For Breast Reconstruction, General Surgeons Don't Ask, Don't Tell

ANN ARBOR, Mich., March 28 -- Reconstruction often gets short shrift from general surgeons treating breast cancer, according to researchers here.

Only about a quarter of general surgeons refer most of their breast cancer patients for a reconstructive surgery consultation at the time of treatment planning, Amy K. Alderman, M.D., M.P.H., a plastic surgeon, and colleagues, reported online in advance of the May 1 issue of Cancer.

A minority of women who are eligible for reconstructive breast surgery undergo the procedure, and it may be because their surgeons never offered them the option, they said.

The surgeons most likely to refer women for plastic surgery consultations were women, high-volume surgeons, and those working in cancer centers, the authors found.

"Our results have important implications for patient care and policy," they wrote. "Prior research suggests that low rates of breast reconstruction reflect unmet need, especially in vulnerable populations. Our findings indicate that there are systematic differences among surgeons with regard to referral to plastic surgeons prior to surgical decisions for patients with breast cancer."

They recommended broader use of patient decision aids that include information about reconstruction as an option. Alternatively, a multidisciplinary approach involving clinicians in different specialties could help to improve patient understanding of surgical options, the investigators wrote.

The investigators surveyed 2,645 women with breast cancer and their surgeons in the Detroit and Los Angeles Metropolitan areas from late 2001 to early 2003. All patients with ductal carcinoma in situ, and about 20% of randomly selected women with invasive non-metastatic breast cancer were accrued into the study, and their surgeons were identified by pathology reports.

The authors surveyed a total of 456 attending general surgeons, and got an 80% response rate. The dependent variable in the survey was each surgeon's report of the percentage of their mastectomy patients they had referred to plastic surgeons before cancer surgery over the past two years. They called this variable the "referral propensity."

Surgeons were classified into one of three categories by their referral propensity - less than 25% of their patients, 25% to 75%, and more than 75%. The authors also performed logistic regression, controlling for Surveillance, Epidemiology, and End Results (SEER) registry, number of years in clinical practice, surgeons' gender, annual breast surgery volume, and hospital setting.

They found that only 24% of surgeons referred more than 75% of their patients to plastic surgeons before cancer surgery. Those who were most likely to make the referral were women (odds ratio, 2.3, 95% confidence interval, 1.09-4.84, P=0.03), surgeons with high clinical breast surgery volume (odds ratio 4.08, 95% CI, 1.76-9.42, P<0.01), and those who work at cancer centers (odds ratio 2.41, 95% CI, 1.16-5.04, P=0.01).

They noted that surgeon beliefs about patients' preference differed according to practice volume, with low-referral propensity surgeons saying that patients had more barriers to plastic surgery access (cost and availability in the area), and that patients had a lower priority for reconstruction.

"Our observation that, compared with higher referral surgeons, low-referral surgeons were more likely to perceive that low patient knowledge was a reason they did not receive reconstruction suggests that patient education level and/or resources devoted to patient education may be lower in their practices," the investigators wrote.

"The finding that low-referral surgeons were more likely to believe that women were more focused on other cancer treatments than reconstruction suggests that resources devoted to coordination of treatment may be more limited in these practices," they continued. "By contrast, there were no differences across surgeons in beliefs about the role of patient desire in the receipt of reconstruction. This suggests that patient interest in reconstruction may be similar across surgeon practices."

Their findings argue for more widespread use of multidisciplinary cancer centers that facilitate referrals between specialties, and for the concentration of surgery in high-volume cancer centers, the authors suggested.