What are the factors that determine whether a woman chooses to have her breast reconstructed or not? And what about the type of reconstruction that a woman chooses?
Obviously, there are multiple issues here. Patient choice, cancer-related issues, family & lifestyle issues, and without a doubt, the inclination of certain surgeons. The question then is, do we need to do more to ensure that patients who want a reconstruction are offered one?
A lot of this argument appears to be theoretical and is often waged (ostensibly on behalf of their patients) by well-meaning clinicians. There are many studies suggesting that women who have a breast reconstruction do “better”: they have better psychological and sexual recovery & they have better quality of life. But is that really true? There are also ample studies to suggest that women who choose not to have a reconstruction (for whatever reason), do just as well with respect to these parameters as those patients who do undergo reconstruction. Whatever the case, the choice to have a reconstruction or not is an intensely personal one.
The actual rates of breast reconstruction (amongst those patients who have had a mastectomy) are wildly variable.
The general literature suggest only between 5-30% of patients have their breast reconstructed. Other studies however from high volume, specialist cancer centres report reconstructive rates between 50-80%.
Obviously there is a huge difference here, and I do wonder ultimately what are the factors responsible for such a discrepancy?
Available data for Australian patients is not perfect, but the most recent (which, unfortunately is only based on 2008 data) report from the Royal Australasian College of Surgeons would suggest that after mastectomy, only 13% of private patients and 6% of public patients receive immediate breast reconstruction. This may be either implant-based or autologous (the report does not differentiate, and such information is very difficult to come by) which would suggest that the number of women who are receiving DIEP flap reconstructions is tiny as a proportion. Much of the data available on this subject would seem to indicate that women are either not offered breast reconstruction, or the options offered to them are severely restricted based on surgeon biases or a perceived lack of availability of expert reconstructive services.
Mr David Pennington, a very experienced Consultant Plastic Surgeon in Sydney has written eloquently on this topic and he highlights a very important issue, which I have seen both in the UK and also at home: the only discussion that many patients have regarding their reconstructive options is with the breast surgeon, or surgical oncologist. The problem with this is that (as Pennington has written), when the breast surgeon who will perform the mastectomy, may only “have a limited armamentarium of reconstructive options…. (he or she) might persuade the patient to undertake a reconstructive procedure that is suboptimal, simply because it is convenient”. Meaning that, of that very small proportion of women who actually have their breast reconstructed, many may not be made aware of their options to discuss breast reconstruction with a Plastic Surgeon. Which seems a pity, really.