring, MD, Tara Breslin, MD, MPH, Venkat K. Rao, MD, MBA and Karol A. Gutowski, MD
INTRODUCTION: Breast reconstruction rates remain low at near 5-15% of patients despite the safety and high patient satisfaction of these procedures1. Reasons for this are multifactorial including the attitudes and biases of the referring breast surgeon, as well as patient factors2-4. In this study, our purpose was to explore the attitudes of breast surgeons towards breast reconstruction.
METHODS: We surveyed 369 General Surgeons in Wisconsin with questions about breast surgery and ideas and opinions about breast reconstruction. We received responses from 36% of surgeons surveyed.
RESULTS: Results: 73% of the respondents performed at least some breast surgery and were eligible for the study. For a little over 50% of the general surgeons surveyed, breast surgery made up less than 10% of their practice. Most (88%) of the respondents never performed nipple sparing mastectomies and 51% never performed a skin-sparing mastectomy. A small number of general surgeons also report performing onco-plastic breast procedures (10%). We found that a large number of breast surgeons (40%) do not routinely refer all mastectomy patients for reconstruction. Reasons that breast surgeons cited as having for not referring patients for reconstruction include the likelihood of cancer recurrence, patient co-morbidities, and high care-taker burden. Patient marital status, household income, and patient education had no effect on referral to a plastic surgeon. Reasons reported by respondents for patients not getting reconstruction included patient's refusal, need for radiation therapy, delaying adjuvant oncologic treatment, patient factors, and having no plastic surgeon available locally (Figure 1). Respondents generally felt that there was no one type of breast reconstruction that was aesthetically superior (Tissue expander, TRAM, Latissimus dorsi with implant, free TRAM, free DIEP). Surprisingly, 48% of general surgeons believe that tissue expansion reconstruction has the fewest complications. On subgroup analysis, community-based surgeons believed that TRAM flaps give superior aesthetic results. Additionally, 45% of community-based surgeons considered age to be a factor in referral for breast reconstruction. Community-based surgeons cited difficulty in coordinating a two-person team (30%) and having no plastic surgeons available (20%) as reasons for referring patients post-mastectomy. The differences in responses between breast surgeons from urban and rural counties were also examined (Figure 2).
CONCLUSIONS: Breast reconstruction rates remain low despite the high level of safety and satisfaction that define these procedures. The decision by a patient to undergo breast reconstruction involves many complex factors. As a specialty, we should focus on improving the availability of breast reconstructive surgeons and educating referring surgeons and patients about reconstructive indications and options in order to positively affect the utilization of breast reconstruction.
Figure 1 –Referring breast surgeons cite many reasons that breast reconstruction utilization is low. The number one reason cited is that the patient does not want it. Delaying treatment and need for radiation therapy were also common reasons that patients are not sent to a plastic surgeon.
Figure 2 – Rural breast surgeons were more likely to take into account the patient’s acceptance of the mastectomy and the likelihood of a cancer recurrence when deciding on which patients to refer for breast reconstruction.
REFERENCES:
1. Alderman, A. K., McMahon, L.,Jr, Wilkins, E. G. The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors. Plast. Reconstr. Surg. 111: 695-703; discussion 704-5, 2003.
2. Alderman, A. K., Hawley, S. T., Waljee, J., et al. Correlates of referral practices of general surgeons to plastic surgeons for mastectomy reconstruction. Cancer 109: 1715-1720, 2007.
3. Takahashi, M., Kai, I., Hisata, M., et al. The association between breast surgeons' attitudes toward breast reconstruction and their reconstruction-related information-giving behaviors: A nationwide survey in japan. Plast. Reconstr. Surg. 118: 1507-14; discussion 1515-6, 2006.
4. Wanzel, K. R., Brown, M. H., Anastakis, D. J., et al. Reconstructive breast surgery: Referring physician knowledge and learning needs. Plast. Reconstr. Surg. 110: 1441-50; discussion 1451-4, 2002.