Regional variation in use of immediate breast reconstruction after mastectomy for breast cancer in England

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Abstract

Aims

English national guidelines recommend that breast reconstruction is made available to women with breast cancer undergoing mastectomy. We examined the use of immediate reconstruction (IR) across English Cancer Networks, who are responsible for the regional organisation of cancer services and ensuring equitable access to treatment.

Methods

We analysed Hospital Episodes Statistics data for all women with breast cancer who underwent mastectomy in the English NHS between April 2006 and February 2009. IR rates were calculated for the 30 Networks. Multivariable logistic regression was used to adjust the rates for patient age, comorbidity, ethnicity and socioeconomic deprivation.

Results

Of 44 837 mastectomy patients, 7375 (16.5%) underwent IR. The IR rate was highest in women under 50 years (32.7%) and lowest in women aged 70 years or over (1.5%), and was lower in women with more comorbidities. Unadjusted IR rates varied from 8.4% to 31.9% among the 30 Networks (p < 0.001). Adjusting for their patient characteristics did not appreciably reduce Network-level variation, with adjusted IR rates still ranging from 8.0% to 29.4% (p < 0.001). The risk-model also suggested that non-white women and those from more deprived areas were less likely to undergo immediate reconstruction.

Conclusions

There is substantial regional variation in immediate reconstruction use in England that is not explained by the characteristics of the local patient population. English Cancer Networks should act to reduce this variation. They should also examine why rates of reconstruction differ between particular patient groups.

Introduction

Each year, 38 000 women are diagnosed with breast cancer in England.1 40% of those treated within the National Health Service (NHS) undergo a mastectomy as part of their treatment.2

Advances in plastic surgical techniques have made immediate breast reconstruction a safe option for most women undergoing mastectomy.3 The United Kingdom National Institute for Health and Clinical Excellence (NICE) stated in 2002 that “reconstruction should be available [to all women with breast cancer] at the initial surgical operation”,4 and in 2009 that clinicians should “discuss immediate breast reconstruction with all patients who are being advised to have a mastectomy, and offer it except where significant comorbidity or (the need for) adjuvant therapy may preclude this option”.5

In England, regional Cancer Networks have responsibility for service delivery and resource allocation.6, 7 Cancer Networks were created to overcome service fragmentation by bringing together health service commissioners and providers. A principal aim is for them to ensure patients within their regions have equitable access to high quality cancer care.

In 2009, the National Mastectomy and Breast Reconstruction Audit, a national prospective cohort study of women undergoing mastectomy with or without immediate reconstruction in England, suggested wide regional variation in immediate reconstruction rates.8 However, only three quarters of eligible patients were included, mastectomy-only patients were under-reported, and regional rates were based on relatively small samples.

In this paper we used Hospital Episode Statistics (HES)9 data to derive rates of immediate breast reconstruction after mastectomy for breast cancer within the English Cancer Networks. The HES database captures all surgical procedures in NHS hospitals, and is less prone to differential reporting of mastectomy and reconstruction procedures. It also provides larger patient samples because it is not restricted to activity within a limited timeframe. We investigated the effect of patient characteristics on immediate reconstruction use, and the extent to which they could explain variation in rates across Networks.

Section snippets

Hospital Episode Statistics

The HES database contains demographic, geographical and clinical information on all patients admitted to NHS hospitals in England. Surgical procedures are described using the UK Office for Population Censuses and Surveys classification, 4th revision (OPCS4)10 while medical conditions are described using the International Classification of Diseases, 10th revision (ICD10).11

Patient population

We extracted the HES records of all women diagnosed with invasive carcinoma of the breast (ICD10: C50) who underwent a

Results

Between 1 April 2006 and 28 February 2009, 44 837 mastectomies were performed in women with breast cancer. Their average age was 60.9 years (SD 13.9) and 6297 (14.0%) had one or more comorbidities. Ethnicity was known for 87.2%, of whom 94.1% were white.

Overall, 16.5% of women had an immediate reconstruction. Unadjusted immediate reconstruction rates among the 30 English Cancer Networks varied from 8.4% to 31.9% (p < 0.001). Excluding the Networks with the three highest and lowest values, the

Discussion

There is considerable variation in the use of immediate breast reconstruction between English Cancer Networks which persists after adjusting for patient characteristics. In addition, women who are non-white or from deprived areas are less likely to undergo immediate reconstruction. Rates of reconstruction were highest amongst women under 50 years.

Conclusion

We have found considerable variation in the regional use of immediate breast reconstruction which persists after adjusting for patient characteristics. The variation in the HES-derived rates is comparable with the findings of the National Mastectomy and Breast Reconstruction Audit and demonstrates that the differences have not existed for a short period of time.

The analysis does not presuppose that there is an optimal rate for immediate breast reconstruction. However, the wide regional

Acknowledgements

We would like to thank Lynn Copley of the Clinical Effectiveness Unit for preparing the extract used in this work, and the NHS Information Centre for Health and Social Care for providing the Hospital Episode Statistics data.

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