Mastectomy Reconstruction Rates Vary

B O S T O N, Aug. 18, 2000 -- Women diagnosed with breast cancer decide whether or not to have reconstructive surgery after a mastectomy based on a variety factors, from surgical stamina to self-image, but where they live shouldn’t be one of them.

Yet that is exactly what may be happening, according to a Connecticut epidemiologist who looked at patterns of reconstructive surgery across the country and found disturbing regional variations.

Anthony Polednak, an epidemiologist with the Connecticut Department of Public Health, wanted to see how his state compared with other regions across the country.

He analyzed statistics from the nine cancer registries sponsored by the National Cancer Institute, which are located in Detroit, San Francisco, Seattle, Atlanta, and the states Utah, Hawaii, Iowa, New Mexico and Connecticut. Although these areas cover only 15 percent of the country, the registries are thought to be statistically representative of the entire United States.

Polednak’s research examined more than 50,000 women under age 70 who’d had mastectomies from 1988 to 1995, and looked at how likely they were to have undergone reconstructive surgery soon after their operations.

Rates Four Times Higher His results, published in this month’s issue of Plastic and Reconstructive Surgery, found that women in Atlanta and Seattle were as much as four times more likely to undergo reconstructive surgery than women in Utah and Hawaii.

Specifically, only 3.3 percent of Hawaiian women and 4.2 percent of Utah women received the surgery, compared to 16 percent of Atlanta women and 11.4 percent of Seattle women, he reports.

Similarly, around 9 percent of women in Detroit and San Francisco received reconstructive surgery, while only half as many residents of New Mexico and Iowa did.

“There’s a large, geographic variation for patients who had reconstruction,” Polednak says. “I don’t know what the explanation is — whether it’s the attitudes of surgeons or the receptivity of the women themselves. I was surprised the differences were as large as they are.”

His study also found that during this time period, only eight percent of women overall received reconstructive surgery soon after their operation.

More Mastectomies That number may be significantly higher today. Currently, the American Society of Plastic Surgeons (ASPS) in Arlington Heights, Ill., estimates that almost half of all women today are opting for reconstructive surgery immediately after a complete mastectomy.

According to the ASPS, 82,975 women nationwide had reconstructive breast surgery last year, nearly double the amount since 1996.

Still, not every woman has the operation. Some fear the risk of additional surgery time itself, or want to wait until they have time to recover from the cancer itself.

Others simply decide against it, proudly wearing their scars as battle wounds from the fight against cancer.

Many Causes for Variation Breast cancer experts say many reasons may be causing the regional discrepancy, including a lack of experienced plastic surgeons in certain rural areas, some physicians’ resistance to new techniques and their exerting a disproportional influence on patients, as well as economic and personal causes.

Dr. Renato Saltz, an associate professor of plastic surgery at the University of Utah’s teaching hospital in Salt Lake City, thinks that much of the fault lies with his fellow physicians.

He says he was so dismayed when he read the study ranking his state second-to-the-bottom, that he faxed it out to surgeons around the state with a scolding note.

“Throughout the state, many general surgeons are not familiar with the advances in breast reconstruction,” he says. “Some don’t think there are indications for it. Some, I think, ignore it. To me, it’s unacceptable not to offer a woman the choice.”

Utah women’s lack of interest is not to blame, he adds. “Women came in and started demanding it,” he says. “Even guys who didn’t like reconstruction or had prejudice against it started referring patients to us.”

But Dr. Christina Finlayson, director of the University of Colorado’s Breast Cancer center, in Denver, Colo., says that access and desire plays a part as well as doctor’s advice.

“Many women live in rural areas a long ways from a plastic surgeon, and to get excellent reconstructive results, you need to come back for multiple visits,” she says. “Many women are not willing to move to another city for a few months.”

Local Talent The sheer numbers of available talented plastic surgeons could also be such a factor.

In Hawaii, for example, the Plastic Surgery Information Service’s Web site, which offers referrals by state, lists only 20 surgeons, while a state like Connecticut, where nearly twice as many women receive reconstruction, lists 58.

Dr. William C. Wood, chairman of the department of surgery at Emory University School of Medicine in Atlanta, Ga., is proud of Atlanta’s high rating in the study, attributing it to the number of Atlanta-based leaders in the field who have developed many of the new reconstructive techniques.

“It takes good plastic surgeons to do this well,” he agrees. “Places that don’t have really good plastic surgeons don’t have the pressure from their patients to do this.”

Dr. Garry Brody, professor of clinical surgery at University of Southern California in Los Angeles, notes that economic factors may play a role.

Since 1998, federal legislation has required that insurance companies cover reconstructive surgery, but some states may have lacked that mandate when the study was conducted.

All Procedures Show Variation Megan Cooper, editor of Dartmouth College’s Atlas, a publication that looks at variations in medical practices nationwide, says that variations in many types of medical procedures have been found to vary by region.

“We don’t expect anymore to find a lot of conformity in surgical rates,” Cooper says. “What happens likely reflects where you live rather than the best standard practice.”

But whatever the reasons, once women know the full story, they can assess their options.

“This is an example of knowledge being power,” Cooper points out. “If someone says, ‘I wouldn’t recommend breast reconstruction,’ that should set off an alarm in your head, thinking, ‘What would I hear if I lived somewhere where the rate was higher? Maybe I should talk to someone else.’”