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4–25 Correlates of Referral Practices of General Surgeons to Plastic Surgeons for Mastectomy Reconstruction
sparing mastectomy are confirmed, it will be a welcome addition to the armamentarium of tools oncologic surgeons can use to optimize breast cancer patients’ outcomes. A. Lucci, MD
References 1. Veronesi U, Saccozzi R, Del Vecchio M, et al: Comparing radical mastectomy with quadrantectomy, axillary dis-
4–25
Correlates of Referral Practices of General Surgeons to Plastic Surgeons for Mastectomy Reconstruction Alderman AK, Hawley ST, Waljee J, et al (Univ of Michigan, Ann Arbor; Veterans Affairs Ctr for Practice Management and Outcomes Research, Ann Arbor; Fox Chase Cancer Ctr, Philadelphia) Cancer 109:1715-1720, 2007
Background.—General surgeons’ attitudes toward breast reconstruction may affect referrals to plastic surgeons. The propensity to refer to plastic surgeons prior to surgical treatment decisions for breast cancer varies markedly across general surgeons and is associated with receipt of reconstruction. In this study, the authors used data from a large physician survey to examine factors associated with general surgeons’ propensity to refer breast cancer patients to plastic surgeons prior to mastectomy. Methods.—The authors surveyed all attending general surgeons (N = 456 surgeons) from a population-based sample of breast cancer patients who were diagnosed in Detroit and Los Angeles during 2002 (N = 1844 patients), with a surgeon
section, and radiotherapy in patients with small cancers of the breast. N Engl J Med 305:6-11, 1981. 2. Fisher B, Bauer M, Margolese R, et al: Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 312:665673, 1985. 3. Caruso F, Ferrara M, Castiglione G, et al: Nipple sparing subcutaneous mas-
response rate of 80%. The dependent variable was surgeon report of the percentage of their mastectomy patients in the past 2 years who they referred to plastic surgeons prior to initial surgery (referral propensity). Referral propensity was collapsed into 3 categories (<25%, 25-75%, and >75%) and regressed on the following covariates using logistic regression: Surveillance, Epidemiology, and End Results registry; number of years in clinical practice; surgeons’ sex; annual breast surgery volume; and hospital setting. Results.—Only 24% of surgeons referred >75% of their patients to plastic surgeons prior to surgery (high referral propensity). High referral propensity was associated independently with surgeons who were women (odds ratio [OR], 2.3; P = .03), high clinical breast surgery volume (OR, 4.1; P < .01), and working in cancer centers (OR, 2.4; P = .01). High-referral surgeons and low-referral surgeons also had different beliefs about women’s preferences for reconstruction, with the lowreferral surgeons perceiving more access barriers (cost, availability of plastic surgeons) and a lower patient priority for reconstruction. Conclusions.—A large proportion of surgeons do not refer breast cancer patients to plastic surgery at the time of sur-
tectomy: Sixty-six months follow-up. Eur J Surg Oncol 32:937-940, 2006. 4. Petit JY, Veronesi U, Luini A, et al: When mastectomy becomes inevitable: The nipple-sparing approach. Breast 14:527-531, 2005. 5. Cheung KL, Blamey RW, Robertson JF, et al: Subcutaneous mastectomy for primary breast cancer and ductal carcinoma in situ. Eur J Surg Oncol 23:343-347, 1997.
gical decision-making. Surgeons who have a high referral propensity are more likely to be women, to have a high clinical breast volume, and to work in cancer centers. These data support the importance of comanagement through multidisciplinary care models. Women need more opportunities to discuss reconstructive options to make informed surgical treatment decisions about their breast cancer. In this survey by Alderman and colleagues, a large percentage of surgeons did not refer to plastic surgeons prior to making treatment decisions, which may relate to a number of factors, including practice patterns, educational needs of patients and physicians, patient access, and institutional support. It is important to note, however, that this survey was conducted in 2002 in 2 large metropolitan cities, suggesting that access to care would be an unlikely explanation for the authors’ observations. The general surgeon, surgical oncologist, or breast surgeon should be the first to introduce reconstruction as an option as part of a mastectomy. At this point, the patient may decline the offer to undergo a formal consultation.
