Viewpoint
Volume 49, Issue 7, July 2020

General practitioners are key to increasing Australia’s low rate of breast reconstruction

Meagan E Brennan    Kathy Flitcroft    Andrew J Spillane   
doi: 10.31128/AJGP-11-19-5162   |    Download article
Cite this article    BIBTEX    REFER    RIS

In Australia, the rate of breast reconstruction after mastectomy for breast cancer has unacceptable variation between socioeconomically and geographically similar areas.1 While some centres offer a full range of options and contemporary best practice, others do not give women information about options that should be available for all. General practitioners (GPs) have a key role to play by ensuring their patients have the opportunity for an informed discussion with multidisciplinary teams (MDTs) that offer choice.

Breast cancer affects one in eight Australian women,2 and approximately 40% will require or choose mastectomy for treatment.3 It is estimated that 50% of women will take up the option of breast reconstruction if it is given.4 Breast reconstruction has proven quality-of-life benefits with no adverse impact on locoregional recurrence or survival.5 The lack of choice regarding breast reconstruction is associated with significant long-term psychological distress; this has been reinforced by recent Australian research.6 Despite the perception by some that breast reconstruction is cosmetic surgery, its purpose is to reconstruct the body after ablative and disfiguring cancer surgery. It should therefore be considered an essential service, not an ‘optional add-on’.

The most recent estimate of Australia’s rate of breast reconstruction is 17–18%.1,7 This rate is lower than that of similar health systems such as the UK, for which the rate is 23.3%.8 Some specialist Australian centres that are committed to offering breast reconstruction to all suitable patients (both public and private) have reported immediate reconstruction rates of more than 40%, whereas one-third of 104 metropolitan hospitals that performed mastectomy in 2013 did no breast reconstruction.1,9,10

The low overall national rate in Australia suggests that there is a large proportion of women who would be interested in breast reconstruction who are not given the option. Further evidence for this lack of opportunity is supported by a member survey by Breast Cancer Network Australia, which found that many women did not receive information about breast reconstruction at the time of their mastectomy, or that they had to initiate the discussion and/or referral themselves.11 The lack of opportunity for breast reconstruction can have a devastating effect on women,6 and they are deprived of the significant quality-of-life benefits that reconstruction achieves for women who feel it is right for them.12,13

Cancer Australia’s statement of best practice specifically states that it is ‘not appropriate to perform a mastectomy without first discussing with the patient the options of immediate or delayed breast reconstruction’,3 and guidelines in the UK also mandate a preoperative discussion of all options, ‘whether or not they are available locally’.14

Significant disparities exist. Women are more likely to undergo breast reconstruction if they are younger, privately insured and treated in metropolitan rather than rural or remote areas.9,11 Some patients  are unsuitable for reconstruction because of tumour factors or comorbidities; however, the proportion is small.9 Satisfactory outcomes from breast reconstruction combined with adjuvant radiotherapy have been reported,15 although some surgeons still consider this to be a contraindication to immediate reconstruction. Instead, delayed reconstruction is offered, and this may require years on a public waiting list; by this time, often the patient has treatment fatigue and does not have reconstructive surgery at all. Other barriers to reconstruction include cost (frequently more than $10,000 out of pocket in the private system) and lack of local expertise in rural areas.11 A range of demarcation issues between surgical oncologist/oncoplastic surgeons and plastic surgeons have been identified; these act as a further barrier to access when surgeons are unsupportive of each other in a hospital or are unwilling to refer to colleagues.16 A further challenge is that some referral centres do not accept patients who reside outside the area, which may limit the options, especially for women in rural areas.

Many of the access barriers to breast reconstruction are health systems issues that are challenging to solve. There are, however, some simple strategies that GPs can use to maximise the chances of their patients having the option of choice (Box 1). Some of these include:

  • mentioning the idea of breast reconstruction to patients at the time of diagnosis and first referral, if appropriate and if the patient is able to absorb the information at this early stage
  • empowering the patient to ask questions of her treatment team
  • referring to an MDT that is able to offer the full range of breast reconstruction options, or one that is willing to refer to another team if this is in the best interest of the patient
  • ensuring the patient has access to a breast care nurse and to consumer organisations.

In conclusion, not all women undergoing mastectomy will desire or choose breast reconstruction. The important issue, however, is that all women have the opportunity to make an informed choice. The GP has a major role in appropriate referral and empowerment of patients to have an active role in their breast cancer care.

