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Patterns and Correlates of Postmastectomy Breast Reconstruction by U.S. Plastic Surgeons: Results From a National Survey
The NQF is a private, nonprofit, open membership, public benefit corporation whose mission is to improve the American health care system so that
it can be counted on to provide safe, timely, compassionate, and accountable care using the best current knowledge. Established in 1999, the NQF is
a unique public-private partnership having broad participation from all parts of the health care industry.
Patterns and Correlates of Postmastectomy Breast Reconstruction by U.S. Plastic Surgeons: Results From a National Survey
providers, and 43 percent reported decreasing their volume over the past year due to poor reimbursement. Resident availability was significantly associated with high volume (odds ratio, 4.93; 95 percent CI, 2.31 to 10.49); years in practice and perceived financial constraints by third-party payers were inversely associated with high volume (>20 years compared with #10 years: odds ratio, 0.23. 95 percent CI, 0.07 to 0.71; odds ratio, 0.22, 95 percent CI, 0.08 to 0.56, respectively). Conclusions.dAlthough plastic surgeons find breast reconstruction professionally rewarding, many are decreasing their practice. Factors associated with low volume include lack of resident coverage and perceived poor reimbursement. Advocacy efforts must be directed at facilitating reconstructive services for this highly demanding patient population.
practice evolves over time. The authors designed a survey study targeting members of the American Society of Plastic Surgeons who perform breast reconstruction to shed light on surgeons’ attitudes toward performing breast reconstruction and to identify correlates with highvolume breast reconstruction practices. Overall, the survey of 429 surgeons had a high response rate (73%), which reflects the importance of this subject within the field of plastic surgery. Respondents were categorized based on case volume per yeardlow (<10 cases), moderate (1050 cases), and high (>50 cases)dand the distribution of these groups was 35%, 50%, and 15%, respectively. As one would anticipate, linear trends often reaching statistical significance were identified based on surgeon case volume for any given variable of interest. Higher-volume surgeons were more motivated to offer breast reconstruction and contribute to resident education in breast reconstruction and were less likely to decrease their case volume because of reimbursement rates. Higher-volume surgeons were less likely to be affected by reimbursement rates when deciding which reconstructive procedures to offer patientsdtissue expanders versus autologous flaps. Higher-volume surgeons were younger, had been in practice for significantly less time, and were more likely to be fellowship trained and affiliated with
Alderman AK, Atisha D, Streu R, et al (The Univ of Michigan Med Ctr, Ann Arbor; St Joseph Mercy Hosp, Ann Arbor, MI; Univ of Iowa; et al) Plast Reconstr Surg 127:1796-1803, 2011
Background.dConcern exists that plastic surgeons have lost interest in postmastectomy breast reconstruction, which has helped enable the oncoplastic movement by general surgery. The authors evaluated patterns and correlates of postmastectomy breast reconstruction among U.S. plastic surgeons. Methods.dA survey was mailed to a national sample of 500 randomly selected members of the American Society of Plastic Surgeons (73 percent of eligible subjects responded; n ¼ 312). The dependent variable was surgeon’s annual volume of breast reconstructions (dichotomized into >50 and #50 cases per year). Logistic regression was used to evaluate factors associated with annual volume, including surgeon demographic and practice characteristics, community support for reconstruction, and surgeons’ attitudes toward insurance reimbursement. Results.dNinety percent found doing breast reconstruction personally rewarding, and nearly all enjoyed the technical aspects of the procedure. The majority of surgeons, however, were low-volume to moderate-volume
422
In this article, Alderman and colleagues endeavor to shed light on the evolving trends in postmastectomy reconstruction, citing overall low postmastectomy reconstruction rates in the United States and large geographic and patient population variations in reconstruction rates. The authors hypothesized that the low rates of reconstruction are the result of a complex interplay of multiple variables, including low referral rates to plastic surgeons, the evolving complexity of breast reconstruction, low reimbursement rates, and a general loss of interest in breast reconstruction as the surgeon’s
Breast Diseases: A Year BookÒ Quarterly Vol 22 No 4 2012
multidisciplinary cancer centers than their lower-volume counterparts. Overall, the perceived medical community support for breast reconstruction did not differ significantly by surgeon volume. However, lower-volume surgeons, the majority of whom had been in practice for more than 10 years, perceived greater financial constraints by thirdparty payers with respect to breast reconstruction using any modality. This may in part explain the overall trend toward a lower volume of breast reconstructions as one’s practice evolves over time, despite the fact that 90% of all surgeons surveyed said that they enjoyed the technical aspects of breast reconstruction and found it personally rewarding to work with breast cancer patients.
