Review
Uptake and predictors of post-mastectomy reconstruction in women with breast malignancy – Systematic review

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Abstract

Purpose

There is enormous range in the reported rates of breast reconstruction. This study explored reasons for this variation by reviewing the published literature to examine rates of reconstruction, factors associated with uptake, and possible barriers.

Methods

A systematic review of the literature was performed. Eligible studies reported rates of breast reconstruction and variables associated with uptake in women undergoing mastectomy for early invasive or in situ breast malignancy.

Results

Twenty-eight eligible studies were included, reporting 159,305 cases of breast reconstruction in 940,678 women. In these studies 16·9% of women underwent immediate or delayed reconstruction (range 4·9–81·2%, median 23·3%). Variables associated with reconstruction were: patient/tumour factors (early stage, no adjuvant therapy, young age, white race, private insurance, higher education/income), surgeon/hospital factors and psychological/other factors (including patient choice).

Conclusion

Rates of breast reconstruction were highly variable. Reconstruction appeared to be offered to a minority of women; around half took up the offer. The main reasons reported for no reconstruction included patient-related and adjuvant therapy-related factors. Clinicians' beliefs about reconstruction may be an important factor. Rates of reconstruction could be increased with early discussion of the options when mastectomy is chosen or required.

Section snippets

Background

There is evidence showing that breast reconstruction is a safe option for the majority of women undergoing mastectomy for breast cancer and that it does not have an adverse effect on rates of recurrence.1, 2 There is some evidence of quality of life benefits of immediate over delayed breast reconstruction,3, 4 although this finding has not been consistent.5 There is very little research comparing outcomes in women who undergo reconstruction and those who choose not to. A prospective study found

Methods

Studies were identified by searching Medline (Pubmed and Ovid) and the Cochrane Database using the search terms ‘breast cancer,’ ‘breast reconstruction,’ and ‘mastectomy.’ The search was limited to studies in English published from January 1980 to December 2011. Additional studies were identified by reviewing the references of eligible studies.

Eligibility criteria were: original study reporting outcomes for at least 25 women with early breast malignancy (invasive or in situ) AND reporting rate

Study selection

The search identified 182 studies; a further 15 studies were added after review of reference lists of eligible studies. Fifty two abstracts met eligibility criteria and 24 were excluded following review of full text articles (Fig. 1).24 Twenty eight studies were eligible for inclusion in the analysis (Fig. 1).11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39

Study characteristics

Included studies are shown in Table 1 (ordered by number of mastectomy cases

Discussion

Enormous variation in rates of breast reconstruction (4·9 to 81·2%) was seen and there are no clear trends to explain this. While there are higher rates of reconstruction in more recent years, the incremental increase is extremely small in most studies.11, 13, 14, 23, 38 The exception is the series of robust audits in the UK that show a large increase in a short period of time. This is the only series to show a significant increase over time, despite the dramatic improvements in technical

Conclusion

In conclusion, rates of breast reconstruction are generally low and highly variable. Studies of breast reconstruction rates have been inconsistent in their methodology, in the type of reconstruction examined (immediate or delayed) and in the variables they assessed. Due to this heterogeneity, it is difficult to draw firm conclusions from the data. The reasons for the variable rate are unclear but appear to be complex and multifactorial. Surgeon, institution, geographical and access issues are

Funding

This research is funded in part by The Friends of the Mater Foundation, North Sydney, Australia, supporting part of A/Prof Spillane's research time.

The funding source played no role in study design, data collection, analysis and interpretation of data, writing of the manuscript or decision to submit the manuscript for publication.

Conflicts of interest

The authors have no conflicts to declare.

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