Recent studies by City of Hope researchers hint at factors that influence whether women undergo reconstruction after mastectomy for breast cancer: their age and race, as well as access to health insurance and advanced hospital facilities.

Laura Kruper (Photo by Walter Urie)

Breast surgeon Laura Kruper, M.D., director of the Rita Cooper Finkel and J. William Finkel Women’s Health Center, and colleagues recently studied reconstruction rates after mastectomy for invasive breast cancer and ductal carcinoma in situ, or DCIS. The studies were published in the Aug. 1 and Oct. 1 issues of the Annals of Surgical Oncology.

The scientists gathered information about nearly 16,000 women treated for breast cancer in four Southern California counties (Los Angeles, Orange, Riverside and San Bernardino) from 2003 to 2007, using data from the California Office of Statewide Health Planning and Development. They wanted to know how likely women were to get reconstruction after surgery — 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 researchers’ August study showed that fewer than one in three women who underwent mastectomy for invasive breast cancer followed their treatment with breast reconstruction.

Women were less likely to opt for reconstruction after invasive cancer as they got older, they found. 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 may have more plastic surgeons on staff who can perform reconstructive surgeries. And insurance issues may limit patients’ access to some plastic surgeons.

Race and ethnicity also played a part in reconstruction. African-American, white Latino and Asian patients were significantly less likely to have immediate reconstruction. Racial inequalities related to reconstruction involve multiple factors and are complicated, she said.

The latest study indicates that women who receive mastectomy for DCIS are twice as likely to undergo reconstruction as women with invasive breast cancer. DCIS is cancer that is confined to the milk duct and has not spread to surrounding tissue, making it highly curable.

Researchers believe that more women with DCIS who are choosing mastectomy also opt for reconstruction after mastectomy because of that cancer’s early stage, meaning that the stage of the cancer is not a factor limiting reconstruction. But many of the factors influencing reconstruction as part of treatment for invasive breast cancer also carried over to DCIS, including age, type of hospital and insurance, and race or ethnicity.

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. The researchers will use the California Teachers Study to explore relationships to the pathology of women’s cancers to see if cancer stage is a factor. They also hope to study whether other diseases and conditions that accompany older age may contribute.

Co-investigators include Xin Xin Xu, Alicia Holt, M.D., Lei Duan, M.S., Katherine Henderson, Ph.D., Joshua Ellenhorn, M.D, and Leslie Bernstein, Ph.D.