Is ‘seasoned’ age a valid concern in breast reconstruction?

Is ‘seasoned’

age alone a valid concern in breast reconstruction?

By Monica Llado-Farrulla, MD, and Paris D. Butler, MD, MPH

(Division of Plastic Surgery, University of Pennsylvania Health System, Philadelphia)

The events that unfolded during the first half of 2020 renewed the national conversation around persistent disparities in modern-

day healthcare. Among the many

documented inequalities in U.S. healthcare, post-mastectomy breast cancer reconstruction remains a continuing concern. National statistics reveal that disparities in breast reconstruction involve not only race/ ethnicity and socioeconomic status, but also age. More specifically, it’s been found that women older than 65 are much less likely to undergo reconstructive surgery compared to their younger counterparts.

This data fuels several questions. First, do these differences span all breast reconstructive surgery options? Second, is this disparity a result of patients’ preferences or are they due to existing biases within the healthcare system? Finally, if biases do exist, are they medically warranted?

Still learning

In 1998, a pivotal turning point in the history of breast cancer reconstruction surgery occurred with the passage of the Women’s Health and Cancer Rights Act (WHCRA). The legislation was instrumental in expanding healthcare benefits to thousands of women diagnosed

with breast cancer who sought immediate or delayed reconstructive surgery after mastectomy. Specifically, the WHCRA mandated that medical insurance providers include coverage for women who desired reconstruction after undergoing unilateral or bilateral mastectomy – as well as a “balancing” surgery for the unaffected breast for purposes of achieving symmetry when indicated. The law’s impact is unquestionable. According to the American College of Surgeons – National Surgery Quality Improvement Program (ACS-NSQIP) database, in a matter of six years, a 14 percent increase was recorded in the number of women who received breast reconstruction surgery, bringing the national average to 33 percent of all mastectomy patients.1

In spite of the entitlement afforded by the WHCRA, however, it has become increasingly apparent that women have benefited dissimilarly depending on a multitude of demographic factors. Our group demonstrated that when compared to women younger than 45, women between the ages of 45-64 and those older than 65 underwent reconstruction 12.8 percent and 41.8 percent less often, respectively. Similarly, African-American and Latina patients had decreased rates of surgery compared to Caucasian patients, by 10.6 percent and 2.2 percent, respectively.1

Interestingly, when evaluating autologous reconstruction – which entails the transfer of tissue from another part of the body to re-create a breast mound – or implant-based reconstruction – which entails using a prosthetic to re-create a breast mound – women older than 45 had lower rates than women younger than 45, regardless of technique used.1

Taking all this into account, the question remains: Are these differences patient- or provider-driven? Contrary to when evaluating racial differences – which vary depending on the type of reconstruction – elderly age has a pervasive negative association, regardless of breast reconstruction type. Unfortunately, evaluating patients’ desires to pursue or forego immediate reconstruction is poorly studied. The shortage of data prohibits our ability to draw meaningful conclusions that could help us address prevailing disparities.

There remains an assumption that the health system and physician bias play a role in this disparity. If a bias exists, presumably secondary to safety concerns in women older than 45, and even more so in women older than 65, is there any scientific evidence to support it? To help answer that question, several retrospective studies actually concluded that age does not independently preclude breast reconstruction efficacy – even in the setting of slightly increased postoperative morbidity.

One of those studies, by Angarita et al., demonstrated a 2.2 percent increase in postoperative complications for women older than 70, relative to younger women (7.5 percent vs 5.3 percent, respectively). The study also found that given the greater number of relative comorbidities in their older cohort, the increase in morbidity is considerably small and should not automatically disqualify this older demographic’s eligibility for breast reconstruction.2 Similarly, the study from our institution also revealed that postoperative breastreconstruction complications were not significantly different for women solely on the basis of age.

Breast reconstruction after mastectomy has greatly changed the quality of life for thousands of women with breast cancer regardless of their age.3 Accessibility to these services has been largely expanded by the WHCRA, but a large chasm continues to exist between the relative percent of older and younger women that undergo reconstruction.

Unfortunately, studies evaluating patient-driven factors are lacking, but from a medical standpoint, the data proves that breast reconstruction is safe and just as efficacious in older patients as it is for younger ones. Age as an independent factor should not preclude any patient from a thorough discussion with her physician regarding their breast reconstruction options.

ASPS member Paris D. Butler, MD, MPH, is an assistant professor in the Division of Plastic Surgery at the University of Pennsylvania. His clinical interests reside in both reconstructive and cosmetic plastic surgery. He’s board certified by the American Board of Surgery and the American Board of Plastic Surgery, and he’s earned an MPH in health policy and management with a special certificate in minority health. Dr. Butler currently serves on the American College of Surgeons (ACS) Committee on Surgical Health Care Disparities, as well as the ASPS Diversity & Inclusion Committee.

Monica LladoFarrulla, MD, is a board-certified general surgeon completing her training in plastic and reconstructive surgery at the University of Pennsylvania. She is interested in serving the transgender community and is presently preparing to apply for a Fellowship in transgender affirming surgery.

Sources: 1. Butler, et al. “Racial and age disparities persist in immediate breast reconstruction: an updated analysis of 48,564 patients from the 2005 to 2011 American College of Surgeons National Surgery Quality

Improvement Program data sets” 2. Angarita, F.A., Dossa, F., Zuckerman, J. et al. Is immediate breast reconstruction safe in women over 70? An analysis of the National

Surgical Quality Improvement Program (NSQIP) database. Breast Cancer Res Treat 177, 215–224 (2019). 3. Sisco Mark, Johnson Donald, Wang

Chihsiung, Rasinski Kenneth, Rundell

V.L.M., Yao Katharine. (2015). The qualityof-life benefits of breast reconstruction do not diminish with age: Breast

Reconstruction in Older Women. Journal of

Surgical Oncology. 111. 10.1002/jso.23864.