®
Breast Diseases: A Year Book Quarterly Vol 18 No 4 2008
371 371
However, the surgeon’s description of reconstructive techniques may not accurately address options and expected outcomes and may create a bias. Without a plastic surgery consultation, the patient cannot make an informed decision, and reconstruction will not occur. Surgeons practicing in a rural setting who see lower volumes of patients may have bigger obstacles than educational issues or treatment biases. It is not clear from this survey if plastic surgeons were available within the treating institutions or if the choice for reconstruction would have incurred additional hardship for the patient. Wellinformed breast surgeons and patients may not be able to pursue immediate reconstruction if resources are not available within their institution. High-volume cancer centers equipped to deliver state-of-the-art cancer treatments should routinely provide access to plastic surgeons. However, most patients with breast cancer are treated by surgeons who see low volumes of patients. In New York state in 2002, 25% of the patients were cared for by physicians who averaged less than 1 case per year, and 50% of the patients
were cared for by physicians who averaged less than 5 cases per year.1 In a Canadian survey, significant variations were identified in the availability and utilization of breast reconstruction.2 Seventy percent of the surgeons had training limited to a general surgery residency, and 76% had practices in which breast disease accounted for less than 25% of their clinical work. Of the variables analyzed, fellowship training in surgical oncology and university practice settings were strongly associated with breast reconstruction.2 However, in the university setting, increased utilization of breast reconstruction was only seen for patients with ductal carcinoma in situ. In the National Cancer Data Base, only 8.3% of the patients undergoing mastectomy underwent immediate breast reconstruction.3 These data suggest that a significant under-utilization of breast reconstruction may relate to a complexity of issues relating to the practice setting, training, and access to care. Responding to this disparity will involve multiple interventions addressing education, access, and centralization of breast cancer therapy. However, the incidence of breast cancer represents a
major impediment for the latter. For surgeons practicing in fully-equipped medical facilities with the support of plastic surgeons, this report highlights surgeons’ responsibility to keep patients fully informed of treatment options, and it points out the validity of multidisciplinary management of breast cancer through patient interaction in breast centers and breast conferences.
4–26
by CNB does not ensure the absence of invasive cancer upon surgical excision and as a result an upstaged patient may need to undergo additional surgery for axillary nodal evaluation. This study evaluates the accuracy of CNB in excluding invasive disease and the preoperative features that predict upstaging of DCIS to invasive breast cancer. Two hundred fiftyfour patients over an 8-year period from 1994 to 2002 with a diagnosis of DCIS alone by CNB were retrospectively reviewed. Underestimation of invasive cancer by CNB was determined. Radiographic, pathologic, and surgical features of the cohort were compared using uni-
variate and multivariate analysis. The mean age was 55 years (range 27-84) and mean follow-up was 25 months with one patient unavailable for follow-up. There were a total of six patient deaths, all of which were not disease-specific. A total of 21 out of 254 patients (8%) with DCIS by CNB were upstaged to invasive cancer following surgical excision. There was a significant inverse relationship between the number of core biopsies and the incidence of upstaging (p < 0.006) in that patients with fewer core samples were more likely to be upstaged at surgical pathology. No relationship was noted between the size of the core samples and the like-
Predictors of Residual Invasive Disease after Core Needle Biopsy Diagnosis of Ductal Carcinoma In Situ Rutstein LA, Johnson RR, Poller WR, et al (Maine Med Ctr, Portland; Univ of Pittsburgh, Pa; Allegheny Gen Hosp, Pittsburgh, Pa) Breast J 13:251-257, 2007
Core needle biopsy (CNB) is used to sample both mammographically and ultrasound detected breast lesions. A diagnosis of ductal carcinoma in situ (DCIS)
372 372
®
Breast Diseases: A Year Book Quarterly Vol 18 No 4 2008
D. J. Winchester, MD
References 1. Health Care Choices: Breast cancer surgery performed by individual doctors in New York. Available at http://www.healthcarechoices.com./br eastsurdrny/breaststatdrny.htm. Accessed September 9, 2007. 2. Porter GA, McMulkin-Tait H: Practice patterns in breast cancer surgery: Canadian perspective. World J Surg 28:80-86, 2004. 3. Morrow M, Scott SK, Menck HR, et al: Factors influencing the use of breast reconstruction postmastectomy: A National Cancer Database study. J Am Coll Surg 192:1-8, 2001.
