MD Anderson Cancer Center
Dr. Michael Fish: Welcome to Cancer Newsline, a podcast series from the University of Texas, MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention providing the latest information on reducing your family's cancer risk. I'm your host, Dr. Michael Fish from the Department of General Oncology at MD Anderson Cancer Center. Today we are talking with Dr. Steve Kronowitz of the Department of Plastic Surgery and Dr. Benjamin Smith from the Department of Radiation Oncology. Welcome.
Dr. Steve Kronowitz: Thank you. Great to be here.
Dr. Benjamin Smith: Thanks.
Dr. Michael Fish: Well, I wanted to talk to you about this very interesting paper about trends and variation in the use of breast reconstruction in the Journal of Clinical Oncology. And the first question I have is sort of a basic question, and it reminds me of something that was asked of me when I was a medical student from a surgery department chair. And he said, "What's so bad about jaundice?" A very simple, basic question. But here, flipping it to what is so important about breast reconstruction? Why does it matter at all? And I wonder if Dr. Smith, if you could get us started. What is so important about breast reconstruction as an issue?
Dr. Benjamin Smith: Sure. Well, you know, women can feel disfigured after having a mastectomy and feel like they are not completely complete with regard to their body. And it has been well documented that women who have mastectomy are more likely to have body image issues than women who are able to preserve their breasts. And so breast reconstruction is a way to try to address that and try to help women look and feel whole again after their cancer treatment.
Dr. Michael Fish: That's important to know. Well, so one of the things that came up in this paper has to do with the variation in the use of breast reconstruction. And so Dr. Kronowitz, one of the things that was noticed here, for example, is that the rate of breast reconstruction of women in California was more like 40 to 50%. And here in Texas it as more like 50 to 60%. And in Florida it was more like 60 to 75%.
Dr. Steve Kronowitz: I think in general there has always been somewhat of a geographic difference in breast reconstruction or aids. I think it's a matter of expectations. I also think it's a matter of density of the plastic surgeons and the type of services that are available to various patients I think that really can make a difference. So I think that has a lot to do with it as well. And also we've seen many times, certainly education levels, of patients with better insurances, or more affluent tend to be more likely to receive reconstruction. And they tend to live more frequently in these areas; more densely populated areas and have more access to it.
Dr. Michael Fish: That makes sense. So this wasn't addressed in the paper per say, but I wonder how you might expect the Affordable Care Act to influence breast reconstruction rates based on these things that you just described?
Dr. Steve Kronowitz: Well, you know, it's hard to know. We'll have to see. Certainly more patients will be covered, but the coverage may not be as good. Certainly, you know, physicians have, you know, only so many hours in the day. And they want to care of patients. And I think the trends have been, as our paper played out, is that in other studies that I've looked at for instance various polls of the American Society of Plastic Surgeons where implant based reconstruction is becoming much more common. There was actually a poll that was taken in 2010 on various trends of reconstruction. Eighty-two percent of the patients receive implant-based reconstruction, which is up from before. And fewer patients are receiving their own tissues to autologous reconstruction which takes much more time to do, is much more labor intensive, and really becomes very difficult with the reimbursement rates even currently but certainly may even become worse as time goes on with the Affordable Care Act where there may be more of a proclivity not to lessen patient care but to keep care more efficient so that more patients can be provided for and that certainly, you know, physicians can keep their doors open. So I think we will continue to see more implant-based reconstruction because of the time efficiency of it. And it just takes overall less hours. And as was noted in the manuscript in our paper that essentially the reimbursement rates when you look at hour to hour basis tend to be higher and allows a lot of physicians who are out there who are in private practice who are trying to essentially keep their doors open from a business perspective to be able to care for these patients.
Dr. Michael Fish: So if a woman comes to your clinic and is trying to understand this autologous reconstruction, I can imagine she might not understand, "Well, what part of my body do you take to reconstruct? And why would anybody want that?" Why should anybody ever consider autologous reconstruction?
Dr. Steve Kronowitz: Sure. Well, you know, there are several basic types. One is implant-based reconstruction. Or sometimes we'll combine an implant with some of their own tissues. That is most frequently is combined with a back muscle, the latissimus muscle or tissue from the back. And then there's usually the more common place is to take the tissue from the abdomen, sometimes the buttock, or sometimes there are some also additional options which are just used less frequently. Well, the reason is obviously some patients do have problems with implant-based reconstruction. But I will tell you, there has been some additional type of options that go along with reconstruction with implants that have really made them much more beneficial in regards to the use of what are called acellular dermal matrices and the use of fat graft which has really improved the outcomes of patients with implant-based reconstruction. The use of autologous reconstruction is still very popular, however it tends to be used now, and this is really the trends that we're seeing, in patients that are receiving radiation in which is very difficult to perform implant-based reconstruction without a very high rate of complications. So the trend seems to be that patients with earlier stage diseases are getting more towards implant-based reconstruction. And a lot of this also has to do with the increase use of bilateral mastectomy as was noted in our paper because you can get much better symmetry with implant-based reconstruction. And it's much simpler than if you were to do it for one breast.
