BREAST Factors Influencing Incidence and Type of Postmastectomy Breast Reconstruction in an Urban Multidisciplinary Cancer Center Mazen E. Iskandar, M.D. Erez Dayan, M.D. David Lucido, Ph.D. William Samson, M.D. Mark Sultan, M.D. Joseph H. Dayan, M.D. Susan K. Boolbol, M.D. Mark L. Smith, M.D. New York, N.Y.
Background: On January 1, 2011, New York State amended the Public Health Law to ensure that patients receive “information and access to breast reconstruction surgery.” The purposes of this study were to investigate the early impact of this legislation on reconstruction rates and to evaluate the influence of patient variables versus physician variables on the incidence and type of breast reconstruction performed. Methods: A retrospective study was conducted on all patients who underwent mastectomy between January 1, 2010, and December 31, 2011. Reconstruction rates were analyzed in relation to timing of legislation, breast surgeon variables, plastic surgeon faculty status, type of reconstruction, and patient variables. Results: Two hundred fifty-eight patients met inclusion criteria. The overall reconstruction rate was 56.59 percent. There was no statistically significant increase in reconstruction rate after the 2011 legislation (OR, 0.45; p = 0.057). Patients whose breast surgeon was female were more likely to undergo reconstruction (OR, 5.17; p = 0.001). Patients who were Asian (OR, 0.22; p = 0.002), older than 60 years (OR, 0.09; p = 0.001), or had stage 3 and 4 cancer (OR, 0.04; p = 0.03) were less likely to undergo reconstruction. Patients reconstructed by a hospital-employed plastic surgeon were significantly more likely to undergo autologous versus implant reconstruction (OR, 6.85; p = 0.001) and to undergo microsurgical versus nonmicrosurgical autologous reconstruction (78.2 percent versus 0 percent; p = 0.001). Conclusions: Breast surgeon sex and plastic surgeon faculty status were the factors that most affected the rate and type of reconstruction, respectively. Legislation mandating the discussion of breast reconstruction options had no impact on reconstruction rate. (Plast. Reconstr. Surg. 135: 270e, 2015.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.
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ach year in the United States, approximately 100,000 women undergo mastectomy for breast cancer treatment or risk reduction. Breast reconstruction rates across the country vary from 15 to 42 percent according to numerous studies.1–3 This variability has raised concern over whether or not patients are adequately informed of reconstructive options and how to access services. Access to breast reconstruction may be affected by From the Department of Surgery, Divisions of General Surgery, Biostatistics, Plastic Surgery, and Breast Surgery, Beth Israel Medical Center. Received for publication February 19, 2014; accepted July 28, 2014. Abstract presented at the 99th Annual Clinical Congress of the American College of Surgeons, in Washington, D.C., October 6 through 10, 2013. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000888
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numerous factors, including patient factors (e.g., ethnicity, insurance, and age), health system factors (e.g.. access to a multidisciplinary cancer team and reconstructive services), and physician factors (e.g., sex, training, and practice setting). The majority of studies have focused on patient and health system factors affecting breast reconstruction. Little has been written on physician factors, especially plastic surgeon factors, which may impact the rate and type of reconstruction performed. On January 1, 2011, New York State amended Section 1, Section 2803-o of the Public Health Law to ensure that patients are informed of their options for breast reconstruction. The law Disclosure: None of the authors has a financial interest in any of the products or devices mentioned in this article.
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Volume 135, Number 2 • Factors Influencing Breast Reconstruction mandates that hospitals in New York State provide patients written information regarding options for immediate breast reconstruction, insurance coverage for breast reconstruction, and how to access a plastic surgeon before undergoing a mastectomy. The effect of this law on reconstruction rates has not been evaluated. Of note, the law did not provide specific information for providers to share with patients regarding reconstructive options; rather, it only mandated that patients be informed of the options. How individual physicians portray these options may impact a patient’s decision to pursue breast reconstruction and the type of reconstruction chosen. The goal of this study was to evaluate the impact of this legislation on reconstruction rate and to identify physician factors that might also impact the rate and type of reconstruction performed.
PATIENTS AND METHODS Institutional review board approval was obtained and a retrospective chart review was performed of patients treated with mastectomy between January 1, 2010, and December 31, 2011 (1 year before to 1 year after enactment of the new law). Two hundred fifty-eight consecutive female patients undergoing mastectomy were identified. Mastectomies were performed by seven hospitalemployed breast surgeons (three female and four male) and eight private practice breast surgeons (two female and six male), and reconstructions were performed by two hospital-employed plastic surgeons and four private practice plastic surgeons. Variables studied included reconstruction rates; breast surgeon sex; breast surgeon faculty status (hospital-employed versus private practice); breast surgeon participation in the institution’s multidisciplinary cancer center; plastic surgeon faculty status (hospital-employed versus private practice); type of reconstruction (autologous versus prosthetic); autologous reconstruction type (microsurgical versus nonmicrosurgical); and patient’s age, race, disease stage, mastectomy laterality (unilateral versus bilateral), and insurance coverage. Insurance coverage was divided into two groups, Medicaid and Medicaid Managed Care plans and the better-reimbursed Medicare and private insurances. Statistical Analysis Numerical data (i.e., age) were converted into categorical variables to facilitate analysis. A model of multivariate logistic regression was constructed to determine odds ratios of reconstruction. A
separate model was used to determine the odds of autologous tissue reconstruction as a factor of the proposed variables. The Pearson chi-square test was used to further analyze the impact of plastic surgeon faculty status on reconstruction type. Stata software version 12.2 (StataCorp, College Station, Texas) was used for calculations.
RESULTS Data on patient demographics and associated operations performed are summarized in Table 1. Our general reconstruction rate over the 2-year period was 56.59 percent. Although there was a trend toward increased reconstruction rate after implementation of the “information and access to breast reconstruction surgery” legislation, this increase did not reach statistical significance (OR, 0.45; p = 0.057). Previously established patient-related predictors impacting reconstruction such as age, stage of disease, and race were confirmed by our results.5–7 Bilateral mastectomy (OR, 4.6; p = 0.003) was a Table 1. Patient Demographics and Operations Performed* Characteristic Patient age† 24–49 years 50–60 years 61–90 years Ethnicity White African American Hispanic Asian Other Reconstruction rate Type of reconstruction Autologous Implant Breast surgeon Hospital-employed vs. private practice faculty Male vs. female Part of MDCC vs. not part of MDCC Stage 0 I II III IV Insurance type Medicaid plus MMC Private plus Medicare Mastectomy type Unilateral Bilateral
Value (%) 83 (32.2) 85 (32.9) 90 (34.9) 104 (40.3) 57 (22.1) 39 (15.1) 55 (21.3) 3 (0.01) 146/258 (56.59) 101 (39.1) 45 (17.4) 159 (61.6) vs. 99 (38.4) 135 (52.3) vs. 123 (47.7) 146 (56.6) vs. 112 (43.4) 52 (20.1) 110 (42.6) 61 (23.6) 31 (12.0) 4 (1.6) 83 (32.2) 175 (67.8) 204 (79.1) 54 (20.9)
MDCC, multidisciplinary cancer center; MCC, Medicaid Managed Care. *Total number of patients, 258. †Mean age, 56.5 years.
