Abstract
Purpose
The COVID-19 pandemic uniquely impacted patients with breast cancer as mastectomies were allowed to proceed, yet breast reconstruction surgeries were halted. The purpose of this study was to examine the effect of the COVID-19 pandemic on the rates of breast reconstruction and patients’ well-being.
Methods
A chart review included all patients who underwent mastectomy from December 2019 to September 2021. Patients were contacted by a member of the research team and asked to participate in a COVID-19-specific survey and to complete the Hospital Anxiety and Depression Scale (HADS). Patients were then grouped into “surge” or “nonsurge” groups based on the date of mastectomy.
Results
Two hundred and fifty-nine patients were included in this study. During the study period, 42% (n = 111) of the patients underwent breast reconstruction. The “surge” group included 106 patients whereas the “nonsurge” group included 153 patients. Fewer patients began breast reconstruction during the surge period compared with the nonsurge period (34.0% vs. 49.0%, p = 0.017).
Eighty-six patients participated in the COVID-19 survey. Forty-one percent (n = 35) of the patients felt that their care was disrupted because of COVID-19. Eighty-three patients completed the HADS survey. Overall, 16.8% and 15.7% of the respondents fell into the moderate to severe ranges for both anxiety and depression scales, respectively.
Conclusions
Patients with breast cancer have faced increased difficulties with access to breast reconstruction throughout the COVID-19 pandemic. Our institution demonstrated decreased rates of breast reconstruction and an increase in anxiety and depression. The positive benefits of breast reconstruction cannot be overlooked when determining resource allocation in the future.
Keywords: Breast cancer, Breast reconstruction, Autologous reconstruction, COVID-19 pandemic
Introduction
The COVID-19 pandemic uniquely impacted the breast cancer patient population. In the United States, several states placed moratoriums on elective surgical cases in an effort to preserve healthcare resources for the care of hospitalized patients with COVID-19 infections. This placed breast cancer patients in an unusual position where mastectomy procedures were deemed medically necessary and allowed to proceed; yet, all reconstructive procedures were considered elective cases and were halted.
A systematic review by Hemal et al. focused on breast reconstruction during the COVID-19 pandemic.1 This study found that breast reconstruction was paused in order to conserve hospital resources. The delay of surgeries due to the COVID-19 pandemic for patients with early-stage breast cancer demonstrated a negative effect on mental well-being in a small cohort.2 However, the psychosocial impact on patients undergoing breast reconstruction due to COVID-19 restrictions has not yet been described.
The positive psychosocial benefits of breast reconstruction within this patient population are well established.3, 4, 5, 6 Patients undergoing immediate breast reconstruction exhibit decreased distress compared with those undergoing delayed breast reconstruction, as demonstrated by various different psychosocial scales, including the Hospital Anxiety and Depression Scale (HADS).4, 5, 7
The goal of this study was to understand the psychological impact of the COVID-19 pandemic on the breast cancer patient population at our institution. Many patients were unable to undergo reconstructive breast surgery following mastectomy due to the moratorium on elective surgical cases and because of other barriers as a result of the pandemic. We hypothesized that patients undergoing mastectomy for the treatment of breast cancer during the pandemic would demonstrate higher levels of anxiety and depression for reasons such as decreased access to breast reconstruction, increased anxiety because of the COVID-19 pandemic, and increased distress because of scheduling difficulties given the COVID-19 restrictions.
Methods
Study design
Following the Institutional Review Board approval, a retrospective chart review was conducted and included all patients undergoing mastectomy for the treatment of breast cancer at a large safety-net hospital from December 2019 through September 2021. Patients that were deceased at the time of data collection, had inadequate follow-up, underwent partial mastectomy, or spoke a language other than English or Spanish were excluded. Demographic, surgical, and referral data were extracted and recorded using Research Electronic Data Capture (REDCap), a secure, web-based software platform designed to support data capture for research studies.8, 9
Our institution most commonly utilizes the two-step delayed-immediate approach to breast reconstruction, with the placement of a tissue expander (TE) at the time of mastectomy, followed by a period of tissue expansion, and completed by either implant-based or autologous-based breast reconstruction.10 Immediate breast reconstruction was defined as implant or TE placement at the time of mastectomy. The completion of breast reconstruction was defined as the replacement of TE with either the permanent implant or autologous tissue. Those who had TEs removed were also noted.