Dr. Michael Fish: So that's a point I'd like to pick up on.
Dr. Steve Kronowitz: Right.
Dr. Michael Fish: And so Dr. Smith, in this paper the rate of bilateral mastectomy which used to be more like 3% of women looks like over time it is trending towards closer to 18%. So that's a big change over time. Why is that happening? And is that good news?
Dr. Benjamin Smith: Yeah, it is a very interesting pattern. And we're not the only investigators to report that. But that was one of the most interesting findings I thought from our study. So it's interesting because those women who had bilateral mastectomy are much more likely to have reconstruction. And so you sort of wonder is it a chicken or egg phenomenon? Are women choosing bilateral mastectomy because they can have breast reconstruction or because it's more available and sort of maybe they're kind of frustrated with the problems their breasts have caused for them, and they kind of want to hit the reset button. So there may be a synergy there I think between increasing availability of plastic surgery and increased patient desire for prophylactic contralateral mastectomy. So I think that's an interesting phenomenon. My general sense is that patients tend to overestimate the risk that they are going to have a problem in the other breast. And I think it's a really important question to ask sort of how do patients feel during and after these procedures and what's their level of satisfaction with the decision that they've made. And it's worth noting that some investigators here at MD Anderson just received a very large grant from the Patient-Centered Outcomes Research Institute to study psychosocial outcomes in patients who opt for or choose not to undergo contralateral prophylactic mastectomy. And so we'll be learning a lot more from that funded research regarding the ramification of this decision on patients' lives.
Dr. Michael Fish: So that's terrific news about the grant. Now some of this issue revolves around the BRCA mutation status. And that has been very much in the news recently. Do you think that more women are getting tested for BRCA and that is driving them to want bilateral mastectomies? Or is it a bigger issue than the BRCA?
Dr. Benjamin Smith: Yeah. That's not something that we could completely look at just with claims-based data because you could look to see potentially who is having testing, but you still don't know who had a positive result. So it still is going to be a relatively small segment of the population with one of these genetic mutations. If you do have one of these genetic mutations it often can make a lot of sense to consider risk-reducing surgery like the bilateral mastectomy. But given the prevalence of these mutations and the population that is probably not sufficient to explain the trends that we're seeing. There's probably most of the women in our study having bilateral mastectomies did not have a genetic mutation just based on prevalence of those mutations in the population.
Dr. Michael Fish: So it turned out also in this research that women receiving radiation were less like to get reconstruction. Are you worried that the message about radiation will be confusing to women? Should they want radiation? Why should women be even thinking about radiation? Or is it better for them to just say, "Why don't we leave that off so I can get reconstruction?"
Dr. Benjamin Smith: I would agree. I think it is confusing. It is confusing to patients. It can be confusing to physicians. And we don't even always know the best course of action. But sort of, you know, from a radiation oncologist perspective, if you think broadly over the last 20 years there's just been a really impressive amount of data that has been published showing that radiation after a mastectomy or we call it post-mastectomy radiation therapy, in the right patients’ saves lives. And so we've been using that more and more. And now the classic indications are if your cancer spread to four or more lymph nodes or if it was larger than 5 centimeters, generally radiation after mastectomy is recommended. Now there's more recent data, much of which is even published yet, but presented which indicates even in patients with sort of this less risky tumors, maybe the tumor has gone to one, two, or three lymph nodes, potentially a lot of those women also might develop, expect a survival benefit from radiation that could be meaningful to them. And so the general trend is more and more patients we are recommending radiation after mastectomy to prevent recurrence of the cancer and to improve their survival. Now that's good news for patients as far as survival. It's bad news for my friends on the fifth floor in plastic surgery because it really makes their life much more challenging, and it makes our patient's lives much more challenging. And there really has yet to crystalize a clear consensus broadly in the medical community as to the optimal strategy for integrating reconstruction and radiation for our patients. And so we have a nice strategy here that I think works very well. But it's strongly dependent on a very good, collaborative, and team based relationship between surgical oncology, breast radiation, and plastic surgery. And if you do have that team in place you can develop a strategy that is going to work and generally give your patients good outcomes. If you don't have that team in place it can be very difficult. And I've personally been involved in patients who have had poor outcomes because of strategies that we were concerned wouldn't work, and lo and behold they did not work well. And it has really harmed patients. And so I think, you know, we really need to have this team-based approach. It is also sort of concerning to me that the rising use of implant-based reconstruction, which generally in our hands does not go very well with radiation, so you have the rising use of a technique that doesn't work well with radiation and the rising use of radiation, it could be a set up for problems.