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Plastic and Reconstructive Surgery • February 2015 positive predictor of reconstruction, whereas age older than 60 years and Asian race were negative predictors (Table 2). Patients who had private insurance or Medicare were not found to have increased reconstruction rates compared to patients with Medicaid or Medicaid Managed Care (OR, 1.56; p = 0.25). A significant variable favoring reconstruction was female sex of the breast surgeon. Patients whose breast surgeon was female had an odds ratio of 5.17 (p = 0.001) favoring reconstruction over their male counterparts (Table 2). Analysis of breast surgeon faculty status and multidisciplinary cancer center participation on reconstruction rate showed no increased likelihood of reconstruction compared with those whose breast surgeon was in private practice or not a member of the multidisciplinary cancer center. However, further analysis of our data comparing sex to faculty status revealed that the large number of mastectomies performed by female breast surgeons who were hospital-employed became a confounding factor in analyzing the effect of breast surgeon faculty status on reconstruction rate (Table 3). Among patients undergoing reconstruction, having a hospital-employed plastic surgeon significantly increased the likelihood of reconstruction with autologous tissue over prosthetic implants, compared with patients treated by a private practice plastic surgeon (OR, 6.85; p = 0.001) (Table 4). Table 2. Likelihood of Reconstruction Characteristic Treatment date: after vs. before January 1, 2011 Breast surgeon faculty status: hospital-employed vs. private practice Breast surgeon sex: female vs. male Breast surgeon part of MDCC: yes vs. no Age group (vs. 24–49 years) 50–60 years 61–90 years Race (vs. white) African American Asian Hispanic Stage (vs. stage 0) I II III IV Insurance: Medicaid plus MMC vs. private plus Medicare Mastectomy type: bilateral vs. unilateral *Total number of patients, 258. †p < 0.05.
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OR
p (95% CI)
0.45
0.057 (0.22–0.91)
0.92
0.885 (0.29–2.83)
5.17
0.001 (3.01–8.89)†
2.36
0.117 (0.8–6.9)
0.46 0.09
0.096 (0.19–1.14) 0.000 (0.04–0.24)†
1.04 0.22 1.5
0.92 (0.42–2.58) 0.002 (0.08–0.58)† 0.44 (0.52–4.35)
0.1 0.07 0.04 0.05
0.1 (0.05–1.52) 0.08 (0.04–1.37) 0.03 (0.002–0.73)† 0.033(0.003–0.78)†
1.56
0.25 (0.72–3.39)
4.6
0.003 (1.66–12.72)†
Table 3. Mastectomies Performed, by Breast Surgeon Sex and Faculty Status* Female
Male
Total
103 20 123
56 79 155
159 99 258
Hospital-employed Private practice Total *Pearson χ2, 48.60; Pr 0.001.
Table 4. Likelihood of Autologous Reconstruction* Characteristic Treatment date: after vs. before January 1, 2011 Plastic surgeon faculty status: hospital-employed vs. private practice Breast surgeon sex: female vs. male Age Race (vs. white) African American Asian Hispanic Stage (vs. stage 0) I II III IV Insurance: Medicaid plus MMC vs. private plus Medicare Mastectomy type: bilateral vs. unilateral
OR
p (95% CI)
1.94
0.06 (0.97–5.54)
6.85
0.001 (2.47–19.03)†
0.86 1.45
0.7 (0.41–1.81) 0.4 (0.60–3.52)
1.38 0.80 1.22
0.58 (0.43–4.34) 0.75 (0.20–3.20) 0.76 (0.32–4.67)
1.22 0.81 0.27 N/A
0.86 (0.11–12.7) 0.87 (0.07–9.52) 0.32 (0.02–3.63) N/A
0.67
0.24 (0.62–6.26)
0.61
0.29 (0.24–1.52)
MMC, Medicaid Managed Care *Total number of patients, 258. †p < 0.05.
Among patients undergoing autologous breast reconstruction, there was a significantly higher percentage of microsurgical free flaps performed in patients operated on by hospital-employed plastic surgeons compared with private practice surgeons (78.2 percent versus 0 percent; p = 0.001) (Table 5).
DISCUSSION This study found that the recent legislation to improve access to breast reconstruction did not have a significant impact at the study hospital. It also confirmed findings from other studies that demonstrate that patient and breast surgeon variables can impact the reconstruction rate after mastectomy. A new finding was the impact of plastic surgeon practice setting on the type of reconstruction performed. Plastic surgeon practice setting may be an important variable affecting a woman’s choice of breast reconstruction type, although the reason for this remains unclear. In the United States, a woman has a one in eight chance of developing breast cancer
Volume 135, Number 2 • Factors Influencing Breast Reconstruction Table 5. Number of Reconstructions Performed, by Plastic Surgeon Faculty Status and Reconstruction Type*
Free flap Implant Pedicled flap Total
HospitalEmployed
Private Practice
Total
68 17 2 87
0 28 28 56
68 45 30 143
*Pearson χ2, 90.76; Pr 0.001.