The authors have successfully identified factors characterizing highvolume breast reconstruction practices; however, the next question is, “How do we continue to encourage newly trained plastic surgeons to develop breast reconstruction practices, encourage established surgeons to focus more [on] breast reconstruction, and encourage all surgeons to continue to perform breast reconstruction over a longer period of their careers?” The answers may be as diverse as the questions, but they should start with focusing on educating our patients and oncology colleagues on the options for and outcomes of breast reconstruction, as these impact a patient’s quality of life and sense of self after completing breast cancer care. The issues of
rising overhead costs and decreasing rates of reimbursement for breast reconstruction procedures cannot be overlooked and need to be actively addressed by state and federal policymakers and third-party medical insurance payers. Finally, our societiesdthe American Society of Plastic Surgeons and the American Society of Breast Surgeonsdmust continue to support high-level outcomes research to substantiate the need for comprehensive breast cancer care with reconstruction as an integral component, to ensure that all breast cancer patients have access to the highest level of care. D. Baumann, MD
BREAST-CONSERVING THERAPY Long-Term Outcomes of Invasive Ipsilateral Breast Tumor Recurrences After Lumpectomy in NSABP B-17 and B-24 Randomized Clinical Trials for DCIS Wapnir IL, Dignam JJ, Fisher B, et al (Natl Surgical Adjuvant Breast and Bowel Project (NSABP) Operations and Biostatistical Ctrs, Pittsburgh, PA; Univ of Pittsburgh, PA; et al) J Natl Cancer Inst 103:478-488, 2011
Background.dIpsilateral breast tumor recurrence (IBTR) is the most common failure event after lumpectomy for ductal carcinoma in situ (DCIS). We evaluated invasive IBTR
(I-IBTR) and its influence on survival among participants in two National Surgical Adjuvant Breast and Bowel Project (NSABP) randomized trials for DCIS. Methods.dIn the NSABP B-17 trial (accrual period: October 1, 1985, to December 31, 1990), patients with localized DCIS were randomly assigned to the lumpectomy only (LO, n ¼ 403) group or to the lumpectomy followed by radiotherapy (LRT, n ¼ 410) group. In the NSABP B-24 double-blinded, placebo-controlled trial (accrual period: May 9, 1991, to April 13, 1994), all accrued patients were randomly assigned to LRT+ placebo, (n¼900) or LRT + tamoxifen (LRT + TAM, n ¼ 899). Endpoints included I-IBTR, DCIS-IBTR, contralateral breast cancers (CBC), over-
all and breast cancer-specific survival, and survival after I-IBTR. Median follow-up was 207 months for the B-17 trial (N ¼ 813 patients) and 163 months for the B-24 trial (N ¼ 1799 patients). Results.dOf 490 IBTR events, 263 (53.7%) were invasive. Radiation reduced I-IBTR by 52% in the LRT group compared with LO (B-17, hazard ratio [HR] of risk of I-IBTR ¼ 0.48, 95% confidence interval [CI] ¼ 0.33 to 0.69, P < .001). LRT + TAM reduced I-IBTR by 32% compared with LRT + placebo (B-24, HR of risk of I-IBTR ¼ 0.68, 95% CI ¼ 0.49 to 0.95, P ¼ .025). The 15-year cumulative incidence of I-IBTR was 19.4% for LO, 8.9% for LRT (B-17), 10.0% for LRT + placebo (B-24), and 8.5% for LRT + TAM. The 15-year cumulative
Breast Diseases: A Year BookÒ Quarterly Vol 22 No 4 2012
423
it can be counted on to provide safe, timely, compassionate, and accountable care using the best current knowledge. Established in 1999, the NQF is
a unique public-private partnership having broad participation from all parts of the health care industry.
