National trends in immediate and delayed post-mastectomy reconstruction procedures in England: A seven-year population-based cohort study

https://doi.org/10.1016/j.ejso.2016.09.019Get rights and content

Abstract

Introduction

Little is known about post-mastectomy reconstruction procedural trends in women diagnosed with breast cancer in England. Our aim was to examine patterns of immediate and delayed reconstruction procedures over time and within regions.

Methods

Women with breast cancer who underwent unilateral index immediate or delayed post-mastectomy reconstruction between 2007 and 2014 were identified using the National Hospital Episode Statistics database. Women were grouped into categories based on the type of reconstruction procedure. Adjusted rates of implant and free flap reconstructions were then calculated across regional Cancer Networks using a regression model to adjust for age, disease, comorbidities, ethnicity, and deprivation.

Results

Between 2007 and 2014, 21 862 women underwent immediate reconstruction and 8653 delayed reconstruction. Immediate implant reconstruction increased from 30% to 54%, and immediate free flap reconstruction from 17% to 21%. Adjusted immediate implant and free flap proportions ranged from 17 to 68% and 9–63%, respectively, across regions. Free flaps became more common in the delayed setting, rising from 25% to 42%. However, adjusted rates ranged from 23% to 74% across regions. Networks with high/low rates of free flaps for immediate tended to have high/low rates for delayed reconstruction.

Conclusion

There has been a substantial increase in the use of immediate implant reconstruction in England. In comparison, there has been an increasing use of autologous free flap reconstruction for delayed procedures. Significant regional variation exists in the type of reconstruction performed, and these patterns need to be examined to determine if variation is related to service provision and/or capacity barriers.

Introduction

The psychosocial impact on women with breast cancer who undergo mastectomy has been well documented.1, 2 In 2002, the National Institute for Health and Clinical Excellence in the UK recommended that post-mastectomy reconstruction should be available to all women.3 Whilst in the US, the 1999 Women's Health and Cancer Rights mandated that health insurance providers cover reconstruction costs. Subsequently breast cancer care services have evolved, and in numerous countries encouraging evidence indicates a rise in reconstruction uptake.4, 5, 6, 7

Currently women have several reconstruction options available to them either at the time of mastectomy or at a later date. These include implants, autologous pedicled flaps with or without implants, and autologous free flap reconstructions.8 In recent years, there has been the development of materials that facilitate direct to implant reconstruction such as accellular dermal matrices (ADM) and titanium mesh.

Studies of immediate breast reconstruction from early 2000s revealed a ratio of 2:1 for autologous to implant procedures.9, 10 Authors have demonstrated higher patient satisfaction following autologous reconstruction, and greater longevity of aesthetic results at long term follow-up comparative to implant reconstruction.11, 12 Despite this evidence, a rise in immediate implant procedures has been reported in the US.13, 14

Little is known about the types of breast reconstruction technique delivered across England, either in immediate or delayed procedures. Further, procedural trends in the delayed setting remain underreported worldwide.15, 16 Understanding such national patterns of breast cancer care is crucial for future service planning, from both a funding and training perspective. Information about regional practice is also required to evaluate whether the health care service is meeting its principle of delivering equality of access for people with equivalent needs.8, 17 The aim of our study was therefore to evaluate the trend in type of immediate and delayed post-mastectomy reconstruction procedures performed in the English NHS. We also examined regional patterns of immediate and delayed reconstruction.

Section snippets

Methods

This study used data extracted from the Hospital Episode Statistics (HES) database between 1 January 2000 and 31 March 2014.18 This database contains records on all patients admitted to English National Health Service (NHS) hospitals, and allocates patients a unique identifier that allows for longitudinal follow-up. Each record contains demographic and clinical information including diagnoses, and operative procedures. Diagnoses are coded using International Classification of Diseases, 10th

Immediate reconstruction

Between April 2007 and March 2014, a total of 21 862 women were identified as having unilateral mastectomy with immediate reconstruction. The annual number of reconstructions increased from 2182 in 2007 (14.9% immediate reconstruction rate) to 3753 in 2013 (24.7% immediate reconstruction rate). The dominant trend in procedure type was related to implant/expander based reconstructions, rising from 30% of all immediate reconstruction in 2007 to 54% in 2013. The use of free flap procedures

Discussion

Between April 2007 and March 2014, there has been a distinct change in types of immediate and delayed post-mastectomy reconstruction procedures being performance within England. Among women with breast cancer undergoing immediate reconstruction, the overwhelming trend was towards implant/expander reconstructions, with proportions rising from 30% to 54%. In those women undergoing delayed reconstruction, however, it was free flap procedures that became more dominant, rising from 25% in 2007 to

Conclusion

Our study found a significant trend toward implant based immediate post-mastectomy reconstruction, rising from 30% in 2007 to 54% in 2013. In the delayed setting, free flap procedures were the dominant trend, rising from 25% to 42% over the seven-year study period. In both immediate and delayed reconstructions, age, deprivation, and ethnicity influenced a woman's likelihood of receiving free flap reconstruction. Substantial variation in type of reconstruction was observed across the regional

Conflict of interests statement

All authors confirm there are no conflicts of interest. This included no financial or personal relationships with other people or organisations that could inappropriately influence our work.

Role of funding source

J.C. Mennie was funded by a grant received from the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS), the Association of Breast Surgeons (ABS), and Johnson and Johnson. None of the authors have any commercial association or financial interest in any of the products, drugs, or devices mentioned in this manuscript, nor in Johnson and Johnson.

Details of ethics approval

The study is exempt from UK NREC approval because it involved the analysis of an existing dataset of anonymous data for service evaluation. Approvals for the use of HES data were obtained as part of the standard Hospitals Episode Statistics approval process.

Acknowledgements

Hospital episode statistics were made available by the NHS Health and Social Care Information Centre (Copyright © 2012, Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.)

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