during her lifetime. Of the approximately 240,000 women diagnosed with breast cancer annually, it is estimated that 60 percent of these women will be treated with breast-conserving therapy and the remaining 40 percent will be treated with mastectomy.8,9 Although morbidity associated with mastectomy is low, the procedure may impose significant psychosocial stress on patients related to negative feelings about their attractiveness, sexuality, and self-confidence.10 Recognizing the importance of breast reconstruction, the Women’s Health and Cancer Rights Act was passed in 1998, mandating insurance coverage for breast reconstruction after mastectomy, thus removing a major financial barrier.11 In 2006, Alderman et al. found that despite passage of the law, there was no reported increase in reconstruction rates.4 Recent reports demonstrate that a wide range of reconstructive rates still exists (15 to 42 percent) depending on the geographic location and the ethnicity of the population studied,1–3 raising concern that patients are not being informed of their options for breast reconstruction. In response to this concern, New York State enacted an amendment to its Public Health Law that went into effect on January 1, 2011, and was designed to ensure that patients received information and access to breast reconstruction surgery.5 There have been no reports on this legislation’s efficacy. Earlier studies attributed the variability of reconstruction rates to patient-related factors such as insurance, ethnicity, geographic location, invasive cancer (as opposed to ductal carcinoma in situ), and comorbid conditions.3,4,6 However, recent literature suggests that the rate of breast reconstruction is related directly to the rate of referral to a plastic surgeon by the breast surgeon, which in turn correlates with breast surgeon variables such as sex, volume of breast surgery performed, and association with a cancer center.12–14 Studies also suggest that treatment at a teaching hospital increases the rate of breast reconstruction.3,9 No studies have specifically examined the plastic
surgeon’s impact on the type of reconstruction performed. In the bill amending the public health codes, the justification for the change stated that: “statistics on the type of treatment women receive for breast cancer care at a particular hospital … are not available [emphasis added]. The best surrogate is to compare the patient population of interest with a similar one from a studied database. The Surveillance, Epidemiology, and End Results (SEER) cancer registry, run by the National Cancer Institute (NCI), provides this opportunity.” Using the Surveillance, Epidemiology, and End Results database, they found that “multiple analyses show that poor, uneducated women are far less likely to receive reconstruction. Their breast surgeons are less likely to discuss it with them.” The new law aims to ensure that patients receive information on reconstructive options by mandating the discussion of these options. Although the law acknowledges the existence of breast surgeon bias when discussing breast reconstruction with patients, the law does not address the potential impact that plastic surgeon bias may have on the discussion of reconstructive options and the type of reconstruction performed.5 One of the shortcomings of the Surveillance, Epidemiology, and End Results registry, and other population-based databases such as the Nationwide Inpatient Sample database, is that the data span multiple geographic areas with differing patient populations and treatment settings. It lacks physician-specific data such as physician sex, practice setting, and participation in a multidisciplinary cancer center. This makes it difficult to evaluate physician factors that might affect recommendations for reconstruction. Controlling for the patient population and treatment setting by looking at a single institution with a diverse mix of physicians allows greater insight into the impact of these factors. The current study was performed at a busy, teaching, community hospital in Manhattan with an ethnically diverse patient population insured by government and private insurers and a mixed surgical faculty consisting of both hospital-employed and private practice breast and plastic surgeons, all with equal access to an American College of Surgeons–accredited cancer program. There was cross-referral between the hospital-employed and private practice physicians. This provided a unique opportunity to evaluate physician variables and their impact on reconstruction rate and type while controlling for the patient population and treatment setting.
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Plastic and Reconstructive Surgery • February 2015 Many factors affect reconstruction rate. Studies using the Surveillance, Epidemiology, and End Results database have demonstrated that there is a significant difference in reconstruction rates based on patient age and geographic location.2,7 Similar to the Surveillance, Epidemiology, and End Results studies, this study found that age older than 60 years was a negative predictor for reconstruction. Because this was a single-center study, no comparison of reconstruction rates based on geographic location was possible. However, the reconstruction rate in this study of 57 percent is one of the highest reported in the literature. When analyzing ethnicity, a strong negative correlation between reconstruction and Asian race was found among our population. Many of the Asian patients in this study were Chinesespeaking from the Chinatown district of Manhattan. Previous studies have demonstrated lower reconstruction rates among minorities such as Asians, Hispanics, and African Americans.1,5–7,12,15 Factors related to racial differences in reconstruction rates are likely multifactorial. Alderman et al. suggested that factors such as cultural influences on body image, communication barriers, and differences in referral patterns might limit access to less acculturated racial groups.16 Insurance was not found to be a contributing factor, as nearly all patients had some type of insurance coverage. Patients with insurance coverage that provided higher reimbursement (i.e., private and Medicare) did not exhibit a higher reconstruction rate compared to those with lower reimbursing plans, and insurance type did not impact reconstruction type. This contrasts with the finding by Albornoz et al. that better insured patients were more likely to undergo autologous rather than implant reconstruction and to have microsurgical free flaps rather than pedicled flaps.9 Although the Women’s Health and Cancer Rights Act of 1998 has minimized financial barriers to reconstruction, prior studies have not shown increased reconstruction rates attributable to this legislation.4 Similarly, this study showed that the new legislation passed by New York State did not result in a statistically significant increase in breast reconstruction rates during the study period. The high rate of reconstruction at the study hospital may indicate that the majority of the patients in the hospital were already being referred to plastic surgeons and may have mitigated the impact of the legislation on this patient population. Despite adequate insurance coverage and discussion of reconstruction options, there will be certain patients who elect to forgo reconstruction.