Box 1. Encouraging informed choice about breast reconstruction: Strategies for general practitioners
1. Start the conversation early
  • At the time of diagnosis and initial referral, it may not be clear to the general practitioner (GP) whether a patient will require mastectomy. A GP may be hesitant to discuss treatment options because of concern about causing alarm or misleading the patient without having all the information available.
  • In this situation, a hypothetical discussion may still occur if the patient is able to absorb the information at this early stage. For example: ‘Sometimes removal of the breast (mastectomy) is needed for breast cancer treatment. If this happens, breast reconstruction (surgery to recreate a breast shape) is possible for most women. Make sure you ask your treating doctors about this if it is something that interests you’.
  • This discussion will ensure that the patient has heard of reconstruction and will empower the patient to ask questions. If the patient expresses an interest in this, it can be mentioned in the referral letter simply by saying: ‘She would like to discuss breast reconstruction should mastectomy be required’.
2. Refer to a multidisciplinary team (MDT) that includes an oncoplastic breast surgeon
and/or plastic surgeon
  • A surgeon who performs breast reconstruction should be a core member of the breast MDT. Some breast cancer surgeons perform implant-based breast reconstruction (oncoplastic surgeons), and others will refer patients. Autologous flap reconstruction is almost always performed by a plastic surgeon. The expertise for the full range of options should be provided within the team, and surgeons must be willing to work together and inter-refer for the benefit of the patient.
  • The CanRefer website, run by the NSW Cancer Institute, provides a directory of individual cancer specialists and MDTs in NSW and it is regularly validated and updated (www.canrefer.org.au). Unfortunately, similar directories are not currently available in other states and territories.
  • By referring all patients to an MDT that includes expertise in breast reconstruction, GPs will ensure that reconstruction is part of the discussion at diagnosis, before any surgery is planned.
3. Continue the conversation
  • Women often benefit from returning to their GPs to discuss the treatment plan after meeting the surgeon and team. This allows the GP a further opportunity to ensure that breast reconstruction has been considered as an option.
  • The GP can discuss the plan with the team and advocate on the patient’s behalf by asking whether reconstruction is an option.
  • The GP can reassure the patient that a second opinion is to be encouraged when there is uncertainty, and that a short delay to allow this will not change survival.
4. Refer for support
  • Breast care nurses are a valuable resource for women with newly diagnosed breast cancer. They are now available throughout Australia, including in rural areas, as a result of significant government and community support through the McGrath Foundation and local hospitals. Breast care nurses can discuss the options with women, provide support throughout their decision making and act as a liaison with larger cancer centres should a patient from a rural area decide to travel for treatment.
  • Women can be encouraged to contact consumer support and information groups. These include:
  • Written information is available at all the websites above and can help to reinforce the message.
Competing interests: None.
Provenance and peer review: Not commissioned, externally peer reviewed.
Funding: None.
References
  1. Flitcroft K, Brennan M, Costa D, Spillane A. Documenting patterns of breast reconstruction in Australia: The national picture. Breast 2016;30:47–53. doi: 10.1016/j.breast.2016.08.013. Search PubMed
  2. Australian Institute of Health and Welfare. Cancer in Australia 2019. Vol Cancer series no.119. Cat. no. CAN 123. Canberra: AIHW, 2019. Search PubMed
  3. Cancer Australia. Cancer Australia Statement – Influencing best practice in breast cancer. Surry Hills, NSW: Cancer Australia, 2016. Search PubMed
  4. Brennan ME, Spillane AJ. Uptake and predictors of post-mastectomy reconstruction in women with breast malignancy – Systematic review. Eur J Surg Oncol 2013;39(6):527–41. doi: 10.1016/j.ejso.2013.02.021. Search PubMed
  5. Gieni M, Avran R, Dickson L, et al. Local breast cancer recurrence after mastectomy and immediate breast reconstruction for invasive cancer: A meta-analysis. Breast 2012;21(3):230–36. doi: 10.1016/j.breast.2011.12.013. Search PubMed
  6. Flitcroft KL, Brennan ME, Spillane AJ. The impact on Australian women of lack of choice of breast reconstruction options: A qualitative study. Psychooncology 2019;28(3):547–52. doi: 10.1002/pon.4974. Search PubMed
  7. Feng Y, Flitcroft K, van Leeuwen MT, Elshaug AG, Spillane A, Pearson SA. Patterns of immediate breast reconstruction in New South Wales, Australia: A population-based study. ANZ J Surg 2019;89(10):1230–35. doi: 10.1111/ans.15381. Search PubMed
  8. Jeevan R, Mennie JC, Mohanna PN, O’Donoghue JM, Rainsbury RM, Cromwell DA. National trends and regional variation in immediate breast reconstruction rates. Br J Surg 2016;103(9):1147–56. doi: 10.1002/bjs.10161. Search PubMed
  9. Wong A, Snook K, Brennan M, et al. Increasing breast reconstruction rates by offering more women a choice. ANZ J Surg 2014;84(1–2):31–36. doi: 10.1111/ans.12471. Search PubMed
  10. Heilat GB, Brennan ME, Kanesalingam K, Sriram N, Meybodi F, French J. Presentation, tumour and treatment features in immigrant women from Arabic-speaking countries treated for breast cancer in Australia. ANZ J Surg 2019. doi: 10.1111/ans.15596. Search PubMed
  11. Breast Cancer Network Australia. Breast Cancer Network Australia: Breast reconstruction survey. Camberwell, Vic: Breast Cancer Network Australia, 2010. Search PubMed
  12. The NHS Information Centre for health and social care. National mastectomy and breast reconstruction audit. Version 2. Leeds, UK: The NHS Information Centre, National Mastectomy and Breast Reconstruction audit, 2009. Search PubMed
  13. Howes BH, Watson DI, Xu C, Fosh B, Canepa M, Dean NR. Quality of life following total mastectomy with and without reconstruction versus breast-conserving surgery for breast cancer: A case-controlled cohort study. J Plast Reconstr Aesthet Surg 2016;69(9):1184–91. doi: 10.1016/j.bjps.2016.06.004. Search PubMed
  14. National Institute for Heath and Care Excellence. Early and locally advanced breast cancer: Diagnosis and management. London: NICE, 2018. Search PubMed
  15. Brennan ME, Flitcroft K, Warrrier S, Snook K, Spillane AJ. Immediate expander/implant breast reconstruction followed by post-mastectomy radiotherapy for breast cancer: Aesthetic, surgical, satisfaction and quality of life outcomes in women with high-risk breast cancer. Breast 2016;30:59–65. doi: 10.1016/j.breast.2016.08.008. Search PubMed
  16. Flitcroft K, Brennan M, Salindera S, Spillane A. On the frontiers of change: Breast surgeons’ views on demarcation between surgical sub-specialties in Australia. ANZ J Surg 2019. doi: 10.1111/ans.15580. Search PubMed

Breast neoplasmsGeneral practitionersMammaplastyMastectomyPatient care teamPatient-centred carePlastic surgeryPsychological distressQuality of lifeReferral and consultationWomen's health

Download article