Low rates of breast reconstruction “shocking”

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.”