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QUALITY-of-life and aesthetic outcomes of breast cancer surgery are taking on ever greater importance as cancer survival rates continue to climb, says a leading breast surgeon, but there are concerns about the ability of some patients to afford best-practice care.
Cancer Council Australia CEO, Professor Sanchia Aranda, said that advances in the surgical management of breast cancer were encouraging, but had the potential to see some patients fall through the cracks.
“We are starting to see a differentiation in medicine between those who can afford to pay and those who cannot,” Professor Aranda told MJA InSight.
“So a woman who can’t afford time off work is much more likely to opt for a mastectomy rather than breast conserving surgery followed by 6 weeks of radiotherapy. It really is a complex set of issues.”
Professor Aranda was commenting on an article published in the MJA, written by Professor Andrew Spillane, a surgical oncologist at the University of Sydney’s Northern Clinical School. The article outlined the latest directions in the surgical management and prevention of breast cancer.
“As survival has improved, the focus of surgical management has rightly undergone a major evolution to recognise the importance of aesthetic and other quality-of-life outcomes, including less extensive axillary surgery and sentinel node biopsy,” wrote Professor Spillane, who is also president of Breast Surgeons of Australia and New Zealand (BreastSurgANZ).
He outlined key shifts in the surgical care of breast cancer patients, including the role of the surgeon in a multidisciplinary approach to care; the potential for oncoplastic breast surgery to reduce the need for mastectomy and improving aesthetic and quality-of-life outcomes for patients; the underuse of neoadjuvant chemotherapy (NACT); and the potential for immediate breast reconstruction.
Professor Spillane also noted that the reported rates of breast reconstruction in Australia remained low (8-12%), compared with rates in similar countries like the US (up to 25%) and the UK (21%).
“Breast reconstruction is recognised to improve both quality of life and recovery from the psychological trauma of mastectomy. In New York, [breast reconstruction] is a legislated right,” he wrote.
Professor Aranda agreed that reconstruction rates in Australia were low, often reflecting long waiting lists in public hospitals for surgery that was considered a cosmetic or non-urgent procedure.
“Many women choose to have breast surgery in the private sector, and often paying for it themselves,” she said.
- Related: MJA — What is new in the surgical management and prevention of breast cancer?
- Related: MJA InSight — Mastectomy requests rise
Dr Elisabeth Elder, specialist breast surgeon and chair of BreastSurgANZ’s oncoplastic subcommittee, said such low rates of breast reconstruction here were “shocking”.
“We want to improve on those rates, but I think it results from a combination of [breast reconstruction] not being offered to women regularly, a lack of expertise in being able to provide this, and a lack of accessibility where it’s not available enough in the public system and there are issues of out-of-pocket costs in the private sector,” she told MJA InSight.
Dr Elder said that, at some specialist units, the availability of immediate breast reconstruction using implant-based or tissue-based techniques had seen the uptake of reconstruction increase to 40-50%.
“There are a lot of things that need to be done. There has been a whole new push for education for breast surgeons, with new educational programs, and that has the dual purposes of raising awareness and raising competence.”
BreastSurgANZ has collaborated with the University of Sydney to develop a Graduate Certificate in Surgery (Breast Surgery), which is available from this year.
Professor Spillane noted that NACT, while not offering any survival advantage, would also potentially result in lower mastectomy rates, broader surgical options and less surgical morbidity. However, he said, NACT was being underused in Australia.
“The benefits of NACT are not being fully realised,” Professor Spillane said, detailing several potential advantages, including a higher rate of breast conservation surgery and improved aesthetic outcomes for suitable patients, and lower rates of axillary lymph node involvement.
Professor Aranda added that more data were needed to confirm the benefits of NACT.
“The NACT research that has been done has focused predominantly on survival outcomes and that’s been equivocal … but we don’t have any idea about the rates of use of NACT or the appropriateness of its use in the Australian setting.”
She said that Cancer Australia was advancing work to collect and integrate stage and treatment data, and recurrence data with population registries.
Professor Aranda welcomed the recognition of the importance of multidisciplinary teams in managing breast cancer.