Dr. Michael Fish: Understood. So it sounds like this teamwork and interdisciplinary model is particularly important. One thing that this reminds me of is that in a previous Cancer Newsline podcast we talked about smoking cessation. And Dr. Kronowitz, I wonder whether smoking cessation plays any role in the work that you do? Do you talk to women about this? Does it matter for breast reconstruction?
Dr. Steve Kronowitz: Oh it certainly does. I mean, it's one of the main risk factors. There are two main risk factors for reconstruction, obesity and cigarette smoking. And they're both, you know, very significant. So in general in patients for elective surgeries where in general there is no urgency, we actually will not perform reconstruction until they stop smoking for a reasonable period of time. And certainly in patients who have cancer and whom it is really not practical to wait that long of time, we very strongly tell them the importance to urgently stop, and we actually have the beauty of having a smoking cessation clinic here at MD Anderson, which has been very helpful in our practice.
Dr. Michael Fish: So another element of multi-disciplinary care. Well, the last thing I wanted to ask is whether there are limitations to this particular study that should sort of be taken into account? What populations or what aspects of this study should people understand so that we understand it clearly?
Dr. Benjamin Smith: Sure. I'd be happy to tackle that. So, you know, our study kind of shows the best-case scenario. So we're studying younger women who have private medical insurance. And so we see that in that population there is a substantial increase in use of breast reconstruction between 1998 and 2007 from about 40% to about 63%. So a really impressive and encouraging increase in women receiving this treatment which is known to be beneficial to them for their psychosocial long term health as a cancer survivor. So that's great news. But, you know, we can't tell you anything about what is happening to the woman who doesn't necessarily have health insurance who perhaps has to show up at a county hospital for her cancer care or also older women. And for some older women they are perfectly content to have a mastectomy and not have reconstruction. But some older women it's very important for them to be able to have access to breast reconstruction. And we didn't particularly study that patient population either. And so other research will be needed to help understand patterns of breast reconstruction in those groups.
Dr. Michael Fish: Great. Well Dr. Kronowitz, are there any resources that people should know about where if they wanted to read more about this stuff to understand it?
Dr. Steve Kronowitz: Yeah. Well, certainly. There's much literature available on the site of the American Society of Plastic Surgeons, and also here at MD Anderson within the plastic surgery area we provide quite a bit of information regarding various options for breast reconstruction. And I think that really that's the most important thing. And anything in medical care, but certainly when you're approaching the complex decisions that are involved when you have a diagnosis of breast cancer. And as I tell my patients, it's very important to get as much information as you can upfront before actions are taken. And that's really what has been successful about our model is that all of the various physicians that are involved in the patient's care, they see the patient prior to any type of action being taken. And that isn't very rare, and that has really led to the success of our program. And I think really that's what is necessary. And I would certainly encourage patients to seek out as much information as possible before they seek treatment.
Dr. Benjamin Smith: I just want to underscore that in the patients we care for if we think they may need a mastectomy it is very common for them to see a surgical oncologist, a radiation oncologist, a medical oncologist, and a plastic surgeon before they have any type of surgery. And that really sets us up for success. We can counsel our patients about their options so that they know, they can make an informed choice about what they want to do. And then we can also work together as a team. And if I am concerned about something about the cancer impacting some of the reconstructive choices I can talk to the plastic surgeon. And our plastic surgeons will listen to me, and then they'll consider that in determining what is the best strategy. And so that is incredibly helpful. And then many of our patients will have a tissue expander placed at the time of their mastectomy, which is kind of like a temporary reconstruction but can create certain challenges in radiation treatment planning. And so our plastic surgeons will be happy to deflate the tissue expander. And so like I always go up to the fifth floor and make sure that we deflate it to a volume that will accommodate radiation therapy treatment planning. And so having that collaborative team-based relationship, and I don't have to beg and plead to the plastic surgeons to do something that is in the patient's oncologic interests is just so helpful. And I think it optimizes both the oncologic and the cosmetic outcome at the end of the day.
Dr. Michael Fish: Well, I can imagine how comforting it is for patients to know that the full spectrum of issues have been covered and that the providers are on the same page. It is very unsettling when it's not like that. So that is a tremendous point to make. Well, Dr. Smith and Dr. Kronowitz, thank you very much for being with us today. If you have questions about anything you've heard today on Cancer Newsline please contact Ask MD Anderson at 1-877-MDA-6789 or you can go online at www.MDAnderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in for the next podcast in our series.
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