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Elmore et al. recently reported a single-institution survey of patients undergoing mastectomy and found that of those who did not undergo reconstruction, 60 percent reported a lack of desire for reconstruction rather than a medical reason for not undergoing reconstruction.17 Therefore, even with full access to information and treatment, there will be patients who elect not to proceed with reconstruction. Although numerous patient factors have been identified that influence reconstruction rate and type, for any single patient, physician factors may ultimately impact their decision process the most. Preminger et al. suggested that referral to a plastic surgeon is the most significant factor affecting breast reconstruction rates; where 91.7 percent of patients referred to plastic surgeons underwent reconstruction compared to 0 percent of those who were not.12 Alderman et al. reported that breast surgeons who are female, perform a high volume breast cancer surgeries and practice in a cancer center are more likely to refer patients to a plastic surgeon.14 Our results also demonstrated that patients treated by female breast surgeons had a higher rate of reconstruction compared with patients treated by their male counterparts. However, the large number of mastectomies performed by female hospital-employed breast surgeons in this study became a confounding factor that prevented further analysis of breast surgeon faculty status and multidisciplinary cancer center participation on reconstruction rate. A significant factor influencing the type of reconstruction performed was plastic surgeon faculty status. Hospital-employed plastic surgeons were more likely to perform autologous tissue reconstruction than private practice plastic surgeons. They were also significantly more likely to perform microsurgical free flaps (e.g., deep inferior epigastric artery flaps) than nonmicrosurgical flaps (e.g., pedicled transverse rectus abdominis myocutaneous flap). Age, race, and insurance were not contributing factors to these findings. Albornoz et al. recently looked at sociodemographic factors and hospital characteristics affecting method of breast reconstruction.9 Using the Nationwide Inpatient Sample database, they found that autologous reconstruction was more likely in patients who were aged 50 to 59 years versus 40 to 49 years, undergoing delayed reconstructions, being treated in a teaching hospital, and who had private insurance carriers versus Medicare. They also found that microsurgical reconstructions were more common in teaching hospitals, patients undergoing delayed reconstruction, patients with
Volume 135, Number 2 • Factors Influencing Breast Reconstruction income between $49,000 and $63,999 compared with those with less than $39,000, and patients with private insurance carriers compared with Medicare. However, the Nationwide Inpatient Sample database provides no information on physician characteristics associated with these different treatments. The current study is the first to demonstrate that a plastic surgeon’s faculty status impacts the type of reconstruction performed. Plastic surgeons performing breast reconstruction face potential conflicts of interest, as compensation, overhead costs, time commitment, logistic support, medicolegal risk, and individual technical expertise may vary drastically between reconstruction types, thus impacting the surgeon’s ability to remain unbiased. For example, the Medicare Relative Value Unit–based compensation model tends to undervalue the time spent on autologous and microsurgical reconstruction compared with implant-based reconstruction, thus providing a financial disincentive for tissuebased reconstruction. In addition, the reimbursement for autologous reconstruction has decreased over the past decade, which has corresponded to the decreasing use of autologous reconstruction nationwide.18 Aside from the reimbursements, when a plastic surgeon is unable or unwilling to provide the full spectrum of reconstructive options, such as microsurgical free tissue transfers, the surgeon may be inclined to guide the patient away from such procedures, even if the patient is a good candidate. “Cognitive bias,” a concept developed by Nobel laureates Amoz Tversky and Daniel Kahneman, describes how certain biases can result in irrational decision-making.19 One type of cognitive bias, called “framing effect,” involves the perception of risk in the decision-making process.20,21 According to this theory, even when equivalent information regarding two reconstructive options is given to a patient, how the risk and certainty of a particular outcome associated with each procedure are presented can affect the reconstructive option selected. Each plastic surgeon may present the risks and outcomes of various reconstructive options differently based on their individual biases, thus impacting the patient’s ultimate decision. This ethical dilemma is not limited to plastic surgeons, as authors have reported that practice setting may influence the type of treatment patients receive in other specialties.22,23 In a single-center study examining breast surgeon use of minimally invasive biopsy versus excisional biopsy in the diagnosis of a breast mass, Clarke-Pearson et al. found that the rate of excisional biopsy was
significantly higher for private practice breast surgeons and general surgeons compared with academic breast surgeons, suggesting that practice setting impacted the type of treatment the physicians provided.23 The elephant in the room, as philosopher-ethicist Albert Jonson pointed out, is the moral tension between physician altruism and physician self-interest, which must be acknowledge when analyzing the ethics behind physician recommendations.22 Our literature review uncovered no studies examining the impact of this conflict of interest on plastic surgeons and the type of reconstruction performed. In the shared decisionmaking model, physicians inform patients about options and they come to a decision together. Ensuring that a plastic surgeon offers patients full access to all reconstructive options requires that the plastic surgeon be unbiased in providing each option. One way to mitigate this bias would be to provide patients with a standardized list of options and associated risks and benefits for each procedure based on peer-reviewed outcome data; however, most patients value their surgeon’s opinion and therefore it remains difficult to completely eliminate the impact of physician bias in the shared decision process. Physician bias may actually steer the patient toward the reconstructive option that the plastic surgeon feels will most reliably provide the best outcome in his or her hands. However, this choice might not be the best among available options for that patient. Ideally, a patient should be able to evaluate all options based on accurate and unbiased information and then find a plastic surgeon that can safely and reliably provide the desired type of reconstruction.
CONCLUSIONS Differences in immediate breast reconstruction rates are a result not solely of patient variables but also physician variables. Although patient age and race affected reconstruction rate, breast surgeon sex and plastic surgeon faculty status were found to have the greatest impact on the reconstruction rate and type, respectively. The impact of plastic surgeon faculty status on the type of reconstruction performed strongly suggests that nonpatient variables influence the type of reconstruction performed and that the plastic surgeon’s reconstructive recommendation may be predicated on considerations beyond just the patient’s interests. To create clinical pathways for breast reconstruction and to ensure that patients are informed regarding all options for reconstruction, further
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Plastic and Reconstructive Surgery • February 2015 evaluation of physician factors impacting reconstruction rate and type is warranted. The recent legislation designed to increase awareness of reconstructive options among women with breast cancer does not fully address the impact of physician bias on a patient’s decision-making process. The study found it had no impact on reconstruction rate or type in the year following its passage. Mark L. Smith, M.D. 10 Union Square East, Suite 2L New York, N.Y. 10003 [email protected]
