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

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.