Why aren't more women having breast reconstruction? 

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Why aren't more women having breast reconstruction? 

Sue Hadden flatly rejected her physician’s suggestion that she consult with a plastic surgeon prior to her mastectomy. “My reaction was, ‘I want [my breast] off. I don’t want any extra surgery. I just want to get on with my life,’ ” Hadden says, recalling those early days after her 2-centimeter stage 1 tumor was found. “I don’t think of myself as very vain. I think of plastic surgery as something you do when you’re vain.”

 But her oncology surgeon persisted, scheduling an appointment for Hadden. Over the next couple of weeks, the 50-year-old pediatric nurse from Michigan reviewed studies on surgical complications and talked to numerous breast cancer survivors—both those who had opted for and against reconstruction. “I went around and around,” she says. “I really, really struggled with this decision.”

In 2005, Hadden underwent a mastectomy of her left breast, along with immediate reconstruction. More than two years later, she describes the decision as “the right one” for her.

Among mastectomy patients, though, Hadden falls into a distinct minority. Nearly 51,200 women underwent a mastectomy between 1998 and 2002. But fewer than one in five eligible women, or 16.5 percent, chose immediate reconstruction, initiating the procedure within four months, according to data published in 2006 in the Journal of the American Medical Association. The rates also didn’t change significantly from year to year, despite the passage of the Women’s Health and Cancer Rights Act of 1998. The federal law requires insurers, including group plans and individual plans, that cover mastectomy to also pay for reconstruction. State laws may provide additional protections.

The current reconstruction rate preoccupies Amy Alderman, MD, author of the JAMA analysis and several other recent studies on access to breast reconstruction. “Is it because not many women want it?” she asks. “Or, is there an access barrier?” Dr. Alderman, an assistant professor of plastic surgery at the University of Michigan Medical School, performed Hadden’s reconstruction.

Access, if it is an issue, is likely not the only reason relatively few women select reconstruction, according to breast cancer clinicians interviewed. Women who are wrestling with complex treatment decisions may not have the energy to also sift through and select a reconstruction procedure. They may be reluctant to undergo the risks of additional surgery, or the scarring that can be involved. They may not place a particularly high priority on regaining cleavage, or they may worry about cost, despite broader insurance coverage requirements.

I consider reconstruction part of [the woman’s] psychological treatment for this disease. She was born with two breasts. She still can have two breasts.

Still, Lillie Shockney, RN, administrative director of the Johns Hopkins Avon Foundation Breast Center in Baltimore, wonders if too many women dismiss reconstruction without measured consideration. “I commonly hear women say, ‘I don’t want to ask for too much. I just want to live.’ Like they will jinx themselves,” says Shockney, a breast cancer survivor who chose reconstruction 10 years after her breast cancer surgery. “I tell women to look at the long view. How do you want to look and feel a year from now?

“I consider reconstruction part of [the woman’s] psychological treatment for this disease. She was born with two breasts. She still can have two breasts,” says Shockney.

Dr. Alderman’s JAMA analysis, based on National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) data, also revealed other trends, such as disparities among ethnic groups. In 2002, the most recent data analyzed, the immediate reconstruction rate was 11 percent for Hispanic women and 8.5 percent for Asian women compared with 17.7 percent for white women and 18.6 percent for African- American women, according to the study’s results. SEER doesn’t track reconstruction data beyond four months after mastectomy, Dr. Alderman says.

Neither do many surgeons routinely refer breast cancer patients for a plastic surgery consult prior to mastectomy, according to another study of Dr. Alderman’s, published earlier this year in the journal Cancer. Only 24 percent of 342 general surgeons surveyed in Detroit and Los Angeles referred more than 75 percent of their patients prior to surgery. (High referral surgeons were more likely to be female and handle a large number of breast surgery cases, among other factors.) Nearly half—44 percent—referred fewer than 25 percent to a plastic surgeon.

Overall, the general surgeons posed a variety of explanations for why they thought women might not be interested: reconstruction was not important (57 percent); reconstruction would take too long (39 percent); or cost of the procedure concerned them (46 percent). “I don’t think these physicians are bad people,” Dr. Alderman says. But they may not be working in a setting, such as an academic medical center or a multi-disciplinary cancer program, where referrals are easily accomplished, she says.

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