Indigent Women With Breast Cancer Are Often Not Referred for Breast Reconstruction

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, Texas.

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 to come."

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 surgeon."

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.