Most General Surgeons Do Not Discuss Reconstruction Before Breast Cancer Surgery

Laurie Barclay
December 26, 2007 — Only one third of patients with breast cancer surveyed reported that their general surgeons discussed breast reconstruction with them before surgery, according to the results of a study reported in the December 21 Online First issue of Cancer. When this discussion did precede surgery, it facilitated an informed surgical treatment decision-making process and increased the likelihood that women would choose a mastectomy.

"Reconstruction is rarely incorporated into the decision-making process for surgical breast cancer treatment," write Amy K. Alderman, MD, MPH, from the University of Michigan Medical Center in Ann Arbor, and colleagues. "All else being equal, the option of breast reconstruction may make mastectomy more appealing to women who strongly value breast preservation. There is virtually no information on whether knowledge of reconstruction before initial surgical treatment choice is associated with an increased propensity to receive mastectomy among women with early stage breast cancer."

Using the Detroit and Los Angeles Surveillance, Epidemiology, and End Results (SEER) cancer registries, the investigators surveyed 1844 women aged 79 years or younger with breast cancer (response rate, 77.4%). Dependent variables were yes-or-no answers to questions of whether patients had a discussion about breast reconstruction with their general surgeon, whether this discussion affected their willingness to be treated with a mastectomy, and whether the patient received a mastectomy. Independent variables were age, race, education, tumor size, tumor behavior, and presence of comorbidities. Statistical analyses included χ² or t test, and logistic regression.

During the surgical decision-making process for their cancer, only one third of patients had a general surgeon discuss breast reconstruction with them. Younger, more educated patients with larger tumors were significantly more likely to report having this discussion with their surgeons.

Being informed of reconstructive options was associated with significantly increased willingness by patients to consider a mastectomy (odds ratio [OR], 2.06; P < .01), and having this discussion also affected actual choice of surgical treatment. Compared with patients who did not discuss reconstruction with their general surgeon, those who did were more than 4 times likely to undergo mastectomy (OR, 4.48; P <.01).

"Most general surgeons do not discuss reconstruction with their breast cancer patients before surgical treatment," the study authors write. "When it occurs, this discussion significantly impacts women's treatment choice, making many more likely to choose mastectomy. This highlights the importance of multidisciplinary care models to facilitate an informed surgical treatment decision-making process."

Limitations of the study include sample restricted to 2 metropolitan areas, limiting generalizability; self-reported outcomes possibly subject to recall bias; inability to determine whether reconstruction discussions were initiated by patients or surgeons; and retrospective design.

"Our findings suggest that the underlying paradigm of informed breast cancer treatment decision-making may need to change to include mastectomy with the option of reconstruction, especially for patients who have clinical contraindications to BCS [breast-conserving surgery], those who express a preference for treatment with mastectomy, and those who are uncertain about their treatment choice," the study authors conclude. "To achieve this shift, general surgeons should consider incorporating discussions of reconstruction or referring patients to plastic surgeons before the patient's surgical decision."

The National Cancer Institute funded this study, and cancer incidence data collection was supported by the California Department of Health Services.

Cancer. Published online December 21, 2007.