Improving access to care: breast surgeons, the gatekeepers to breast reconstruction.
BACKGROUND
Fewer than half of patients undergo reconstruction after breast cancer treatment, despite its quality of life benefits. Earlier studies demonstrated that most general surgeons do not discuss reconstructive options with patients. The aim of this study was to examine the likelihood of reconstruction within a cohort of mastectomy patients and compare rates of reconstruction between those referred and not referred for plastic surgery evaluation.


METHODS
Retrospective review of the records of 471 consecutive patients between the ages of 19 and 94 years who underwent mastectomy between 2003 and 2007. Variables evaluated were age, body mass index, diabetes, laterality (unilateral vs bilateral), TNM staging, history of radiation, smoking history, insurance type, and race.


RESULTS
Of 471 patients, 313 were referred for consultation with a plastic surgeon and 158 were not; 91.7% of those referred were reconstructed and 100% of those not referred were not reconstructed. The 2 groups differed considerably in terms of age (mean age 61.84 years in the nonreferred group vs 51.83 years in the referred group), body mass index (25.9 in referred group, 27 in nonreferred group), diabetes (15% in nonreferred group vs 3.5% in referred group), and laterality (14% of nonreferred group underwent bilateral mastectomies vs 26% of those referred). The groups did not differ significantly in terms of race or tobacco use. Those with private insurance were more likely to be reconstructed, but no independent effect of insurance type was seen on multivariate analysis.


CONCLUSIONS
The breast surgeon's decision to refer a patient for reconstruction significantly affects whether the patient will receive breast reconstruction. Factors that appear to influence the referral decision are age, diabetes, body mass index, and laterality of mastectomy (bilateral more than unilateral).
Division of Plastic Surgery, Harlem Hospital, New York, NY 10032, USA.
Beth Aviva
BA
Preminger
Koiana
K
Trencheva
Catherine S
CS
Chang
Austin
A
Chiang
Mahmoud
M
El-Tamer
Jeffrey
J
Ascherman
Christine
C
Rohde
D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015992:Body Mass Index; D048909:Diabetes Complications; D005260:Female; D006801:Humans; D007348:Insurance, Health; D016462:Mammaplasty; D008408:Mastectomy; D008875:Middle Aged; D009367:Neoplasm Staging; D044469:Racial Groups; D012017:Referral and Consultation; D012189:Retrospective Studies; D012907:Smoking