References 1. Veronesi U, Saccozzi R, Del Vecchio M, et al: Comparing radical mastectomy with quadrantectomy, axillary dis-
4–25
Correlates of Referral Practices of General Surgeons to Plastic Surgeons for Mastectomy Reconstruction Alderman AK, Hawley ST, Waljee J, et al (Univ of Michigan, Ann Arbor; Veterans Affairs Ctr for Practice Management and Outcomes Research, Ann Arbor; Fox Chase Cancer Ctr, Philadelphia) Cancer 109:1715-1720, 2007
Background.—General surgeons’ attitudes toward breast reconstruction may affect referrals to plastic surgeons. The propensity to refer to plastic surgeons prior to surgical treatment decisions for breast cancer varies markedly across general surgeons and is associated with receipt of reconstruction. In this study, the authors used data from a large physician survey to examine factors associated with general surgeons’ propensity to refer breast cancer patients to plastic surgeons prior to mastectomy. Methods.—The authors surveyed all attending general surgeons (N = 456 surgeons) from a population-based sample of breast cancer patients who were diagnosed in Detroit and Los Angeles during 2002 (N = 1844 patients), with a surgeon
section, and radiotherapy in patients with small cancers of the breast. N Engl J Med 305:6-11, 1981. 2. Fisher B, Bauer M, Margolese R, et al: Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 312:665673, 1985. 3. Caruso F, Ferrara M, Castiglione G, et al: Nipple sparing subcutaneous mas-
response rate of 80%. The dependent variable was surgeon report of the percentage of their mastectomy patients in the past 2 years who they referred to plastic surgeons prior to initial surgery (referral propensity). Referral propensity was collapsed into 3 categories (<25%, 25-75%, and >75%) and regressed on the following covariates using logistic regression: Surveillance, Epidemiology, and End Results registry; number of years in clinical practice; surgeons’ sex; annual breast surgery volume; and hospital setting. Results.—Only 24% of surgeons referred >75% of their patients to plastic surgeons prior to surgery (high referral propensity). High referral propensity was associated independently with surgeons who were women (odds ratio [OR], 2.3; P = .03), high clinical breast surgery volume (OR, 4.1; P < .01), and working in cancer centers (OR, 2.4; P = .01). High-referral surgeons and low-referral surgeons also had different beliefs about women’s preferences for reconstruction, with the lowreferral surgeons perceiving more access barriers (cost, availability of plastic surgeons) and a lower patient priority for reconstruction. Conclusions.—A large proportion of surgeons do not refer breast cancer patients to plastic surgery at the time of sur-
tectomy: Sixty-six months follow-up. Eur J Surg Oncol 32:937-940, 2006. 4. Petit JY, Veronesi U, Luini A, et al: When mastectomy becomes inevitable: The nipple-sparing approach. Breast 14:527-531, 2005. 5. Cheung KL, Blamey RW, Robertson JF, et al: Subcutaneous mastectomy for primary breast cancer and ductal carcinoma in situ. Eur J Surg Oncol 23:343-347, 1997.
gical decision-making. Surgeons who have a high referral propensity are more likely to be women, to have a high clinical breast volume, and to work in cancer centers. These data support the importance of comanagement through multidisciplinary care models. Women need more opportunities to discuss reconstructive options to make informed surgical treatment decisions about their breast cancer. In this survey by Alderman and colleagues, a large percentage of surgeons did not refer to plastic surgeons prior to making treatment decisions, which may relate to a number of factors, including practice patterns, educational needs of patients and physicians, patient access, and institutional support. It is important to note, however, that this survey was conducted in 2002 in 2 large metropolitan cities, suggesting that access to care would be an unlikely explanation for the authors’ observations. The general surgeon, surgical oncologist, or breast surgeon should be the first to introduce reconstruction as an option as part of a mastectomy. At this point, the patient may decline the offer to undergo a formal consultation.