references 1. Christian C, Niland J, Edge S, et al. A multi-institutional analysis of the socioeconomic determinants of breast reconstruction: A study of the national comprehensive cancer network. Ann Surg. 2006;243:241–249. 2. In H, Jiang W, Lipsitz SR, Neville BA, Weeks JC, Greenberg CC. Variation in the utilization of reconstruction following mastectomy in elderly women. Ann Surg Oncol. 2013;20:1872–1879. 3. Reuben BC, Manwaring J, Neumayer LA. Recent trends and predictors in immediate breast reconstruction after mastectomy in the United States. Am J Surg. 2009;198:237–243. 4. Alderman AK, Wei Y, Birkmeyer JD. Use of breast reconstruction after mastectomy following the Women’s Health and Cancer Rights Act. JAMA 2006;295:387–388. 5. A10094B/S6993-B Information and Access to Breast Reconstruction Surgery. Available at: http://open.nysenate. gov/legislation/bill/S6993-2009. Accessed November 10, 2012. 6. Kruper L, Xu X, Henderson K, Bernstein L. Disparities in reconstruction rates after mastectomy for ductal carcinoma in situ (DCIS): Patterns of care and factors associated with the use of breast reconstruction for DCIS compared with invasive cancer. Ann Surg Oncol. 2011;18:3210–3219. 7. Polednak AP. Geographic variation in postmastectomy breast reconstruction rates. Plast Reconstr Surg. 2000;106:298–301. 8. Rowland JH, Desmond KA, Meyerowitz BE, Belin TR, Wyatt GE, Ganz PA. Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst. 2000;92:1422–1429. 9. Albornoz CR, Bach PB, Pusic AL, et al. The influence of sociodemographic factors and hospital characteristics on the method of breast reconstruction, including
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microsurgery: A U.S. population-based study. Plast Reconstr Surg. 2012;129:1071–1079. 10. Bellino S, Fenocchio M, Zizza M, Rocca G, Bogetti P, Bogetto F. Quality of life of patients who undergo breast reconstruction after mastectomy: Effects of personality characteristics. Plast Reconstr Surg. 2011;127:10–17. 11. The Women’s Health and Cancer Rights Act. Available at: http://www.cms.gov/CCIIO/Programs-and-Initiatives/ Other-Insurance-Protections/whcra_factsheet.html. Accessed December 22, 2014. 12. Preminger BA, Trencheva K, Chang CS, et al. Improving access to care: Breast surgeons, the gatekeepers to breast reconstruction. J Am Coll Surg. 2012;214:270–276. 13. Katz SJ, Hawley ST, Abrahamse P, et al. Does it matter where you go for breast surgery? Attending surgeon’s influence on variation in receipt of mastectomy for breast cancer. Med Care 2010;48:892–899. 14. Alderman AK, Hawley ST, Waljee J, Morrow M, Katz SJ. Correlates of referral practices of general surgeons to plastic surgeons for mastectomy reconstruction. Cancer 2007;109:1715–1720. 15. Yang RL, Newman AS, Reinke CE, et al. Racial disparities in immediate breast reconstruction after mastectomy: Impact of state and federal health policy changes. Ann Surg Oncol. 2013;20:399–406. 16. Alderman AK, Hawley ST, Janz NK. Racial and ethnic disparities in the use of postmastectomy breast reconstruction: Results from a population-based study. J Clin Oncol. 2009;27:5325–5330. 17. Elmore L, Myckatyn TM, Gao F, et al. Reconstruction patterns in a single institution cohort of women undergoing mastectomy for breast cancer. Ann Surg Oncol. 2012;19:3223–3229. 18. Brody H, Zientek D. Is the surgery necessary now? The surgeon’s conflict of interest. Virtual Mentor 2007;9:476–482. 19. Tversky A, Kahneman D. Judgment under uncertainty: Heuristics and biases. Science 1974;185:1124–1131. 20. Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science 1981;211:453–458. 21. Nguyen F, Carrere M, Moumjid N. Framing effects of risk communication in health-related decision making: Learning from a discrete choice experiment. Available at: ftp://ftp.gate.cnrs. fr/RePEc/2009/0921.pdf. Accessed December 22, 2014. 22. Hernandez-Boussard T, Zeidler K, Barzin A, Lee G, Curtin C. Breast reconstruction national trends and healthcare implications. Breast J. 2013;19:463–469. 23. Clarke-Pearson EM, Jacobson AF, Boolbol SK, et al. Quality assurance initiative at one institution for minimally invasive breast biopsy as the initial diagnostic technique. J Am Coll Surg. 2009;208:75–78.
Background: On January 1, 2011, New York State amended the Public Health Law to ensure that patients receive “information and access to breast reconstruction surgery.” The purposes of this study were to investigate the early impact of this legislation on reconstruction rates and to evaluate the influence of patient variables versus physician variables on the incidence and type of breast reconstruction performed. Methods: A retrospective study was conducted on all patients who underwent mastectomy between January 1, 2010, and December 31, 2011. Reconstruction rates were analyzed in relation to timing of legislation, breast surgeon variables, plastic surgeon faculty status, type of reconstruction, and patient variables. Results: Two hundred fifty-eight patients met inclusion criteria. The overall reconstruction rate was 56.59 percent. There was no statistically significant increase in reconstruction rate after the 2011 legislation (OR, 0.45; p = 0.057). Patients whose breast surgeon was female were more likely to undergo reconstruction (OR, 5.17; p = 0.001). Patients who were Asian (OR, 0.22; p = 0.002), older than 60 years (OR, 0.09; p = 0.001), or had stage 3 and 4 cancer (OR, 0.04; p = 0.03) were less likely to undergo reconstruction. Patients reconstructed by a hospital-employed plastic surgeon were significantly more likely to undergo autologous versus implant reconstruction (OR, 6.85; p = 0.001) and to undergo microsurgical versus nonmicrosurgical autologous reconstruction (78.2 percent versus 0 percent; p = 0.001). Conclusions: Breast surgeon sex and plastic surgeon faculty status were the factors that most affected the rate and type of reconstruction, respectively. Legislation mandating the discussion of breast reconstruction options had no impact on reconstruction rate. (Plast. Reconstr. Surg. 135: 270e, 2015.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.
E
ach year in the United States, approximately 100,000 women undergo mastectomy for breast cancer treatment or risk reduction. Breast reconstruction rates across the country vary from 15 to 42 percent according to numerous studies.1–3 This variability has raised concern over whether or not patients are adequately informed of reconstructive options and how to access services. Access to breast reconstruction may be affected by From the Department of Surgery, Divisions of General Surgery, Biostatistics, Plastic Surgery, and Breast Surgery, Beth Israel Medical Center. Received for publication February 19, 2014; accepted July 28, 2014. Abstract presented at the 99th Annual Clinical Congress of the American College of Surgeons, in Washington, D.C., October 6 through 10, 2013. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000888
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numerous factors, including patient factors (e.g., ethnicity, insurance, and age), health system factors (e.g.. access to a multidisciplinary cancer team and reconstructive services), and physician factors (e.g., sex, training, and practice setting). The majority of studies have focused on patient and health system factors affecting breast reconstruction. Little has been written on physician factors, especially plastic surgeon factors, which may impact the rate and type of reconstruction performed. On January 1, 2011, New York State amended Section 1, Section 2803-o of the Public Health Law to ensure that patients are informed of their options for breast reconstruction. The law Disclosure: None of the authors has a financial interest in any of the products or devices mentioned in this article.
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Volume 135, Number 2 • Factors Influencing Breast Reconstruction mandates that hospitals in New York State provide patients written information regarding options for immediate breast reconstruction, insurance coverage for breast reconstruction, and how to access a plastic surgeon before undergoing a mastectomy. The effect of this law on reconstruction rates has not been evaluated. Of note, the law did not provide specific information for providers to share with patients regarding reconstructive options; rather, it only mandated that patients be informed of the options. How individual physicians portray these options may impact a patient’s decision to pursue breast reconstruction and the type of reconstruction chosen. The goal of this study was to evaluate the impact of this legislation on reconstruction rate and to identify physician factors that might also impact the rate and type of reconstruction performed.