“This sort of care should not be undertaken by solo practitioners, it should be undertaken in multidisciplinary teams. It should be undertaken in centres of excellence that have volume to really be able to understand the nuances of best treatment for individual women based on risk factors and disease factors that really do need to come into play if women want to get both the best survival and the best cosmetic outcomes,” she said.
Professor Aranda said the MJA article provided a promising overview of the potential improvements in breast cancer care – adding that hypofractionated radiotherapy, which almost halved radiotherapy treatment time from 6 to 3.5 weeks, was another development with variable uptake in Australia.
“The next challenge is to say which of these areas are priorities for women and need to be thought about in a whole-of-system approach, and which ones are the icing on the cake [in terms of] our capacity to pay.”
I had a mastectomy & axillary node clearance in 2013 with a tissue expander inserted at the time so that a reconstruction would be easier.
I had no follow up from the breast surgeon at all, although at the end of 2015 he must have been aware that I requested my notes to be transfered to a plastic surgeon, who was perturbed about the length of time the tissue expander had remained. I have also had no follow up from the oncologist after finishing chemotherapy 2 years ago.
The reconstruction, now nearly 9 months on, is still settling and only starting to become acceptable in appearance with skin needling and dermal fillers to the scar from the original mastectomy, and still awaits a nipple tattoo. The firmness of the implant is quite different to natural breast and I am hoping it will soften over time. I think reconstructions must be more difficult than we imagine and therefore there is a mismatch between expectations and outcomes.
Interestingly the surgeons seem happy to not bother with the recreation of a nipple in many cases.
Lymphoedema interferes significantly with reconstruction and general well being and is poorly addressed by surgeons.
All in all I was very surprised that breast cancer management seems disjointed and inadequate with poor follow up, given the amount of attention and funding it attracts. I have had my fair share of hospitalization and procedures and have been much more impressed by the management of other problems I have had.
I am NOT surprised that most women do not have a reconstruction as it is not explained, offered or made easy to obtain, can be expensive, and often the results are uninspiring.
In answer to some of the questions posted: my DIEP reconstruction cost me some $12000 out of pocket expenses and was a far longer, harder recovery than mastectomy. The simpler, cheaper implant reconstruction was not an option for me. I am happy with the results. Not many surgeons perform DIEP reconstruction either, and transflap/dorsi flap reconstructions have other functional/cosmetic repercussions, that I and many others I suspect would baulk at. As a doctor I could afford the cost (and the indirect cost of a lengthy time off work) of having a DIEP but of course many could not. I do think the fees are rather exorbitant though and put this surgery out of reach for many.
It would be interesting to know
1. The number of patients who would have reconstruction if offered it at a rebate only/gap cover cost
2. The number of patients post reconstruction who are happy with their reconstruction….
Those are figures I am interested in
Plastic and reconstructive surgeons enjoy a wide range of tasks to which they might apply their surgical skills.
Understandably. a certain number of surgeons devote a certain proportion of their time to purely cosmetic tasks including tasks that require zero surgical skill aside from some adroitness with a syringe (here recognising that *knowledge* of anatomy, physiology and aesthetics are indeed items of knowledge not skill, and are readily accessible to non-surgeons).
And if plastic and reconstructive surgeons were granted, either by regulation or in a de facto sense, rights to practise in the aesthetic field to the exclusion of other doctors (as some plastic surgeons may desire), we might reasonably expect such aesthetic non-surgical work to absorb more and more of the plastic surgeons’ precious and limited time and attention.
As a result, even less actual reconstructive work might well thence occur.
Therefore, the ongoing participation of non-surgeons in the aesthetic sphere is, in all likelihood, helping to encourage plastic and reconstructive surgeons to maintain their interest in reconstructive work, to the benefit of patients needing the breast reconstructions that only plastic and reconstructive surgeons can offer.
Finally, as a comment coming from a non-surgeon working in cosmetic medicine, this observation and surmise may be seen as self-serving, but that would not mean it is untrue.
Even self-serving comments can be true.
It would be interesting to survey the 12% to see what the recontructions cost them finacially to understand why there is such a discrepency!