Jan. 27, 2006 - Less than one out of five American women who have mastectomies also have breast reconstruction surgery, but cost does not seem to be the only thing driving the decision, new research suggests.
A review of breast reconstruction practices in the U.S. found that reconstruction rates overall have not increased since 1999 -- the year legislation was enacted mandating insurance coverage for the surgery.
Figures from the American Society of Plastic Surgeons show a 22% decline in breast reconstruction procedures between 2000 and 2004.
Regional, Ethnic Disparities
Despite the law, researchers concluded that reconstruction practices after mastectomy still vary greatly from region to region and among different racial and ethnic groups.
White women continued to have the highest rates of breast reconstruction after mastectomy. Blacks, Asians and Hispanics were only about half as likely to have the surgery.
And women living in Atlanta -- where the reconstruction rates were highest of any region studied -- were more than seven times more likely to have the surgery than women living in Alaska, where rates were lowest.
The research was published in the Jan. 25 issue of The Journal of the American Medical Association.
"Our study found that the law has done nothing to improve usage among women," researcher Amy K. Alderman, MD, tells WebMD.
Alderman, a reconstructive surgeon, says there is no single explanation for why so few women have reconstructive surgery following breast removal.
The Women's Health and Cancer Rights Act was designed to take economic considerations out of the equation by mandating that health insurers who pay for mastectomies also pay for reconstructive surgery.
But it does not tell them how much they have to pay. As a result many plastic surgeons have stopped doing the procedure, Alderman says, because they are so poorly reimbursed.
In an effort to assess the law's impact, Alderman and colleagues with the University of Michigan and the Ann Arbor VA Health System reviewed treatment data for roughly a quarter of the breast cancer patients in the U.S. who had mastectomies between 1998 and 2002.
They found that only 16.5% had breast reconstruction surgery.
Patient Preference, Doctor Bias
Certainly, some women who are offered reconstructive surgery chose not to have it. This is especially true among older women.
Roughly three out of four breast cancer patients in the U.S. are age 50 or older at diagnosis. Yet less than half of breast reconstruction surgeries are performed on patients age 50 and older, and fewer than one in 12 reconstructive surgery patients are over age 64.
"It may be that older women have different priorities that drive their decision, and that there are cultural and social differences that make African-Americans half as likely to want reconstructive surgery," Alderman says.
"But it may also be that these women aren't being offered the surgery because of physician bias."
She says many general surgeons may still believe that reconstructive surgery makes it harder to identify cancer recurrences, even though studies have shown that this is not the case.
There may also be more reconstructive surgeons in some regions of the country than in others, she says, which might help explain regional differences.
Albany, Ga., plastic surgeon Walter Erhardt, MD, tells WebMD that advances in reconstructive surgery should make it a more attractive option for breast cancer patients in the future.
More and more general surgeons are performing skin-sparing mastectomies, for example, that make it much easier to reconstruct the breast.
"This is one of the biggest changes that I have seen," he says. "As more general surgeons begin doing this we may see the reconstruction rates go up."