PATIENTS AND METHODS Institutional review board approval was obtained and a retrospective chart review was performed of patients treated with mastectomy between January 1, 2010, and December 31, 2011 (1 year before to 1 year after enactment of the new law). Two hundred fifty-eight consecutive female patients undergoing mastectomy were identified. Mastectomies were performed by seven hospitalemployed breast surgeons (three female and four male) and eight private practice breast surgeons (two female and six male), and reconstructions were performed by two hospital-employed plastic surgeons and four private practice plastic surgeons. Variables studied included reconstruction rates; breast surgeon sex; breast surgeon faculty status (hospital-employed versus private practice); breast surgeon participation in the institution’s multidisciplinary cancer center; plastic surgeon faculty status (hospital-employed versus private practice); type of reconstruction (autologous versus prosthetic); autologous reconstruction type (microsurgical versus nonmicrosurgical); and patient’s age, race, disease stage, mastectomy laterality (unilateral versus bilateral), and insurance coverage. Insurance coverage was divided into two groups, Medicaid and Medicaid Managed Care plans and the better-reimbursed Medicare and private insurances. Statistical Analysis Numerical data (i.e., age) were converted into categorical variables to facilitate analysis. A model of multivariate logistic regression was constructed to determine odds ratios of reconstruction. A
separate model was used to determine the odds of autologous tissue reconstruction as a factor of the proposed variables. The Pearson chi-square test was used to further analyze the impact of plastic surgeon faculty status on reconstruction type. Stata software version 12.2 (StataCorp, College Station, Texas) was used for calculations.
RESULTS Data on patient demographics and associated operations performed are summarized in Table 1. Our general reconstruction rate over the 2-year period was 56.59 percent. Although there was a trend toward increased reconstruction rate after implementation of the “information and access to breast reconstruction surgery” legislation, this increase did not reach statistical significance (OR, 0.45; p = 0.057). Previously established patient-related predictors impacting reconstruction such as age, stage of disease, and race were confirmed by our results.5–7 Bilateral mastectomy (OR, 4.6; p = 0.003) was a Table 1. Patient Demographics and Operations Performed* Characteristic Patient age† 24–49 years 50–60 years 61–90 years Ethnicity White African American Hispanic Asian Other Reconstruction rate Type of reconstruction Autologous Implant Breast surgeon Hospital-employed vs. private practice faculty Male vs. female Part of MDCC vs. not part of MDCC Stage 0 I II III IV Insurance type Medicaid plus MMC Private plus Medicare Mastectomy type Unilateral Bilateral
Value (%) 83 (32.2) 85 (32.9) 90 (34.9) 104 (40.3) 57 (22.1) 39 (15.1) 55 (21.3) 3 (0.01) 146/258 (56.59) 101 (39.1) 45 (17.4) 159 (61.6) vs. 99 (38.4) 135 (52.3) vs. 123 (47.7) 146 (56.6) vs. 112 (43.4) 52 (20.1) 110 (42.6) 61 (23.6) 31 (12.0) 4 (1.6) 83 (32.2) 175 (67.8) 204 (79.1) 54 (20.9)
MDCC, multidisciplinary cancer center; MCC, Medicaid Managed Care. *Total number of patients, 258. †Mean age, 56.5 years.
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Plastic and Reconstructive Surgery • February 2015 positive predictor of reconstruction, whereas age older than 60 years and Asian race were negative predictors (Table 2). Patients who had private insurance or Medicare were not found to have increased reconstruction rates compared to patients with Medicaid or Medicaid Managed Care (OR, 1.56; p = 0.25). A significant variable favoring reconstruction was female sex of the breast surgeon. Patients whose breast surgeon was female had an odds ratio of 5.17 (p = 0.001) favoring reconstruction over their male counterparts (Table 2). Analysis of breast surgeon faculty status and multidisciplinary cancer center participation on reconstruction rate showed no increased likelihood of reconstruction compared with those whose breast surgeon was in private practice or not a member of the multidisciplinary cancer center. However, further analysis of our data comparing sex to faculty status revealed that the large number of mastectomies performed by female breast surgeons who were hospital-employed became a confounding factor in analyzing the effect of breast surgeon faculty status on reconstruction rate (Table 3). Among patients undergoing reconstruction, having a hospital-employed plastic surgeon significantly increased the likelihood of reconstruction with autologous tissue over prosthetic implants, compared with patients treated by a private practice plastic surgeon (OR, 6.85; p = 0.001) (Table 4). Table 2. Likelihood of Reconstruction Characteristic Treatment date: after vs. before January 1, 2011 Breast surgeon faculty status: hospital-employed vs. private practice Breast surgeon sex: female vs. male Breast surgeon part of MDCC: yes vs. no Age group (vs. 24–49 years) 50–60 years 61–90 years Race (vs. white) African American Asian Hispanic Stage (vs. stage 0) I II III IV Insurance: Medicaid plus MMC vs. private plus Medicare Mastectomy type: bilateral vs. unilateral *Total number of patients, 258. †p < 0.05.
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OR
p (95% CI)
0.45
0.057 (0.22–0.91)
0.92
0.885 (0.29–2.83)
5.17
0.001 (3.01–8.89)†
2.36
0.117 (0.8–6.9)
0.46 0.09
0.096 (0.19–1.14) 0.000 (0.04–0.24)†
1.04 0.22 1.5
0.92 (0.42–2.58) 0.002 (0.08–0.58)† 0.44 (0.52–4.35)
0.1 0.07 0.04 0.05
0.1 (0.05–1.52) 0.08 (0.04–1.37) 0.03 (0.002–0.73)† 0.033(0.003–0.78)†
1.56
0.25 (0.72–3.39)
4.6
0.003 (1.66–12.72)†
Table 3. Mastectomies Performed, by Breast Surgeon Sex and Faculty Status* Female
Male
Total
103 20 123
56 79 155
159 99 258
Hospital-employed Private practice Total *Pearson χ2, 48.60; Pr 0.001.
Table 4. Likelihood of Autologous Reconstruction* Characteristic Treatment date: after vs. before January 1, 2011 Plastic surgeon faculty status: hospital-employed vs. private practice Breast surgeon sex: female vs. male Age Race (vs. white) African American Asian Hispanic Stage (vs. stage 0) I II III IV Insurance: Medicaid plus MMC vs. private plus Medicare Mastectomy type: bilateral vs. unilateral
OR
p (95% CI)
1.94
0.06 (0.97–5.54)
6.85
0.001 (2.47–19.03)†
0.86 1.45
0.7 (0.41–1.81) 0.4 (0.60–3.52)
1.38 0.80 1.22
0.58 (0.43–4.34) 0.75 (0.20–3.20) 0.76 (0.32–4.67)
1.22 0.81 0.27 N/A
0.86 (0.11–12.7) 0.87 (0.07–9.52) 0.32 (0.02–3.63) N/A
0.67
0.24 (0.62–6.26)
0.61
0.29 (0.24–1.52)
MMC, Medicaid Managed Care *Total number of patients, 258. †p < 0.05.
