US breast reconstruction trends highlighted

The number of women undergoing breast reconstruction immediately after mastectomy has increased in recent years in the USA, with implant use being the most common approach, research shows.

Although the reason for the increase in implant use is multifactorial, changes in mastectomy patterns, such as an increased use of bilateral mastectomies, are important contributors, write Evan Matros (Memorial Sloan-Kettering Cancer Center, New York, USA) and team.

The researchers believe that the trend toward immediate reconstruction and implant use signals a paradigm shift in breast reconstruction after mastectomy in the USA.

The serial cross-sectional study of 178,603 total mastectomies registered in the Nationwide Inpatient Sample database from 1998-2008 revealed that 51,410 immediate breast reconstructions were performed. Immediate breast reconstruction rates increased significantly by an average of 5.0% each year, from 20.8% in 1998 to 37.8% in 2008.

The rate of autologous breast reconstruction remained unchanged. However, the use of implants rose significantly by an average 11% each year, surpassing autologous reconstruction as the most common reconstructive technique after 2002.

The strongest predictors for implant use included having a procedure performed between 2003 and 2008, during which time the odds ratio for having an implant increased from 1.41 to 2.26 compared with in 1998.

Having bilateral mastectomies, being operated on in the Midwest/West regions of the USA, and being a Medicare recipient were also strong predictors for implant use, at respective odds ratios of 1.86, 1.22/1.52, and 1.45, compared with unilateral mastectomies, patients operated on in the Northeast, and non Medicare recipients.

In contrast to bilateral mastectomies, which increased significantly by 17% each year, unilateral mastectomies decreased significantly by 2% each year. Bilateral mastectomy defects had significantly higher reconstruction rates than unilateral ones.

The authors say that as well as the increase in bilateral mastectomy rates, another contributor to the rising level of immediate implant reconstruction may have been the 1998 Women's Health and Cancer Rights Act. This Act ensures coverage for breast reconstruction after mastectomy.

Although it is difficult to prove a direct causal effect of this Act, "the steady increase in reconstruction rates since its introduction is suggestive," say Matros and colleagues.

"More information is needed about patient and physician decision making to more comprehensively understand contemporary preferences," they conclude in Plastic and Reconstructive Surgery.

In a related commentary, Alexander Nguyen and David Chang, both from the University of Texas MD Anderson Cancer Center in Houston, USA, add: "Patient education about breast cancer reconstructive options is essential and should be led by the field of plastic surgery."

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