Catalyst for data collection

While it is a unique exercise, much remains to be done to drive up the standards of breast reconstruction, say the authors2. These comments were made with the UK in mind, but their tenor applies in international markets requiring a catalyst for research and development on more efficient methods of data collection.

Breast reconstruction can take place immediately post-mastectomy, but there are a range of issues for the patients to consider, at what is a very strange time for them. The UK report notes that during the period of the 2011 audit, 16,485 UK women underwent mastectomy, of which 3389 (21%) had a concurrent immediate reconstruction, and 1731 (10.45%) underwent a delayed breast reconstruction.

These 2011 data were collected from all 150 NHS acute trusts in England that provide mastectomy and breast reconstruction surgery; 114 independent sector hospitals; and six NHS trusts in Wales and Scotland. The results showed that the overall experience of care for women undergoing mastectomy and breast reconstruction in England was very good in what is the first national data collection to demonstrate the positive effects of breast reconstruction on quality of life following mastectomy.

The authors recommend that women diagnosed with breast cancer should be informed of these findings, and clinicians should ensure that they are supported in making informed decisions about whether or not to have breast reconstruction surgery. The results should also be used to inform women undergoing mastectomy of the likely outcomes of the different types of reconstruction, and what to expect when undergoing these procedures.

UK practice can now be benchmarked against the figures, and hospitals should identify areas in which local improvements are required, and ‘act to improve the outcomes of surgery in this group of women’, say the authors.

This is clearly a significant step forward in clinical terms, and with regard to choices that women are able to make and, indeed, demand.

More advice needed

In the UK, mastectomy as part of cancer treatment is available on the NHS. The procedure is also available privately. The Macmillan Cancer Support charity says NHS centres should make available the full range of breast reconstruction options, including advice on saline and silicone implants. This is in view of any ongoing nervousness about the remaining silicone brands on the market — understandable, if not clinically justified — in the wake of the PIP implant scandal.

In the US, under the 1998 Federal Breast Reconstruction Law, beneficiaries of health plans/health insurers undergoing mastectomy are covered for reconstruction of the breast on which the mastectomy has been performed, and surgery and reconstruction of the other breast to produce a symmetrical appearance. Physical complications may be subject to coinsurance. Individual states interpret the law in different ways3, and sometime impose (18- or 24-month) time limits for delayed surgery.

So, with clinical standards rising and procedure availability improving, the last part of the jigsaw is to improve patient and public awareness of the concept, in the way that the Dallas texting initiative has gone some way to chieve.

Fortunately, the awareness wave is already rolling. Given the assertion by the ASPS that 70% of women diagnosed with breast cancer remain in the dark about their reconstruction options following a mastectomy, the US Center for Restorative Breast Surgery (CRBS) is leading an initiative called ‘BRA Day USA’, on 17 October 2012. The Plastic Surgery Foundation (PSF) is a co-organiser with the ASPS.

The groups say that there remains a ‘consistent lack of awareness among patients regarding their rights and options for breast reconstruction’. This can have devastating results, which is what this BRA Day aims to do: ‘educate and empower these women’, according to CRBS co-founder and surgeon, Scott Sullivan MD.

BRA Day USA is just one example of awareness-raising initiatives surrounding breast reconstruction. Details can be found at www.bradayusa.org, and, of course, on Facebook (Facebook.com/BreastReconAwareness) and Twitter (@BRADayUSA).

Conclusions

More generally, what is happening in breast reconstruction is indicative of how health care is changing, and indeed moving from the prescriptive delivery of services to a system whereby the patient has a decision-making role in his or her own care, and is increasingly able to self‑manage. It is a maturing approach to health care which is centred on improving outcomes.