Among patients undergoing autologous breast reconstruction, there was a significantly higher percentage of microsurgical free flaps performed in patients operated on by hospital-employed plastic surgeons compared with private practice surgeons (78.2 percent versus 0 percent; p = 0.001) (Table 5).
DISCUSSION This study found that the recent legislation to improve access to breast reconstruction did not have a significant impact at the study hospital. It also confirmed findings from other studies that demonstrate that patient and breast surgeon variables can impact the reconstruction rate after mastectomy. A new finding was the impact of plastic surgeon practice setting on the type of reconstruction performed. Plastic surgeon practice setting may be an important variable affecting a woman’s choice of breast reconstruction type, although the reason for this remains unclear. In the United States, a woman has a one in eight chance of developing breast cancer
Volume 135, Number 2 • Factors Influencing Breast Reconstruction Table 5. Number of Reconstructions Performed, by Plastic Surgeon Faculty Status and Reconstruction Type*
Free flap Implant Pedicled flap Total
HospitalEmployed
Private Practice
Total
68 17 2 87
0 28 28 56
68 45 30 143
*Pearson χ2, 90.76; Pr 0.001.
during her lifetime. Of the approximately 240,000 women diagnosed with breast cancer annually, it is estimated that 60 percent of these women will be treated with breast-conserving therapy and the remaining 40 percent will be treated with mastectomy.8,9 Although morbidity associated with mastectomy is low, the procedure may impose significant psychosocial stress on patients related to negative feelings about their attractiveness, sexuality, and self-confidence.10 Recognizing the importance of breast reconstruction, the Women’s Health and Cancer Rights Act was passed in 1998, mandating insurance coverage for breast reconstruction after mastectomy, thus removing a major financial barrier.11 In 2006, Alderman et al. found that despite passage of the law, there was no reported increase in reconstruction rates.4 Recent reports demonstrate that a wide range of reconstructive rates still exists (15 to 42 percent) depending on the geographic location and the ethnicity of the population studied,1–3 raising concern that patients are not being informed of their options for breast reconstruction. In response to this concern, New York State enacted an amendment to its Public Health Law that went into effect on January 1, 2011, and was designed to ensure that patients received information and access to breast reconstruction surgery.5 There have been no reports on this legislation’s efficacy. Earlier studies attributed the variability of reconstruction rates to patient-related factors such as insurance, ethnicity, geographic location, invasive cancer (as opposed to ductal carcinoma in situ), and comorbid conditions.3,4,6 However, recent literature suggests that the rate of breast reconstruction is related directly to the rate of referral to a plastic surgeon by the breast surgeon, which in turn correlates with breast surgeon variables such as sex, volume of breast surgery performed, and association with a cancer center.12–14 Studies also suggest that treatment at a teaching hospital increases the rate of breast reconstruction.3,9 No studies have specifically examined the plastic
surgeon’s impact on the type of reconstruction performed. In the bill amending the public health codes, the justification for the change stated that: “statistics on the type of treatment women receive for breast cancer care at a particular hospital … are not available [emphasis added]. The best surrogate is to compare the patient population of interest with a similar one from a studied database. The Surveillance, Epidemiology, and End Results (SEER) cancer registry, run by the National Cancer Institute (NCI), provides this opportunity.” Using the Surveillance, Epidemiology, and End Results database, they found that “multiple analyses show that poor, uneducated women are far less likely to receive reconstruction. Their breast surgeons are less likely to discuss it with them.” The new law aims to ensure that patients receive information on reconstructive options by mandating the discussion of these options. Although the law acknowledges the existence of breast surgeon bias when discussing breast reconstruction with patients, the law does not address the potential impact that plastic surgeon bias may have on the discussion of reconstructive options and the type of reconstruction performed.5 One of the shortcomings of the Surveillance, Epidemiology, and End Results registry, and other population-based databases such as the Nationwide Inpatient Sample database, is that the data span multiple geographic areas with differing patient populations and treatment settings. It lacks physician-specific data such as physician sex, practice setting, and participation in a multidisciplinary cancer center. This makes it difficult to evaluate physician factors that might affect recommendations for reconstruction. Controlling for the patient population and treatment setting by looking at a single institution with a diverse mix of physicians allows greater insight into the impact of these factors. The current study was performed at a busy, teaching, community hospital in Manhattan with an ethnically diverse patient population insured by government and private insurers and a mixed surgical faculty consisting of both hospital-employed and private practice breast and plastic surgeons, all with equal access to an American College of Surgeons–accredited cancer program. There was cross-referral between the hospital-employed and private practice physicians. This provided a unique opportunity to evaluate physician variables and their impact on reconstruction rate and type while controlling for the patient population and treatment setting.
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Plastic and Reconstructive Surgery • February 2015 Many factors affect reconstruction rate. Studies using the Surveillance, Epidemiology, and End Results database have demonstrated that there is a significant difference in reconstruction rates based on patient age and geographic location.2,7 Similar to the Surveillance, Epidemiology, and End Results studies, this study found that age older than 60 years was a negative predictor for reconstruction. Because this was a single-center study, no comparison of reconstruction rates based on geographic location was possible. However, the reconstruction rate in this study of 57 percent is one of the highest reported in the literature. When analyzing ethnicity, a strong negative correlation between reconstruction and Asian race was found among our population. Many of the Asian patients in this study were Chinesespeaking from the Chinatown district of Manhattan. Previous studies have demonstrated lower reconstruction rates among minorities such as Asians, Hispanics, and African Americans.1,5–7,12,15 Factors related to racial differences in reconstruction rates are likely multifactorial. Alderman et al. suggested that factors such as cultural influences on body image, communication barriers, and differences in referral patterns might limit access to less acculturated racial groups.16 Insurance was not found to be a contributing factor, as nearly all patients had some type of insurance coverage. Patients with insurance coverage that provided higher reimbursement (i.e., private and Medicare) did not exhibit a higher reconstruction rate compared to those with lower reimbursing plans, and insurance type did not impact reconstruction type. This contrasts with the finding by Albornoz et al. that better insured patients were more likely to undergo autologous rather than implant reconstruction and to have microsurgical free flaps rather than pedicled flaps.9 Although the Women’s Health and Cancer Rights Act of 1998 has minimized financial barriers to reconstruction, prior studies have not shown increased reconstruction rates attributable to this legislation.4 Similarly, this study showed that the new legislation passed by New York State did not result in a statistically significant increase in breast reconstruction rates during the study period. The high rate of reconstruction at the study hospital may indicate that the majority of the patients in the hospital were already being referred to plastic surgeons and may have mitigated the impact of the legislation on this patient population. Despite adequate insurance coverage and discussion of reconstruction options, there will be certain patients who elect to forgo reconstruction.
