A Paradigm Shift in U.S. Breast Reconstruction : Part 2. The Influence of Changing Mastectomy Patterns on Reconstructive Rate and Method

Despite its benefits in body image, self-esteem, sexuality, and quality of life, historically fewer than 25 percent of patients undergo immediate breast reconstruction. After passage of the Women Health and Cancer Rights Act, studies failed to demonstrate changes in reconstructive rates. A recent single-year report suggests significant shifts in U.S. breast reconstruction patterns. The authors' goal was to assess long-term trends in rates and types of immediate reconstruction. A serial cross-sectional study of immediate breast reconstruction trends was performed using the Nationwide Inpatient Sample database from 1998 to 2008. Data on mastectomies, reconstructive method (autologous/implant), and sociodemographic/hospital predictors were obtained. Immediate breast reconstruction rates increased on average 5 percent per year, from 20.8 percent to 37.8 percent (p < 0.01). Autologous reconstruction rates were unchanged. Implant use increased by an average of 11 percent per year (p < 0.01), surpassing autologous methods as the leading reconstructive modality after 2002. The strongest predictors of implant use were procedures performed after 2002, bilateral mastectomies, patients operated on in Midwest/West regions, and Medicare recipients. In contrast to bilateral mastectomies, which increased by 17 percent per year (p < 0.01), unilateral mastectomies decreased by 2 percent per year (p < 0.01). Bilateral mastectomy defects had significantly higher reconstruction rates than unilateral counterparts (p < 0.01). The significant rise in immediate reconstruction rates in the United States correlates closely to a 203 percent expansion in implant use. Although the reason for the increase in implant use is multifactorial, changes in mastectomy patterns, such as increased use of bilateral mastectomies, are one important contributor.

Many patients with unilateral breast cancer choose contralateral prophylactic mastectomy to prevent cancer in the opposite breast. The purpose of our study was to determine the use and trends of contralateral prophylactic mastectomy in the United States. We used the Surveillance, Epidemiology and End Results database to review the treatment of patients with unilateral breast cancer diagnosed from 1998 through 2003. We determined the rate of contralateral prophylactic mastectomy as a proportion of all surgically treated patients and as a proportion of all mastectomies. We identified 152,755 patients with stage I, II, or III breast cancer; 4,969 patients chose contralateral prophylactic mastectomy. The rate was 3.3% for all surgically treated patients; 7.7%, for patients undergoing mastectomy. The overall rate significantly increased from 1.8% in 1998 to 4.5% in 2003. Likewise, the contralateral prophylactic mastectomy rate for patients undergoing mastectomy significantly increased from 4.2% in 1998 to 11.0% in 2003. These increased rates applied to all cancer stages and continued to the end of our study period. Young patient age, non-Hispanic white race, lobular histology, and previous cancer diagnosis were associated with significantly higher rates. Large tumor size was associated with a higher overall rate, but with a lower rate for patients undergoing mastectomy. The use of contralateral prophylactic mastectomy in the United States more than doubled within the recent 6-year period of our study. Prospective studies are needed to understand the decision-making processes that have led to more aggressive breast cancer surgery.

To determine whether increasing rates of contralateral prophylactic mastectomy (CPM) are due to recognition of risk factors for contralateral breast cancer (CBC) or treatment factors related to the index lesion. From 1997 to 2005, 2,965 patients with stage 0 to III primary unilateral breast cancer underwent mastectomy at Memorial Sloan-Kettering Cancer Center. Patients who did and did not undergo CPM within 1 year of treatment for their index cancer were compared to identify independent predictors of CPM. The rate of CPM was 13.8% (n = 407), increasing from 6.7% in 1997 to 24.2% in 2005 (P < .0001). Patients with BRCA mutations or prior mantle radiation (n = 52) accounted for 13% of those having CPM. The rate of CPM by surgeon varied from 1% to 26%. Multivariate logistic regression adjusting for surgeon-identified white race (odds ratio [OR] = 3.3), immediate reconstruction (OR = 3.3), family history of breast cancer (OR = 2.9), magnetic resonance imaging (MRI) at diagnosis (OR = 2.8), age younger than 50 years (OR = 2.2), noninvasive histology (OR = 1.8), and prior attempt at breast conversation (OR = 1.7) to be independent predictors of CPM. These data suggest that increasing use of CPM is not associated with increased recognition of patients at high risk for CBC. Treatment factors, such as immediate reconstruction, preoperative MRI, and unsuccessful attempts at breast conservation, are associated with increased rates of CPM. Efforts to optimize breast conservation, minimize unnecessary tests, and improve patient education about the low risk of CBC may help to curb this trend.