Introduction

Breast reconstruction performed at the time of mastectomy is now widely accepted as safe and effective.[1,2] Although several studies have demonstrated the psychological benefits of breast reconstruction, the Canadian Clinical Practice Guidelines for the Care and Treatment of Breast Cancer (1998) make no reference to breast reconstruction.[3-5]

In order for women to make an informed choice, the option of immediate breast reconstruction should be discussed by the surgeon prior to mastectomy. Women come to UBC Hospital for delayed breast reconstruction from all regions of BC. Many of these women state they were not informed about the option of immediate breast reconstruction prior to their mastectomy.

The purpose of this survey was to determine, first, what options are presented by surgeons and general practitioners to women who require mastectomy, and second, whether the public is aware of the option of immediate breast reconstruction. Breast reconstruction options at present include reconstructing the breast using a breast implant, typically following a period of tissue expansion (alloplastic reconstruction) or by reconstructing the breast using the patient’s own tissues, providing she has a suitable donor site (autogenous reconstruction—TRAM flap from the abdomen or latissimus dorsi flap from the back). These procedures can be done at the time of mastectomy or any time thereafter, providing the patient’s overall health is appropriate.

Skin-sparing mastectomy is a major advantage over delayed reconstruction when a patient chooses autogenous immediate breast reconstruction[6] because it preserves the majority of the natural skin brassiere and thereby reduces visible breast scars while optimizing breast shape. In the majority of cancer the only skin that needs to be removed as part of the mastectomy is the nipple areolar complex and any biopsy scars. The traditional elliptical mastectomy incision is done to allow for a technically easy and thorough removal of the underlying breast. Several studies with acceptably long-term follow-up have shown no increased risk of local recurrence with skin-sparing techniques.[2,7]

The benefits of immediate breast reconstruction include improved psychological well-being, improved aesthetic outcomes, and reduced cost.[3,4] Selection of immediate reconstruction patients is done in consultation with the patient’s surgical oncologist, medical oncologist, and reconstructive surgeon. Although the known need for adjuvant chemotherapy or radiotherapy is not a contraindication to immediate reconstruction, it adds a potential additional complexity and may make the patient better suited for one type of reconstruction than another. The only disadvantage of immediate reconstruction is that some patients expect to retain their natural breast; because they have never lived with a mastectomy deformity, they may be less satisfied than patients who have delayed reconstruction.

Methods

The survey tools for general surgeons and general practitioners were based in part on questionnaires from previous studies.[8-10] The surgeon survey consisted of 21 items. These addressed demographics, referral practices, volume of breast cancer surgery performed, preoperative discussion of reconstruction, criticism/attitude related to breast reconstruction, and patient satisfaction with reconstruction.

The general practitioner survey tool consisted of 24 items. It addressed demographics, referral practices, and knowledge, attitudes, and beliefs related to breast reconstruction.

The general public tool consisted of eight items based on questions frequently asked by women about reconstruction. The public was asked to participate in the survey through three venues: an organization providing service to women (YWCA), a provincial general meeting for teachers, and a breast cancer fundraising event.

The response rates from the surgeons and the general practitioners were 45% and 33% respectively. The number of surveys completed by the general public was 439 in total.

Patterns of referral and experience with breast reconstruction

General surgeons

Sixty-nine percent of the responding surgeons performed more than 10 mastectomies a year. However, of those surgeons, 76% referred fewer than two patients a year for breast reconstruction. Only 16% referred their patients to a plastic surgeon prior to mastectomy. Twenty percent of general surgeon respondents indicated they do not refer their patients for reconstruction at any time.

The most common reasons given by surgeons for not referring patients for immediate reconstruction are given in Table 1.

Fifty-one percent of surgeons initiated the discussion about the option of breast reconstruction, while 8% waited for the patient to broach the subject (Figure 1 [12]).

Of those surgeons initiating the discussion, patient’s age (63%) is more often a deciding factor than the disease stage (36%) (Table 2). Only 14% of the surgeons surveyed discuss reconstruction as a standard part of their consultation with a breast cancer patient, even though 87% said they believed reconstruction is an integral part of the care of a mastectomy patient. Interestingly, 80% of surgeons surveyed would advise a family member or friend to consider breast reconstruction, despite their lack of discussion with the majority of their patients.

Only half (52%) of the responding surgeons reported that they have a working relationship with a plastic surgeon, although 79% have a plastic surgeon working in their community.

General practitioners

Ten percent of the general practitioners had no patients undergo mastectomy surgery. The majority (85%) had between one and 10 women undergo mastectomy surgery over the previous 3 years. Almost half (47%) of the general practitioners did not have any patients undergo breast reconstruction and only 4% state the majority of their mastectomy patients choose to have breast reconstruction.

One-third of general practitioners have never referred their patients to a plastic surgeon for potential breast reconstruction either on a delayed or immediate basis. Only 8% stated their practice was to refer to a plastic surgeon at the same time as the referral to a general surgeon. General practitioners were twice as likely as surgeons to wait for the patient to ask about reconstruction (17% as shown in Figure 2 [13] versus 8% as shown in Figure 1 [12]).

