The option of reconstruction after mastectomy for breast cancer
is often not discussed with indigent patients, according to a
study presented at the 65th Annual Meeting of the American Society
of Plastic and Reconstructive Surgeons (ASPRS) held in Dallas,
The retrospective review, which covered a period of 10 years,
showed that fewer than 20% of indigent women were offered breast
reconstruction and only 4.5% actually underwent the procedure.
"The number of women referred for reconstruction after mastectomy
among indigent patients was extremely low," said plastic
surgeon Sharon Kalina, md, Loma Linda University Medical Center,
Loma Linda, California, one of the clinical investigators. "Even
though women may not choose to have breast reconstruction, they
have a right to know it is available to them even in the years
The study, conducted at Riverside General Hospital, included 155
indigent patients treated for breast cancer between 1984 and 1994.
The average age of the patients was 52 years. Although the group
included African-American (10%), Hispanic (29%), and other ethnic
groups (6%), more than half the women (55%) were Caucasian.
Almost all (96.8%) of the patients underwent mastectomy, but only
30 patients (19.4%) were offered reconstruction by the general
surgeon or oncologist. Among the subgroup offered reconstruction,
four were not referred due to severe medical problems or lack
of interest. Of the 26 patients referred for reconstruction, only
23 (14.8%) kept their initial appointment and 7 patients (4.5%)
underwent reconstruction. Of the remaining 16 patients, 3 declined
reconstruction, 2 had severe medical or psychiatric problems,
and 11 were totally lost to follow-up.
Many of the women were overweight, and some were heavy smokers.
Others were undergoing chemotherapy or radiation therapy. While
these conditions may have influenced the decision, they should
not have ruled out the possibility of breast reconstruction for
all these women.
"The first thing we have to do is to improve awareness of
the situation," said Dr. Kalina. "Even if some of these
special conditions may be present, the patient should have an
opportunity to discuss breast reconstruction with the plastic
In some states, insurance companies are now required to cover
breast reconstruction after mastectomy for breast cancer. When
patients are given the option of breast reconstruction, they are
able to discuss their choices with a plastic surgeon and make
the most appropriate decision for themselves.
"At the very least, the patient should be provided with a
prescription for a prosthesis to allow them some measure of normal
appearance," said Dr. Kalina. "They also need to be
referred to local support groups for assistance in coping with
the emotional impact of the disease and the recovery process."
In addition, indigent patients need to be educated about the importance
of keeping medical appointments to complete medical treatments.
Dr. Kalina indicated that additional research needs to be done
to investigate the reasons for poor follow-up of medical appointments
among this patient population.