Patterns and Correlates of Postmastectomy Breast Reconstruction by U.S. Plastic Surgeons: Results From a National Survey
providers, and 43 percent reported decreasing their volume over the past year due to poor reimbursement. Resident availability was significantly associated with high volume (odds ratio, 4.93; 95 percent CI, 2.31 to 10.49); years in practice and perceived financial constraints by third-party payers were inversely associated with high volume (>20 years compared with #10 years: odds ratio, 0.23. 95 percent CI, 0.07 to 0.71; odds ratio, 0.22, 95 percent CI, 0.08 to 0.56, respectively). Conclusions.dAlthough plastic surgeons find breast reconstruction professionally rewarding, many are decreasing their practice. Factors associated with low volume include lack of resident coverage and perceived poor reimbursement. Advocacy efforts must be directed at facilitating reconstructive services for this highly demanding patient population.
practice evolves over time. The authors designed a survey study targeting members of the American Society of Plastic Surgeons who perform breast reconstruction to shed light on surgeons’ attitudes toward performing breast reconstruction and to identify correlates with highvolume breast reconstruction practices. Overall, the survey of 429 surgeons had a high response rate (73%), which reflects the importance of this subject within the field of plastic surgery. Respondents were categorized based on case volume per yeardlow (<10 cases), moderate (1050 cases), and high (>50 cases)dand the distribution of these groups was 35%, 50%, and 15%, respectively. As one would anticipate, linear trends often reaching statistical significance were identified based on surgeon case volume for any given variable of interest. Higher-volume surgeons were more motivated to offer breast reconstruction and contribute to resident education in breast reconstruction and were less likely to decrease their case volume because of reimbursement rates. Higher-volume surgeons were less likely to be affected by reimbursement rates when deciding which reconstructive procedures to offer patientsdtissue expanders versus autologous flaps. Higher-volume surgeons were younger, had been in practice for significantly less time, and were more likely to be fellowship trained and affiliated with
Alderman AK, Atisha D, Streu R, et al (The Univ of Michigan Med Ctr, Ann Arbor; St Joseph Mercy Hosp, Ann Arbor, MI; Univ of Iowa; et al) Plast Reconstr Surg 127:1796-1803, 2011
Background.dConcern exists that plastic surgeons have lost interest in postmastectomy breast reconstruction, which has helped enable the oncoplastic movement by general surgery. The authors evaluated patterns and correlates of postmastectomy breast reconstruction among U.S. plastic surgeons. Methods.dA survey was mailed to a national sample of 500 randomly selected members of the American Society of Plastic Surgeons (73 percent of eligible subjects responded; n ¼ 312). The dependent variable was surgeon’s annual volume of breast reconstructions (dichotomized into >50 and #50 cases per year). Logistic regression was used to evaluate factors associated with annual volume, including surgeon demographic and practice characteristics, community support for reconstruction, and surgeons’ attitudes toward insurance reimbursement. Results.dNinety percent found doing breast reconstruction personally rewarding, and nearly all enjoyed the technical aspects of the procedure. The majority of surgeons, however, were low-volume to moderate-volume
422
In this article, Alderman and colleagues endeavor to shed light on the evolving trends in postmastectomy reconstruction, citing overall low postmastectomy reconstruction rates in the United States and large geographic and patient population variations in reconstruction rates. The authors hypothesized that the low rates of reconstruction are the result of a complex interplay of multiple variables, including low referral rates to plastic surgeons, the evolving complexity of breast reconstruction, low reimbursement rates, and a general loss of interest in breast reconstruction as the surgeon’s
Breast Diseases: A Year BookÒ Quarterly Vol 22 No 4 2012
multidisciplinary cancer centers than their lower-volume counterparts. Overall, the perceived medical community support for breast reconstruction did not differ significantly by surgeon volume. However, lower-volume surgeons, the majority of whom had been in practice for more than 10 years, perceived greater financial constraints by thirdparty payers with respect to breast reconstruction using any modality. This may in part explain the overall trend toward a lower volume of breast reconstructions as one’s practice evolves over time, despite the fact that 90% of all surgeons surveyed said that they enjoyed the technical aspects of breast reconstruction and found it personally rewarding to work with breast cancer patients.
