Regional variation in use of immediate breast reconstruction after mastectomy for breast cancer in England
Introduction
Each year, 38 000 women are diagnosed with breast cancer in England.1 40% of those treated within the National Health Service (NHS) undergo a mastectomy as part of their treatment.2
Advances in plastic surgical techniques have made immediate breast reconstruction a safe option for most women undergoing mastectomy.3 The United Kingdom National Institute for Health and Clinical Excellence (NICE) stated in 2002 that “reconstruction should be available [to all women with breast cancer] at the initial surgical operation”,4 and in 2009 that clinicians should “discuss immediate breast reconstruction with all patients who are being advised to have a mastectomy, and offer it except where significant comorbidity or (the need for) adjuvant therapy may preclude this option”.5
In England, regional Cancer Networks have responsibility for service delivery and resource allocation.6, 7 Cancer Networks were created to overcome service fragmentation by bringing together health service commissioners and providers. A principal aim is for them to ensure patients within their regions have equitable access to high quality cancer care.
In 2009, the National Mastectomy and Breast Reconstruction Audit, a national prospective cohort study of women undergoing mastectomy with or without immediate reconstruction in England, suggested wide regional variation in immediate reconstruction rates.8 However, only three quarters of eligible patients were included, mastectomy-only patients were under-reported, and regional rates were based on relatively small samples.
In this paper we used Hospital Episode Statistics (HES)9 data to derive rates of immediate breast reconstruction after mastectomy for breast cancer within the English Cancer Networks. The HES database captures all surgical procedures in NHS hospitals, and is less prone to differential reporting of mastectomy and reconstruction procedures. It also provides larger patient samples because it is not restricted to activity within a limited timeframe. We investigated the effect of patient characteristics on immediate reconstruction use, and the extent to which they could explain variation in rates across Networks.
Section snippets
Hospital Episode Statistics
The HES database contains demographic, geographical and clinical information on all patients admitted to NHS hospitals in England. Surgical procedures are described using the UK Office for Population Censuses and Surveys classification, 4th revision (OPCS4)10 while medical conditions are described using the International Classification of Diseases, 10th revision (ICD10).11
Patient population
We extracted the HES records of all women diagnosed with invasive carcinoma of the breast (ICD10: C50) who underwent a
Results
Between 1 April 2006 and 28 February 2009, 44 837 mastectomies were performed in women with breast cancer. Their average age was 60.9 years (SD 13.9) and 6297 (14.0%) had one or more comorbidities. Ethnicity was known for 87.2%, of whom 94.1% were white.
Overall, 16.5% of women had an immediate reconstruction. Unadjusted immediate reconstruction rates among the 30 English Cancer Networks varied from 8.4% to 31.9% (p < 0.001). Excluding the Networks with the three highest and lowest values, the
Discussion
There is considerable variation in the use of immediate breast reconstruction between English Cancer Networks which persists after adjusting for patient characteristics. In addition, women who are non-white or from deprived areas are less likely to undergo immediate reconstruction. Rates of reconstruction were highest amongst women under 50 years.
Conclusion
We have found considerable variation in the regional use of immediate breast reconstruction which persists after adjusting for patient characteristics. The variation in the HES-derived rates is comparable with the findings of the National Mastectomy and Breast Reconstruction Audit and demonstrates that the differences have not existed for a short period of time.
The analysis does not presuppose that there is an optimal rate for immediate breast reconstruction. However, the wide regional
Acknowledgements
We would like to thank Lynn Copley of the Clinical Effectiveness Unit for preparing the extract used in this work, and the NHS Information Centre for Health and Social Care for providing the Hospital Episode Statistics data.
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Barriers and facilitators to breast reconstruction in ethnic minority women—A systematic review
2021, Journal of Plastic, Reconstructive and Aesthetic SurgeryBreast reconstruction patterns from a Swedish nation-wide survey
2020, European Journal of Surgical OncologyCitation Excerpt :Overall, the rate of BR after mastectomy had increased nationwide from 29% reported in group 2000 to 32% in 2010. The optimal rate of postmastectomy BR in general is hard to determine; available data on the national rates of BR in other countries for the similar time period have been reported as follows: Australia: 14% (1999-2006) [24], Denmark: 10% (1982-2000) [25], England: 16.5% (2006-2009) [26], USA: 16.5% (1998-2002) in the Surveillance, Epidemiology and End Results (SEER) database [27] and 23% in the later National Cancer Database (1998-2007) [28]. These rates and their variation are difficult to interpret due to differences in health-care systems and national guidelines for breast surgery and reconstruction, where patient selection and resources might play a role.
National trends in immediate and delayed post-mastectomy reconstruction procedures in England: A seven-year population-based cohort study
2017, European Journal of Surgical OncologyPatterns and outcomes of breast reconstruction in older women - A systematic review of the literature
2016, European Journal of Surgical OncologyCitation Excerpt :Australia,23 France,24 the Netherlands25 and Spain26 had one study each. The majority of studies reported on women aged ≥60 years (19 studies).16–19,23,24,27–36 Fifteen studies reported on women aged ≥65 years,6,13,15,20,21,37–46 and three studies reported on women ≥70 years.26,47,48
Variation in rates of breast cancer surgery: A national analysis based on French Hospital Episode Statistics
2016, European Journal of Surgical OncologyCitation Excerpt :Disparities in access to certain surgical procedures considered as state-of-the-art interventions continue despite two national Cancer Plans. Further work is warranted in order to understand the determinants of these variations in practice because variations in cancer treatment have been shown to emanate from multiple sources including differences in the socioeconomic status of the patient, patient preferences and provider beliefs regarding indications for a procedure [Jeevan et al.,4 Zhong et al.,6 Farrow et al.,16 Morrow et al.,17 Joslyn et al.18]. This research study was supported by the French Institute for Public Health Research (IRESP) on the occasion of a call for proposals launched in 2012 alongside the Plan Cancer 2009–2013.