General public

The responses from our general public group indicated that the women surveyed had some knowledge of breast reconstruction before completing the survey. Almost 80% had previously heard about breast reconstruction. A majority (56%) believed that breast reconstruction could be done at the same time or any time following the mastectomy.

Responses to the question about what resources the public currently uses to find information about breast reconstruction and where they intend to go in future for this information varied significantly with the sources. The largest changes in the source for this information came in the use of physicians. Only 6% indicated that they currently seek this type of information from their physicians; however, 89% indicated that in future they would go to their physicians for this information. Six percent indicated that they currently use the Internet to locate this type of information, but 43% indicated they plan to use the Internet in future.

The public group had similar response patterns to the general practitioners when asked to comment on whether reconstruction hides new cancer or delays cancer treatment. Knowledge related to the reconstruction options was also similar to general practitioners, with 75% of respondents from the public group being aware of the option to use the patient’s own tissues for breast reconstruction. We acknowledge that the public groups we surveyed, specifically the teachers and breast cancer fundraising group, were probably more educated than the general public.

Knowledge of options

Half of the surgeons (54%) and three-quarters of the general practitioners (76%) believed their knowledge about breast reconstruction was inadequate.

Sixty percent of surgeons and 73% of the general practitioners expressed a desire for more education regarding breast reconstruction. The majority in both groups agreed that reconstruction does not hide new cancer or that immediate reconstruction does not delay treatment of cancer (73% of surgeons and 88% general practitioners, respectively). The majority of general practitioners realized that there are options other than implant reconstruction, with 73% recognizing the option to use the patient’s own tissue.

Perception of patient satisfaction

Only 5% of surgeons believed that their patients were not satisfied with the results; 39% of the general practitioners had the same belief.

Discussion

Practitioners in the field hear many misconceptions surrounding the appropriateness of immediate breast reconstruction. These factors, as well as the apparent omission of information about breast reconstruction in the Clinical Practice Guidelines for the Care and Treatment of Breast Cancer (1998) prompted the surveys. The survey results provide information and an understanding of the existing knowledge and attitudes about reconstruction.

With the incidence of breast cancer increasing and the mammographic detection of ductal carcinoma in situ occurring more commonly in younger women, many of these women are choosing mastectomy. Women who have the BRCA 1 or 2 gene mutation now have the option to proactively reduce their oncologic risk by having prophylactic mastectomies. Despite the improved outcomes and availability of breast reconstruction in recent years, it is a concern that the majority of women facing mastectomy are never given the option even to discuss the possibility of immediate reconstruction. Most breast reconstruction surgeons do not believe that all patients facing mastectomy are interested in or are suitable candidates for breast reconstruction. However, we believe that women should at least be given the information and opportunity to discuss this option prior to mastectomy.

To date there have been no studies reported in the literature to support the belief that breast reconstruction prevents appropriate surveillance for recurrence of disease, or that it affects disease-free survival or mortality.

Despite the availability of the literature, many practising physicians who see breast cancer patients daily choose not to inform them of this aspect of their care. This was supported strongly in the survey data of general surgeons in the province. Only 14% of those responding discussed breast reconstruction routinely, but 87% thought it was an important part of care for a patient requiring a mastectomy, and 80% would recommend it to a family member or friend. Similarly, many (45%) of these physicians believed that undertaking immediate reconstruction could compromise disease control. The surgeons felt the majority of patients (95%) were satisfied with their reconstructive outcomes. Thirty-nine percent of family practitioners felt their patients were not satisfied due to poor reconstructive outcomes. However, it should be noted that 47% of the responding general practitioners had never had a patient undergo breast reconstruction. Many studies included in the literature show that a significant number of patients and physicians find the outcomes after breast reconstruction to be excellent.[1,11]

All those physicians indicating a desire for further literature were sent a reference list and a review article about breast reconstruction to assist in their education on the subject. The public education issues regarding breast reconstruction will be one of the focal points of a 4-year BC and Yukon breast cancer public education project (“Dialogue on Breast Cancer”). This project is sponsored by the Scotiabank through Vancouver General Hospital, in collaboration with the BC Cancer Agency and the Alliance for Breast Cancer Information and Support BC & Yukon. As well, a web site has recently been created by the Breast Reconstruction Program at the Vancouver General Hospital to provide an information base for both the public and health care communities (www.vanhosp.bc.ca/breastreconstruction [14]). The hope is that the more information physicians have, the more informed they will be when faced with guiding their patients to make these often difficult and complex decisions.

Competing interests

None declared.

Table 1. Surgeons’ reasons not to consider immediate reconstruction.

Table 2. Factors affecting a surgeon’s decision to discuss reconstruction.

Patricia Clugston, MD, FRCSC, FACS, Sheila B. Lamb RN, MSN, Hamish Farrow, MD, FRACS, Paul Oxley, MD, and Robin Watts, MD

Dr Clugston is clinical assistant professor in the Division of Plastic Surgery at the University of British Columbia. Ms Lamb is clinical nurse specialist at the Breast Reconstruction Program, Vancouver General Hospital and adjunct professor at the School of Nursing, UBC. Dr Farrow is a clinical fellow in the Division of Plastic Surgery at UBC. Dr Oxley is a resident in the Division of Plastic Surgery at UBC. At the time of writing, Dr Watts is a medical student at UBC.