Mastectomy — surgical removal of one or both breasts — to treat breast cancer can be a daunting option. Recovery includes coping with complex feelings surrounding not just the cancer, but body image and sexuality, as well.

Fortunately, breast reconstruction techniques for these patients have advanced significantly in recent decades. Even better, studies have shown reconstruction helps patients to feel better about themselves and improves their quality of life.

Laura Kruper (Photo by Walter Urie)

So why do many breast cancer patients who undergo mastectomy not follow up with reconstruction?

Researchers led by breast surgeon Laura Kruper, M.D., director of City of Hope’s Rita Cooper Finkel and J. William Finkel Women’s Health Center, may have found some answers.

Two recent studies show that factors including age and access to health insurance and advanced hospital facilities may play a role.

Each study centered on a particular group of breast cancer patients who underwent mastectomy. The first focused on those with invasive breast cancer — the kind that has spread away from the original tumor site. The second looked at patients having ductal carcinoma in situ, or DCIS, which is confined to the milk duct and has not spread to surrounding tissue.

Kruper and her colleagues wanted to know how likely women were to get reconstruction after mastectomy — and what factors contributed to that treatment.

“Reconstruction is something that we feel is psychologically beneficial to patients, but not everybody is getting it,” said Kruper, head of the Breast Surgery Service at City of Hope. “If it’s a personal choice that’s fine — but if there are other factors that are limiting a woman’s choice for reconstruction, those need to be addressed.”

Rates of reconstruction have climbed steadily in recent years. But the first study found that fewer than one in three women who underwent mastectomy for invasive breast cancer followed their treatment with reconstruction. And women were less likely to choose reconstruction after invasive cancer as they got older.

Women with private insurance and those treated at teaching hospitals or National Cancer Institute-designated cancer centers were more likely to receive reconstruction. Kruper suspects that academic hospitals and cancer centers have more plastic surgeons on staff to perform reconstructive surgeries. Also, insurance issues may limit access to some plastic surgeons.

Following the second study, the researchers found that women who receive mastectomy for DCIS are twice as likely to undergo reconstruction as women with invasive breast cancer. Researchers believe that this is so because of DCIS’s early stage.

But many of the factors influencing reconstruction as part of treatment for invasive breast cancer also carried over to DCIS, including age and type of hospital and insurance.

Studies are now under way to understand the reasons for women’s choices — and how much access to care and personal factors weigh into the use of breast reconstruction.

They also hope to study whether other diseases and conditions that accompany older age may contribute.