Breast reconstruction after cancer less common at cash-strapped hospitals

(Reuters Health) - Women with breast cancer who have one or both breasts removed are less likely to get immediate reconstruction surgery at hospitals that are struggling financially, a U.S. study suggests.

Most women with breast cancer have some type of surgery - either a lumpectomy that removes malignant tissue while sparing the rest of the breast or a mastectomy that removes the entire breast. After surgery, many of them also receive chemotherapy to destroy any remaining abnormal cells and reduce the risk of cancer coming back.

Cancer doctors recommend that all women be given the option to have breast reconstruction surgery immediately after mastectomy because it has been linked to a variety of health benefits including improved self-esteem, body image and sexual functioning as well as lower odds of depression and anxiety, researchers note in JAMA Surgery.

Compared to women treated at hospitals with few or no financial problems, women treated at hospitals with high levels of financial distress were 21 percent less likely to receive immediate breast reconstruction, the study found.

“It is not surprising that hospital factors have an influence on receipt of care,” said senior study author Dr. Dawn Hershman, leader of the breast cancer program at Columbia University Medical Center/New York Presbyterian Hospital in New York City.

“If a hospital has fewer resources, they may be more interested in hiring surgeons that perform procedures that are lucrative,” Hershman said by email.

In any given year, anywhere from 7 percent to 30 percent of hospitals in the U.S. are in financial distress and at risk of closure, researchers note.

For the study, they examined data on 5,760 women diagnosed with what’s known as ductal carcinoma in situ (DCIS), a common, early form of breast cancer that has not invaded neighboring tissue.

All of the women had a mastectomy between 2008 and 2012 at one of 1,156 hospitals in different counties across 26 U.S. states. Overall, about 41 percent of women got immediate breast reconstruction.

About 37 percent of the women treated at hospitals with high levels of financial distress received immediate breast reconstruction. These hospitals were at risk of closure for financial reasons. By comparison, about 44 percent of women treated at hospitals with solid finances got immediate breast reconstruction.

Women were more likely to get reconstruction when they were younger, white, had private insurance and received care at a teaching hospital or a cancer center. Immediate reconstruction also happened more often in counties where more residents had health insurance.

The study wasn’t a controlled experiment designed to prove whether or how hospital finances might influence the odds of women getting immediate reconstruction.

Even so, the results underscore the importance of women seeing a plastic surgeon to make an informed decision about breast reconstruction, said Dr. Brigid Killelea, co-author of an accompanying editorial and chief of breast surgery at Yale University School of Medicine in New Haven, Connecticut.

“I think it is important for patients to understand that getting a referral to a plastic surgeon to discuss reconstruction after mastectomy is standard and in most cases, encouraged; it’s not something extra or unnecessary,” Killelea said by email.

Patients shouldn’t feel limited in their treatment options by hospital finances,” Killelea added.

“Ideally, breast reconstruction should be performed at the same time as mastectomy,” Killelea said. “This allows surgeons to preserve as much skin as possible, reduces the number of operations, and results in a better overall cosmetic outcome.”

SOURCES: and JAMA Surgery, online December 6, 2017.