2011 SABCS, San Antonio Breast Cancer Symposium, 6-10 December, San Antonio, USA

Effects of breast reconstructive surgery after mastectomy

Dr Dawn Hershman – Columbia University Medical Center, New York, NY

Just as a bit of background, immediate breast cancer reconstruction after mastectomy is known to improve psychological health, self-esteem and body image. It’s been found to be safe and not interfere with breast cancer recurrence either locally or systemically. In 1998, as a result of this, the Women’s Health and Cancer Rights Act was passed that mandated that health insurance and HMOs that covered the cost of mastectomy must also cover the cost of reconstruction.

We used Premier prospective database, which is a hospital based database, commercial, that covers about 15% of US hospitals. We found that in terms of women with breast cancer, we found 108,000 women that underwent mastectomy and 14,000 women with DCIS that underwent mastectomy between the years of 2000 and 2010. We identified women that had simple, radical or skin-sparing mastectomy based on ICD9 and billing codes, and reconstruction was defined as a flap implant tissue expander during the same hospitalisation as their mastectomy. In terms of the patient characteristics, of the patients with invasive breast cancer over this ten year period, 23.4% underwent immediate reconstruction. Of patients with ductal carcinoma in situ, 36.4% of the women underwent immediate reconstruction. You can see that, when stratified by age, women under the age of 50 41.8% underwent reconstruction and over 50 16.5% underwent reconstruction. And then looking at it by insurance status, you can see a wide variability with 7% of women with Medicare, 16% with Medicaid and 37% with commercial insurance.

When you look at annual rates of immediate reconstruction over this ten year period, you can see that for women over the age of 70 the rates are low and remain constant over this period of time. When you look at women under the age of 40 and between 40 and 49, the rates are pretty similar, they’re the highest rates and they increased incrementally over time. With each subsequent age decade they also increased but the rates were lower as age increased. When you look at the annual rates of immediate reconstruction by race you can see that Caucasian women have a higher rate of immediate reconstruction than African-American women and, while both increased over time, it does appear that the differences between them may be coming together by 2010.

We looked at the influence of insurance and, if you look at either self-pay, Medicare or Medicaid, you can see that the rates have increased over time but at a pretty modest rate. When you look at patients that have commercial insurance you can see that the rates have increased quite substantially over time showing that the influence of commercial insurance on rates of immediate reconstruction have increased with a significant test for interaction at a p 1.002.

We also looked at the hospital costs associated with reconstruction. The hospital costs associated with mastectomy alone have been relatively constant over time while hospital costs of either implant or flap reconstruction have increased substantially, almost threefold over this ten year period.

We did a multi-variant analysis to control for factors that may be influencing or confounding the relationships that we saw. In terms of the age relationship, we saw consistently that younger age was associated with increased likelihood and older age associated with a decreased likelihood of undergoing immediate reconstruction. With regard to race, you could see an odds ratio of 0.66 associated with African-American race and a lower likelihood of undergoing immediate reconstruction.

With regard to commercial insurance we saw close to a threefold increase in likelihood of undergoing immediate reconstruction in patients that had commercial insurance. We looked at hospital related factors – patients seen at urban hospitals had half the likelihood of undergoing reconstruction; patients seen at non-teaching hospitals had an increased likelihood; the higher the bed size of the hospital, the higher the likelihood of undergoing reconstruction; the higher the hospital volume of mastectomies, the higher the likelihood of reconstruction and the higher the surgeon volume, the higher the likelihood of undergoing reconstruction.

We found identical odds ratios for predictors of immediate reconstruction in women with invasive cancer and ductal carcinoma in situ. However, we did find that the odds ratios for commercial insurance do differ by age, those less than 50 had a stronger relationship than those over 50. We also looked at hospital complications and found similar rates between mastectomy and immediate reconstruction; we looked at length of stay and found similar rates between mastectomy and implant with longer length of stay with flap reconstruction.

So, in summary, the immediate reconstruction rates are higher in women with ductal carcinoma in situ than invasive cancer. Since the Women’s Health and Cancer Rights Act immediate reconstruction rates have increased over time, however, they are strongly associated with the presence of commercial insurance. The association between immediate reconstruction and commercial insurance is strongest in younger women and the costs of mastectomy have been stable, however, the costs of immediate reconstruction have increased nearly threefold over this decade.

This has implications for public policy. Young women may be most vulnerable to the impact of insurance; women should be informed about and have access to immediate reconstruction before receiving mastectomy. The Women’s Health and Cancer Rights Act may be expanded to increase access to immediate reconstruction for women with all types of insurance and having any health insurance may not be enough to influence quality of care if reimbursement rates differ between health insurance plans.

Thank you.