Australia’s rate of breast reconstruction is one of the lowest in the Western world. One of the main reasons is that many women are not informed about their options by their surgeons in a timely way. Thankfully this is starting to change as a new wave of surgeons seeks to shift the focus of breast surgery away from simply removing the cancer, to recognising that offering breast reconstruction should be an integral part of the treatment pathway, and has a vital part to play in many women’s quality of life post-mastectomy.
Reclaim Your Curves recently spoke to President of BreastSurgANZ, and oncology surgeon at Sydney’s Mater Hospital, A/Prof Andrew Spillane and his research colleague, Kathy Flitcroft PhD, about the reasons for their hospital’s unusually high reconstruction rate and their efforts to break down the barriers to reconstruction.
RYC: The Poche Centre at the Mater Hospital’s rate of breast reconstruction is reported to be around 41%, which is amongst the highest in the world. What factors do you believe contribute to this high rate of reconstruction?
AS: The critical thing is to start the conversation about reconstruction early, as soon as the woman has been diagnosed with breast cancer, so that she has access to the full range of possible options. For many women, reconstruction, particularly implant reconstruction, can occur at the same time as mastectomy and there may be the options of skin and nipple sparing mastectomy to improve the look and feel of the reconstructed breast.
We believe that nearly every woman who has a mastectomy could have a reconstruction if she chose to. Giving women the choice, upfront, to have reconstruction if they want it, and as part of a package of treatment options, has led to almost half of the women we see wanting to take up the offer.
RYC: What are the barriers to reconstruction?
AS: The biggest barrier can be the surgeon. Traditionally, surgeons are focused just on removing the cancer before further treatment, and reconstruction, if offered, tends to be an afterthought and not all the options may be explored. In fact, quite often the discussion and referral never happens.
The other major barrier is the worry that chemotherapy or radiotherapy may be delayed if reconstruction takes place at the same time as mastectomy. However, there is the possibility for many women that they can have their chemotherapy and radiotherapy prior to surgery, so that this is not an issue. For those women who have surgery first and are going on to have other treatments, they can still decide to have an expander inserted at the same time as their mastectomy and then choose later if they wish to have an implant or free flap reconstruction, or not to pursue reconstruction at all – you don’t lose anything by this approach but have a lot to gain as the chest has been prepared for later reconstruction if required.
RYC: We sometimes hear from women that their surgeons say; “…let’s just deal with the cancer and think about reconstruction later.” What are your thoughts?
AS: That is the standard approach but our research work and clinical practice is demonstrating that there are other ways to work which have good outcomes for the patient, and that it is OK to take a different approach which ensures the woman knows she is entitled to reconstruction if she wants it.
RYC: Why do you think the rates are so low in some other hospitals?
AS: The services are led by the surgeons and there needs to be a cultural shift in order to start making a difference for those women who do not have the same access to the reconstruction options that the women coming to our clinic, and some other hospitals, have.
RYC: Do you think there needs to be law or policy changes to make reconstruction options more widely accessible, such as that in New York where legislation states that the surgeon must offer reconstruction as part of breast cancer treatment?
AS: We believe education of surgeons is more important as there are ways to get around these types of laws. There needs to be systemic, cultural changes in order to improve access across the board and this can best happen through better training as a result of solid research.
At BreastSurgANZ, we are focused on educating breast surgeons about incorporating new approaches and from next year, for the first time in Australia, we will be offering a Graduate Certificate in Breast Surgery for Fellows of the Royal Australian College of Surgeons to upgrade their surgical skills and knowledge. This training will include teaching oncoplastic techniques so that a surgeon has a greater array of tools to offer their patients. The Certificate will also enhance their understanding of the multidisciplinary care of breast cancer patients, so that surgery and reconstruction is viewed in context with the patient’s full package of care.
This course is based on a successful program developed in the UK, which in part contributed to the reconstruction rate going from 6% to 25% due to training and major organisational changes in the way that reconstruction was viewed. I trained for 2 years in the UK and women’s attitudes to reconstruction in that country are vastly different as they are aware that they are entitled to reconstruction under the National Health Service (NHS).
KF: That’s true. From my research into improving access to reconstruction, women in Australia seem to have a very different psyche when it comes to reconstruction. There seems to be this feeling that we are just lucky to survive and Australian women tend to feel guilty about wanting to reconstruct their breasts, whereas in the UK reconstruction is simply expected under the NHS and women see it as their right.
RYC: Why would surgeons want to change?
AS: More surgeons are coming through that are trained in oncoplastic techniques, and their focus is not just on the very important oncological issues but also restoring the appearance of the breast and achieving the best aesthetic outcome for their patient. As their skills become more widely known, competitive pressure will force more traditionally trained general surgeons to gain new skills. Also, the range of surgical options and advances in the field mean that it is becoming a more interesting area to specialise in, offering greater status and a more compelling career path.
RYC: Kathy, can you tell us a bit more about your current research and how it will be used to improve patient care?
KF: I’m in charge of a 4 year study which is looking at the uneven rates of reconstruction across Australia and exploring the reasons behind these inequities. The project includes reviewing different models of care and widespread consultation with women with breast cancer, surgeons, breast care nurses and policy-makers. The research will produce recommendations for practice and policy changes to address gaps and variations in the quality of care that women receive.
As there is no publicly-available local level data from Medicare or the Australian Institute of Health & Welfare that tells us where reconstruction occurs, we have used hospital level data provided by BreastSurgANZ members to paint a picture of what happens in the various States and Territories.
While the data is not perfect, it is the best available information we have in Australia about what is happening and it shows there are large disparities between States, but also within areas of each State. It also tells us that, surprisingly, it is not necessarily location or resource issues that are the primary drivers responsible for low (or no) rates of reconstruction. Some well-resourced, centrally-located hospitals have low rates of breast reconstruction because not all surgeons who operate there offer it to their patients. This reinforces BreastSurgANZ’s view that education of surgeons is the key to overcoming these inequities.
RYC: Final thoughts?
AS: Women, not surgeons, should make the choice and hopefully our work at BreastSurgANZ and groups such as ours will create the shift needed to guarantee that every woman diagnosed with breast cancer, no matter where she lives in Australia, is able to access reconstruction if she wants it.
Interview by Jane Goodwin-Moore
Publicity and Consumer Information, Reclaim Your Curves
Jane Goodwin-Moore is a writer and consumer. She interviews Australian health professionals about their role and thoughts on breast reconstruction in Australia