The authors have successfully identified factors characterizing highvolume breast reconstruction practices; however, the next question is, “How do we continue to encourage newly trained plastic surgeons to develop breast reconstruction practices, encourage established surgeons to focus more [on] breast reconstruction, and encourage all surgeons to continue to perform breast reconstruction over a longer period of their careers?” The answers may be as diverse as the questions, but they should start with focusing on educating our patients and oncology colleagues on the options for and outcomes of breast reconstruction, as these impact a patient’s quality of life and sense of self after completing breast cancer care. The issues of
rising overhead costs and decreasing rates of reimbursement for breast reconstruction procedures cannot be overlooked and need to be actively addressed by state and federal policymakers and third-party medical insurance payers. Finally, our societiesdthe American Society of Plastic Surgeons and the American Society of Breast Surgeonsdmust continue to support high-level outcomes research to substantiate the need for comprehensive breast cancer care with reconstruction as an integral component, to ensure that all breast cancer patients have access to the highest level of care. D. Baumann, MD
BREAST-CONSERVING THERAPY Long-Term Outcomes of Invasive Ipsilateral Breast Tumor Recurrences After Lumpectomy in NSABP B-17 and B-24 Randomized Clinical Trials for DCIS Wapnir IL, Dignam JJ, Fisher B, et al (Natl Surgical Adjuvant Breast and Bowel Project (NSABP) Operations and Biostatistical Ctrs, Pittsburgh, PA; Univ of Pittsburgh, PA; et al) J Natl Cancer Inst 103:478-488, 2011
Background.dIpsilateral breast tumor recurrence (IBTR) is the most common failure event after lumpectomy for ductal carcinoma in situ (DCIS). We evaluated invasive IBTR
(I-IBTR) and its influence on survival among participants in two National Surgical Adjuvant Breast and Bowel Project (NSABP) randomized trials for DCIS. Methods.dIn the NSABP B-17 trial (accrual period: October 1, 1985, to December 31, 1990), patients with localized DCIS were randomly assigned to the lumpectomy only (LO, n ¼ 403) group or to the lumpectomy followed by radiotherapy (LRT, n ¼ 410) group. In the NSABP B-24 double-blinded, placebo-controlled trial (accrual period: May 9, 1991, to April 13, 1994), all accrued patients were randomly assigned to LRT+ placebo, (n¼900) or LRT + tamoxifen (LRT + TAM, n ¼ 899). Endpoints included I-IBTR, DCIS-IBTR, contralateral breast cancers (CBC), over-
all and breast cancer-specific survival, and survival after I-IBTR. Median follow-up was 207 months for the B-17 trial (N ¼ 813 patients) and 163 months for the B-24 trial (N ¼ 1799 patients). Results.dOf 490 IBTR events, 263 (53.7%) were invasive. Radiation reduced I-IBTR by 52% in the LRT group compared with LO (B-17, hazard ratio [HR] of risk of I-IBTR ¼ 0.48, 95% confidence interval [CI] ¼ 0.33 to 0.69, P < .001). LRT + TAM reduced I-IBTR by 32% compared with LRT + placebo (B-24, HR of risk of I-IBTR ¼ 0.68, 95% CI ¼ 0.49 to 0.95, P ¼ .025). The 15-year cumulative incidence of I-IBTR was 19.4% for LO, 8.9% for LRT (B-17), 10.0% for LRT + placebo (B-24), and 8.5% for LRT + TAM. The 15-year cumulative
Breast Diseases: A Year BookÒ Quarterly Vol 22 No 4 2012
423