Women who undergo mastectomy for breast cancer are now offered reconstruction in line with national guidelines but the majority decline: A UK teaching hospital experience

1. Introduction

Breast cancer is the most common form of cancer in the United Kingdom (UK) with approximately one in eight women being diagnosed in their lifetime [1]. Despite advances in breast-conserving surgery, mastectomy remains a commonly performed operation. Among women who have been treated in English National Health Service (NHS) hospitals, around two thirds will retain their breast four years following diagnosis [2]. The psychological impact on women who undergo mastectomy is well described in the literature. The loss of a breast can negatively impact satisfaction with appearance, as well as emotional and sexual well-being [3]. Numerous reconstruction options are available to women who undergo mastectomy and recent studies have indicated that older women are not necessarily at higher risk of complications [4]. As such, the National Institute for Health and Care Excellence (NICE) recommends that all women who undergo mastectomy for early or locally advanced breast cancer, including those who require radiotherapy, should be offered reconstruction unless they have significant co-morbidities, whether this service is available locally or not [5]. Despite this, gross inequalities in access to reconstruction have been demonstrated [6,7].

The primary aim of this study was to calculate what proportion of breast cancer patients were offered reconstruction following mastectomy, and to assess whether our unit complied with NICE guidelines (as described above). Until recently, reconstruction was not offered at our unit at all. The secondary aim was to evaluate why women were not offered reconstruction and to assess whether the rationale behind this was appropriate.

2. Methods

This is a retrospective review of all patients who underwent mastectomy at University Hospitals Plymouth NHS Trust, UK, between September 2018 and November 2019. Data was collected from a prospectively maintained database. Missing information was obtained from electronic patient records. The study was approved by a local institutional review board and followed local protocols. This study was performed in accordance with the ethical standards laid down by the Declaration of Helsinki.

In November 2019, the following details were collected: age at time of operation, site of surgery, whether the lesion was screen-detected, type of cancer, size of tumour, indication for surgery, type of axillary surgery performed, and final histology. Cases where mastectomy was performed as part of treatment for cancer were then identified (i.e. cases where mastectomy was performed for risk reduction or for symmetry were excluded). Outpatient clinic letters were then used to identify whether or not patients were offered reconstruction and whether or not they accepted. If a patient was not offered reconstruction, then the reasoning behind this was recorded.

Categorical data are presented as frequency counts and associated percentages; comparisons were made using Student’s t-test and Fisher’s exact test. Continuous data are presented as medians and range. A p-value less than 0.05 was considered statistically significant. Statistical analyses were performed using Microsoft Excel and Graphpad.com.

3. Results

During the study period, 201 mastectomies were performed on 179 patients (left: 111, right: 90, bilateral: 22, left only: 89, right only: 68). Median patient age was 62 years (range 33–88). Patient demographics and operation details are presented in Table 1. A screen-detected lesion was the indication for surgery in 46 cases (22.9%). There was a diagnosis of invasive cancer in 120 cases (59.7%). Median tumour size was 27.5 mm (range 3–120). Ninety-five tumours (55.2%) were unifocal and 77 (44.8%) were multifocal. Sentinel lymph node biopsy was performed in 145 cases (72.1%) and axillary node clearance was performed in 45 cases (22.4%). The most common indications for mastectomy over wide local excision were: patient preference (30.8%), size of lesion relative to breast (22.4%), multicentric nature of disease (19.9%), and risk reduction (10.9%) (Table 2).

A total of 179 mastectomies were performed on 165 patients as part of treatment for breast cancer. Four patients had already undergone contra-lateral mastectomy and three were lost to follow-up. One hundred and twenty five of 158 patients (79.1%) were offered breast reconstruction surgery. The most common reasons reconstruction was not offered included: deemed too frail following surgeon assessment (29.7%), advanced cancer (16.2%), and deemed high-risk following anaesthetist assessment (16.2%) (Table 3). All patients, bar one, who were not offered reconstruction, had an ASA grade of III or above. Fourteen patients underwent mastectomy for ductal carcinoma in-situ (DCIS) only. Thirteen (92.9%) of these were offered immediate reconstruction.

Of those who were offered reconstruction, 83 (57.2%) declined (Table 4). Mean age in those who accepted reconstruction was 52.9 years and mean age in those who declined was 64.4 years. This difference was highly significant (P < 0.01). Mean tumour diameter was 5.3 mm larger in those who accepted reconstruction (P = 0.17).

Almost a third of patients in this study elected to undergo mastectomy and chose this treatment option over breast-conserving surgery. This figure varies considerably between studies and the reasons behind this are multifactorial [8]. Gu et al. who performed a systematic review, found that the proportion of patients electing for mastectomy over breast-conserving surgery can be as high as 77.6% and as low as 25.0% [9–11]. Larger tumour size and increased cancer stage were found to be associated with increased mastectomy rates [9]. In addition, old and young extremes of diagnostic age, and reduced local availability of immediate reconstruction were found to be associated with increased mastectomy rates [9]. Higher socio-economic status, short distance to location of radiotherapy, and female surgeon were among the factors associated with higher rate of breast-conserving therapy [9]. Diagnostic and treatment improvements in recent years have increased long term breast cancer survival rates to almost 90.0% [12]. As breast cancer survival increases, particularly in the developed world, the focus of therapy has shifted to include patient quality of life following treatment [12]. In Canada, where guidelines on offering reconstruction following mastectomy are similar to that of the UK, it is thought reconstruction rates are between 2.7% and 18.5% [12].

