Most Women Delay Breast Reconstruction
Researchers found that immediate breast reconstruction, surgery to rebuild the breast done at the same time as mastectomy, is most likely to be used by young women in big cities who have private insurance and few chronic medical problems. Overall though, more women do NOT have their breasts rebuilt at that time.
Background and Goals
Immediate breast reconstruction can improve a woman’s body image. Yet only about a fourth to a third of women who have a mastectomy have reconstruction at the same time as mastectomy.
Studies have looked at why certain groups of people are more or less likely to have reconstruction, but most did not focus on immediate breast reconstruction, and most came before the Women’s Health and Cancer Rights Act of 1998. The act requires health insurance to cover breast reconstruction after mastectomy.
This study focused on immediate breast reconstruction and looked at women who had a mastectomy after the act came into effect. The goal was to get as complete a picture as possible of differences in how people from different economic, ethnic and geographic backgrounds get immediate reconstruction.
Researchers used the Nationwide Inpatient Sample (NIS) database from the Healthcare Cost and Utilization Project, which contains information from 1,000 hospitals in 42 states. They found 14,764 women who had a mastectomy in the U.S. in 2008 and divided them into three groups:
- No immediate reconstruction (NR)
- Immediate breast implant reconstruction (TE), which involves a device filled with salt water or silicone gel. A tissue expander may be used to stretch the skin to make room for the implant.
- Immediate “flap” or autologous reconstruction (FLAP), in which a breast is created using tissue from your own body
They also looked at other factors, including age, race, median income by zip code and insurance type. Reconstruction was considered immediate if it happened during the same hospital stay as the mastectomy.
Most of the women did not receive immediate reconstruction. Women who did get immediate reconstruction were more likely to live in a big city and be young and privately insured, with fewer chronic health problems.
- 63.9 percent of women had NR, 23.9 percent had TE and 12.2 percent had FLAP.
- The median age was 64.9 for the NR group, 51.3 for the TE group and 51.1 for the FLAP group.
- The median number of additional chronic, non-cancer health problems was 3.8 in the NR group, 2.6 in the TE group and 2.54 in the FLAP group.
- Of the NR group, 51.4 percent used Medicare and 8.7 percent used Medicaid. Of the TE group, 12.8 percent used Medicare and 4.2 percent used Medicaid. Of the FLAP group, 9 percent used Medicare and 4.9 percent used Medicaid.
- 35.2 percent of the NR group, 80.1 percent of the TE group and 81.1 percent of the FLAP group had private insurance.
When comparing the two types of reconstruction,
- Significantly more women from the lowest income group had FLAP reconstruction. Women in the mid-level income groups didn’t show a significant use of one over the other. Significantly more women in the highest income group had TE.
- Women who had Medicare were significantly more likely to get TE. Women who had Medicaid and women who had private insurance didn’t show a significant use of one over the other.
- White women were more likely to get TE than FLAP. Black women were more likely to get FLAP than TE.
Researchers do not know how many of the women who didn’t get immediate reconstruction went on to have reconstruction later. They also did not have information about the type of cancer or tumors, or about the women’s values or decision-making processes. It is not known if all the women were aware of the different reconstruction options available to them.
What This Means for You
You may feel comfortable leaving your breast as it is after a mastectomy. Or you might choose to use a prosthesis, a device that can be worn under your clothes to create a natural look. Or you could choose to have breast reconstruction surgery. Your doctor should talk to you about all of these options.
It’s important to think about and look into reconstruction before you have surgery, so that you can decide if you want surgery right away or not. Immediate breast reconstruction allows you to get both surgeries over with at once and lets you avoid seeing the empty space where your removed breast was. But delayed reconstruction allows you to make one big decision at a time and recover from one surgery before having another. It’s also the suggested choice if you are planning to have radiation or chemotherapy, since those treatments can affect the reconstructed breast. If you do decide to have surgery, you have still more choices: Ask your doctor about implant versus flap reconstruction.
Your personal preferences will play a big role in what you decide to do after a mastectomy. But your age, income, race or location shouldn’t limit your options. If you feel that your doctor is not telling you everything you need to know about reconstruction, bring it up yourself or consider getting a second opinion.
Wexelman, Barbara; Schwartz, Jamie A.; Lee, David. Socioeconomic and Geographic Differences in Immediate Reconstruction after Mastectomy in the United States. The Breast Journal. Volume 20, Issue 4, pages 339–346, July/August 2014; doi: 10.1111/tbj.12274.