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Elmore et al. recently reported a single-institution survey of patients undergoing mastectomy and found that of those who did not undergo reconstruction, 60 percent reported a lack of desire for reconstruction rather than a medical reason for not undergoing reconstruction.17 Therefore, even with full access to information and treatment, there will be patients who elect not to proceed with reconstruction. Although numerous patient factors have been identified that influence reconstruction rate and type, for any single patient, physician factors may ultimately impact their decision process the most. Preminger et al. suggested that referral to a plastic surgeon is the most significant factor affecting breast reconstruction rates; where 91.7 percent of patients referred to plastic surgeons underwent reconstruction compared to 0 percent of those who were not.12 Alderman et al. reported that breast surgeons who are female, perform a high volume breast cancer surgeries and practice in a cancer center are more likely to refer patients to a plastic surgeon.14 Our results also demonstrated that patients treated by female breast surgeons had a higher rate of reconstruction compared with patients treated by their male counterparts. However, the large number of mastectomies performed by female hospital-employed breast surgeons in this study became a confounding factor that prevented further analysis of breast surgeon faculty status and multidisciplinary cancer center participation on reconstruction rate. A significant factor influencing the type of reconstruction performed was plastic surgeon faculty status. Hospital-employed plastic surgeons were more likely to perform autologous tissue reconstruction than private practice plastic surgeons. They were also significantly more likely to perform microsurgical free flaps (e.g., deep inferior epigastric artery flaps) than nonmicrosurgical flaps (e.g., pedicled transverse rectus abdominis myocutaneous flap). Age, race, and insurance were not contributing factors to these findings. Albornoz et al. recently looked at sociodemographic factors and hospital characteristics affecting method of breast reconstruction.9 Using the Nationwide Inpatient Sample database, they found that autologous reconstruction was more likely in patients who were aged 50 to 59 years versus 40 to 49 years, undergoing delayed reconstructions, being treated in a teaching hospital, and who had private insurance carriers versus Medicare. They also found that microsurgical reconstructions were more common in teaching hospitals, patients undergoing delayed reconstruction, patients with
Volume 135, Number 2 • Factors Influencing Breast Reconstruction income between $49,000 and $63,999 compared with those with less than $39,000, and patients with private insurance carriers compared with Medicare. However, the Nationwide Inpatient Sample database provides no information on physician characteristics associated with these different treatments. The current study is the first to demonstrate that a plastic surgeon’s faculty status impacts the type of reconstruction performed. Plastic surgeons performing breast reconstruction face potential conflicts of interest, as compensation, overhead costs, time commitment, logistic support, medicolegal risk, and individual technical expertise may vary drastically between reconstruction types, thus impacting the surgeon’s ability to remain unbiased. For example, the Medicare Relative Value Unit–based compensation model tends to undervalue the time spent on autologous and microsurgical reconstruction compared with implant-based reconstruction, thus providing a financial disincentive for tissuebased reconstruction. In addition, the reimbursement for autologous reconstruction has decreased over the past decade, which has corresponded to the decreasing use of autologous reconstruction nationwide.18 Aside from the reimbursements, when a plastic surgeon is unable or unwilling to provide the full spectrum of reconstructive options, such as microsurgical free tissue transfers, the surgeon may be inclined to guide the patient away from such procedures, even if the patient is a good candidate. “Cognitive bias,” a concept developed by Nobel laureates Amoz Tversky and Daniel Kahneman, describes how certain biases can result in irrational decision-making.19 One type of cognitive bias, called “framing effect,” involves the perception of risk in the decision-making process.20,21 According to this theory, even when equivalent information regarding two reconstructive options is given to a patient, how the risk and certainty of a particular outcome associated with each procedure are presented can affect the reconstructive option selected. Each plastic surgeon may present the risks and outcomes of various reconstructive options differently based on their individual biases, thus impacting the patient’s ultimate decision. This ethical dilemma is not limited to plastic surgeons, as authors have reported that practice setting may influence the type of treatment patients receive in other specialties.22,23 In a single-center study examining breast surgeon use of minimally invasive biopsy versus excisional biopsy in the diagnosis of a breast mass, Clarke-Pearson et al. found that the rate of excisional biopsy was
significantly higher for private practice breast surgeons and general surgeons compared with academic breast surgeons, suggesting that practice setting impacted the type of treatment the physicians provided.23 The elephant in the room, as philosopher-ethicist Albert Jonson pointed out, is the moral tension between physician altruism and physician self-interest, which must be acknowledge when analyzing the ethics behind physician recommendations.22 Our literature review uncovered no studies examining the impact of this conflict of interest on plastic surgeons and the type of reconstruction performed. In the shared decisionmaking model, physicians inform patients about options and they come to a decision together. Ensuring that a plastic surgeon offers patients full access to all reconstructive options requires that the plastic surgeon be unbiased in providing each option. One way to mitigate this bias would be to provide patients with a standardized list of options and associated risks and benefits for each procedure based on peer-reviewed outcome data; however, most patients value their surgeon’s opinion and therefore it remains difficult to completely eliminate the impact of physician bias in the shared decision process. Physician bias may actually steer the patient toward the reconstructive option that the plastic surgeon feels will most reliably provide the best outcome in his or her hands. However, this choice might not be the best among available options for that patient. Ideally, a patient should be able to evaluate all options based on accurate and unbiased information and then find a plastic surgeon that can safely and reliably provide the desired type of reconstruction.
CONCLUSIONS Differences in immediate breast reconstruction rates are a result not solely of patient variables but also physician variables. Although patient age and race affected reconstruction rate, breast surgeon sex and plastic surgeon faculty status were found to have the greatest impact on the reconstruction rate and type, respectively. The impact of plastic surgeon faculty status on the type of reconstruction performed strongly suggests that nonpatient variables influence the type of reconstruction performed and that the plastic surgeon’s reconstructive recommendation may be predicated on considerations beyond just the patient’s interests. To create clinical pathways for breast reconstruction and to ensure that patients are informed regarding all options for reconstruction, further
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Plastic and Reconstructive Surgery • February 2015 evaluation of physician factors impacting reconstruction rate and type is warranted. The recent legislation designed to increase awareness of reconstructive options among women with breast cancer does not fully address the impact of physician bias on a patient’s decision-making process. The study found it had no impact on reconstruction rate or type in the year following its passage. Mark L. Smith, M.D. 10 Union Square East, Suite 2L New York, N.Y. 10003 [email protected]
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