Physicians may be obstacles to breast reconstruction

Significant differences in plastic surgery referral practices by general surgeons treating newly diagnosed breast cancer patients partially explain the low rates of breast reconstructive surgery in the United States, according to a new study.

Published in the May 1, 2007 issue of CANCER, a peer-reviewed journal of the American Cancer Society, the study suggests that only one quarter of general surgeons refer most breast cancer patients for a reconstruction consultation at the time of treatment planning.

Despite the fact that insurance covers the procedure, only 16 percent of breast cancer patients treated with a mastectomy receive breast reconstruction in the US. Studies have shown that age and race predict low rates of this reconstructive procedure. However, studies also suggest that healthcare providers have an impact on utilization through their referral and information sharing practices.

Dr. Amy Alderman from the University of Michigan in Ann Arbor and co-investigators surveyed 456 general surgeons in Detroit and Los Angeles who treat breast cancer patients. Their objective was to analytically describe physician and clinical practice characteristics and their plastic surgery referral patterns in the context of women eligible for mastectomy.

They found that nearly half (44 percent) of surgeons referred less than 25 percent of their eligible patients for a reconstruction consult and only about one in four (24 percent) referred more than 75 percent of patients to a plastic surgeon. Female surgeons, those who performed more than 50 surgeries per year, and those whose clinical practices were located in cancer centers were more likely to refer a high proportion of eligible patients.

There were also significant differences in the attitudes of high- versus low-referral surgeons. Low referral surgeons identified inadequate patient knowledge, high cost, and unavailability of plastic surgeons as reasons for not referring patients for a plastic surgeon consult. Interestingly, low-referral surgeons also noted that breast reconstruction was of little concern to breast cancer patients compared to other aspects of their breast cancer management.

Dr. Alderman and co-authors conclude that "there are systematic differences among surgeons with regard to referral to plastic surgeons prior to surgical decisions for breast cancer. The most significant barrier , to co-management may exist especially in smaller surgeon practices, which may have a more challenging patient mix and limited resources."