The number of women electing to undergo breast reconstruction following mastectomy is on the rise [12]. This trend is apparent in both developed and developing countries [12,13]. There are usually three main considerations in the decision-making process: medical, sexual, and physical. Medical concerns include recovery time and risk of post-operative complications, sexual concerns include how a woman may feel a mastectomy will impact on future sexual encounters, and physical concerns include the impact of a breast on femininity and sense of self [13]. Prior studies have suggested that women are more likely to consider reconstruction if they are younger, live in an urban area, and have a higher income [13]. Post-mastectomy immediate breast-reconstruction continues to experience an upward trend. The fastest-rate of growth has been observed in the over 65 age group. This is due to increased patient awareness, advances in reconstruction methods, reports of improved patient outcomes, and a change in the pattern of mastectomies being performed [13]. In the present study, almost 80% of women who underwent mastectomy for cancer were offered reconstruction. These patients were all discussed at a weekly multi-disciplinary reconstruction team meeting which included breast surgeons, a plastic surgeon, breast care nurses, and an oncology specialist nurse. The pros and cons of each reconstructive option in each individual case will have been discussed prior to a consultation with each patient. Fifty-four patients (94.7%) underwent prepectoral implant reconstruction, two (3.5%) underwent Goldilocks procedure and one patient (1.8%) underwent deep inferior epigastric perforator (DIEP) flap surgery.

Patients who were not offered reconstruction included those who were deemed too frail following surgeon assessment, deemed high-risk following anaesthetist assessment, those who had already undergone contra-lateral mastectomy and hence did not wish to be considered, and those who required ongoing cancer treatment and hence were not eligible for immediate reconstruction. No patients who expressed an interest in immediate reconstruction were denied this option and so our unit now complies with NICE guidelines.

The majority of patients who were offered reconstruction following mastectomy for breast cancer declined. This was unexpected. The reasons behind this are unknown as investigating this was not part of the original study design. Mean age in those who declined reconstruction was significantly higher than in those who accepted. This is in keeping with the findings of prior studies from both developed and developing countries [13–15]. Women who accepted reconstruction also had larger mean tumour size. A follow-on questionnaire is proposed to investigate why such a high proportion of women who are being offered reconstruction are declining this option. Having this information will allow us to ensure we are counselling women appropriately and providing all the information they require in order to make an informed decision which takes their own individual interests in to account. Shameem et al, who interviewed Malaysian women who were offered reconstruction following mastectomy, found the most common reason women declined was fear of further surgery and associated complications [15]. Time to completion of therapy and need to travel to location of therapy were not deemed important factors [15]. Women who underwent reconstruction in this study were more likely to be married. However, women did not opt for reconstruction with the view that it would positively impact on their marriage or sexual relations [15].

Whilst breast cancer is often considered a disease of the developed world, almost half of all new diagnoses and over half of all breast cancer deaths now occur in developing countries [16]. With both population and life expectancy increasing in developing countries at a faster rate, and the continued “westernisation” of developed countries, this proportion is set to increase [17]. This emerging epidemic will provide its own challenges. Developing countries typically lack the infrastructure and resources required to provide a robust screening service. As such, patients are more often diagnosed at a late stage and will often be offered palliative therapy rather than treatment with curative intent [15]. Indeed, two thirds of women diagnosed with breast cancer in Nigeria present at a stage where therapy offers minimal benefit [14]. Since patients will typically present later, breast-conserving therapy is less often suitable. Therefore, women in developed countries who undergo surgery for breast cancer are more likely to undergo mastectomy. Despite limited resources, immediate reconstruction is not uncommon in the developed world. In a Malaysian study, Shameem et al. found that over a third of women who underwent mastectomy were offered immediate reconstruction [15]. In Nigeria, where the number of oncoplastic breast surgeons in low and the workload is heavy, it is thought educating women on breast reconstructive options will encourage earlier presentation and improve overall prognosis [14].

Whilst I feel I have come to reasonable conclusions, I accept that this study has limitations. This is an audit study, and the standard of care was that all patients be offered reconstruction unless they have significant co-morbidities. I accept that the use of the word “significant” is ambiguous and open to interpretation in this context.

5. Conclusion

In this case series, almost 80% of women were offered reconstruction following mastectomy for invasive breast cancer and over 90% were offered reconstruction following mastectomy for DCIS. A majority of patients declined immediate reconstruction; a follow-on questionnaire is proposed to explore the reasoning behind this. All patients should receive education about breast reconstruction as soon as surgical treatment is proposed.

Disclosure statement

Thomas B Russell reports no conflicts of interest.

Funding

Nil.