®
Breast Diseases: A Year Book Quarterly Vol 18 No 4 2008
371 371
However, the surgeon’s description of reconstructive techniques may not accurately address options and expected outcomes and may create a bias. Without a plastic surgery consultation, the patient cannot make an informed decision, and reconstruction will not occur. Surgeons practicing in a rural setting who see lower volumes of patients may have bigger obstacles than educational issues or treatment biases. It is not clear from this survey if plastic surgeons were available within the treating institutions or if the choice for reconstruction would have incurred additional hardship for the patient. Wellinformed breast surgeons and patients may not be able to pursue immediate reconstruction if resources are not available within their institution. High-volume cancer centers equipped to deliver state-of-the-art cancer treatments should routinely provide access to plastic surgeons. However, most patients with breast cancer are treated by surgeons who see low volumes of patients. In New York state in 2002, 25% of the patients were cared for by physicians who averaged less than 1 case per year, and 50% of the patients
were cared for by physicians who averaged less than 5 cases per year.1 In a Canadian survey, significant variations were identified in the availability and utilization of breast reconstruction.2 Seventy percent of the surgeons had training limited to a general surgery residency, and 76% had practices in which breast disease accounted for less than 25% of their clinical work. Of the variables analyzed, fellowship training in surgical oncology and university practice settings were strongly associated with breast reconstruction.2 However, in the university setting, increased utilization of breast reconstruction was only seen for patients with ductal carcinoma in situ. In the National Cancer Data Base, only 8.3% of the patients undergoing mastectomy underwent immediate breast reconstruction.3 These data suggest that a significant under-utilization of breast reconstruction may relate to a complexity of issues relating to the practice setting, training, and access to care. Responding to this disparity will involve multiple interventions addressing education, access, and centralization of breast cancer therapy. However, the incidence of breast cancer represents a
major impediment for the latter. For surgeons practicing in fully-equipped medical facilities with the support of plastic surgeons, this report highlights surgeons’ responsibility to keep patients fully informed of treatment options, and it points out the validity of multidisciplinary management of breast cancer through patient interaction in breast centers and breast conferences.
4–26
by CNB does not ensure the absence of invasive cancer upon surgical excision and as a result an upstaged patient may need to undergo additional surgery for axillary nodal evaluation. This study evaluates the accuracy of CNB in excluding invasive disease and the preoperative features that predict upstaging of DCIS to invasive breast cancer. Two hundred fiftyfour patients over an 8-year period from 1994 to 2002 with a diagnosis of DCIS alone by CNB were retrospectively reviewed. Underestimation of invasive cancer by CNB was determined. Radiographic, pathologic, and surgical features of the cohort were compared using uni-
variate and multivariate analysis. The mean age was 55 years (range 27-84) and mean follow-up was 25 months with one patient unavailable for follow-up. There were a total of six patient deaths, all of which were not disease-specific. A total of 21 out of 254 patients (8%) with DCIS by CNB were upstaged to invasive cancer following surgical excision. There was a significant inverse relationship between the number of core biopsies and the incidence of upstaging (p < 0.006) in that patients with fewer core samples were more likely to be upstaged at surgical pathology. No relationship was noted between the size of the core samples and the like-
Predictors of Residual Invasive Disease after Core Needle Biopsy Diagnosis of Ductal Carcinoma In Situ Rutstein LA, Johnson RR, Poller WR, et al (Maine Med Ctr, Portland; Univ of Pittsburgh, Pa; Allegheny Gen Hosp, Pittsburgh, Pa) Breast J 13:251-257, 2007
Core needle biopsy (CNB) is used to sample both mammographically and ultrasound detected breast lesions. A diagnosis of ductal carcinoma in situ (DCIS)
372 372
®
Breast Diseases: A Year Book Quarterly Vol 18 No 4 2008
D. J. Winchester, MD
References 1. Health Care Choices: Breast cancer surgery performed by individual doctors in New York. Available at http://www.healthcarechoices.com./br eastsurdrny/breaststatdrny.htm. Accessed September 9, 2007. 2. Porter GA, McMulkin-Tait H: Practice patterns in breast cancer surgery: Canadian perspective. World J Surg 28:80-86, 2004. 3. Morrow M, Scott SK, Menck HR, et al: Factors influencing the use of breast reconstruction postmastectomy: A National Cancer Database study. J Am Coll Surg 192:1-8, 2001.