Indigent Women With Breast Cancer Are Often Not Referred for Breast Reconstruction

The option of reconstruction after mastectomy for breast canceris often not discussed with indigent patients, according to astudy presented at the 65th Annual Meeting of the American Societyof Plastic and Reconstructive Surgeons (ASPRS) held in Dallas,Texas.

The retrospective review, which covered a period of 10 years,showed that fewer than 20% of indigent women were offered breastreconstruction and only 4.5% actually underwent the procedure.

"The number of women referred for reconstruction after mastectomyamong indigent patients was extremely low," said plasticsurgeon Sharon Kalina, md, Loma Linda University Medical Center,Loma Linda, California, one of the clinical investigators. "Eventhough women may not choose to have breast reconstruction, theyhave a right to know it is available to them even in the yearsto come."

The study, conducted at Riverside General Hospital, included 155indigent patients treated for breast cancer between 1984 and 1994.The average age of the patients was 52 years. Although the groupincluded African-American (10%), Hispanic (29%), and other ethnicgroups (6%), more than half the women (55%) were Caucasian.

Almost all (96.8%) of the patients underwent mastectomy, but only30 patients (19.4%) were offered reconstruction by the generalsurgeon or oncologist. Among the subgroup offered reconstruction,four were not referred due to severe medical problems or lackof interest. Of the 26 patients referred for reconstruction, only23 (14.8%) kept their initial appointment and 7 patients (4.5%)underwent reconstruction. Of the remaining 16 patients, 3 declinedreconstruction, 2 had severe medical or psychiatric problems,and 11 were totally lost to follow-up.

Many of the women were overweight, and some were heavy smokers.Others were undergoing chemotherapy or radiation therapy. Whilethese conditions may have influenced the decision, they shouldnot have ruled out the possibility of breast reconstruction forall these women.

"The first thing we have to do is to improve awareness ofthe situation," said Dr. Kalina. "Even if some of thesespecial conditions may be present, the patient should have anopportunity to discuss breast reconstruction with the plasticsurgeon."

In some states, insurance companies are now required to coverbreast reconstruction after mastectomy for breast cancer. Whenpatients are given the option of breast reconstruction, they areable to discuss their choices with a plastic surgeon and makethe most appropriate decision for themselves.

"At the very least, the patient should be provided with aprescription for a prosthesis to allow them some measure of normalappearance," said Dr. Kalina. "They also need to bereferred to local support groups for assistance in coping withthe emotional impact of the disease and the recovery process."

In addition, indigent patients need to be educated about the importanceof keeping medical appointments to complete medical treatments.Dr. Kalina indicated that additional research needs to be doneto investigate the reasons for poor follow-up of medical appointmentsamong this patient population.