Patients were then divided into two groups: the “surge” group and the “nonsurge” group, based on the date of mastectomy. Patients included in the “surge” cohort were those who underwent mastectomy during either of the surgical moratoriums in Texas (March 22, 2020–May 1, 2020; June 25, 2020–September 17, 2020), during the winter COVID-19 surge (December 1, 2020–March 1, 2021), or during the Delta variant surge (July 15, 2021–November 1, 2021). All patients with mastectomy dates falling outside of these ranges were then placed into the “nonsurge” group. Outcomes were then compared between the two cohorts, with our institution’s historical data and with previously published literature.
Surveys
Patients meeting the inclusion criteria were contacted by a research team member and administered a survey pertaining to their care during the COVID-19 pandemic, as shown in Figure 1. All contacted patients were also asked to complete the HADS survey, a validated questionnaire to measure anxiety and depression.11, 12, 13 Scores were classified as follows: 0–7 points defined as normal, 8–10 points as mild, 11–14 points as moderate, and 15–21 as severe.4
Figure 1.
COVID-19 specific survey.
Statistical analysis
Demographic, surgical, and referral data were extracted and recorded using REDCap, a secure, web-based software platform designed to support data capture for research studies.8, 9 Primary outcome variables included the results of the nonvalidated ten-question survey and the HADS survey.
Descriptive statistics were reported as mean ± standard deviation. Categorical outcomes were compared between groups using the Chi-squared test or Fisher-exact test and the strength of association when appropriate, whereas continuous outcomes were compared using the independent-sample t-test. All statistics were completed by SPSS Version for Mac, version 28.0.14 A p-value of less than 0.05 indicated statistical significance.
Results
Patient demographics and surgical data
Two hundred and fifty-nine patients were identified and included in this study. The average age at the time of mastectomy was 51.7 (±10.4) years old. The majority of the patients spoke English as their primary language (n = 140, 54.5%) were of Hispanic ethnicity (n = 158, 61.0%), and were Caucasian (n = 182, 70.3%). Patient demographics and surgical data are outlined in Table 1.
Table 1.
Patient demographics and surgical data.
| Surge | Nonsurge | Total study cohort | |
|---|---|---|---|
| Number of patients | 106 | 153 | 259 |
| Age at mastectomy | 52.5 (±11.0) | 51.3 (±9.9) | 51.7 (±10.4) |
| Ethnicity | |||
| Hispanic Non-Hispanic Unknown |
64 (60.4%) 42 (39.6%) 0 (0.0%) |
94 (61.4%) 58 (37.9%) 1 (0.7%) |
158 (61.0%) 100 (38.6%) 1 (0.4%) |
| Primary language | |||
| English Spanish |
57 (54.3%) 48 (45.7%) |
83 (54.6%) 69 (45.4%) |
140 (54.5%) 117 (45.5%) |
| Race | |||
| White African American Asian American Indian Other Pacific Islander Unknown |
77 (72.7%) 26 (24.6%) 1 (0.9%) 0 (0.0%) 1 (0.9%) 1 (0.9%) |
105 (68.6%) 43 (28.1%) 2 (1.3%) 0 (0.0%) 1 (0.7%) 2 (1.3%) |
182 (70.2%) 69 (26.6%) 3 (1.2%) 0 (0.0%) 2 (0.8%) 3 (1.2%) |
| Laterality of mastectomy | |||
| Unilateral Bilateral |
73 (68.9%) 33 (31.1%) |
94 (61.4%) 59 (38.6%) |
167 (64.5%) 92 (35.5%) |
| Underwent reconstruction | |||
| Yes No |
36 (34.0%) 70 (66.0%) |
75 (49.0%) 78 (51.0%) |
111 (42.9%) 148 (57.1%) |
| Reconstruction timing | |||
| Immediate Delayed |
34 (94.4%) 2 (5.6%) |
63 (84.0%) 12 (16.0%) |
97 (87.4%) 14 (12.6%) |
| Underwent final reconstruction | 15 (14.2%) | 53 (34.6%) | 67 (25.9%) |
| Final reconstruction types | |||
| Autologous Implant-based TE removal/explant |
3 (20.0%) 7 (46.7%) 5 (33.3%) |
29 (54.7%) 16 (30.2%) 8 (15.1%) |
32 (47.1%) 23 (33.8%) 13 (19.1%) |
During the study period, 42% (n = 111) of the patients underwent breast reconstruction. Eighty-seven percent (n = 97) of these patients underwent immediate breast reconstruction at the time of mastectomy with either placement of a TE or a permanent implant. The remaining 13% (n = 14) of these patients underwent delayed breast reconstruction. Nearly half (49.5%, n = 55) completed breast reconstruction during the study period. Of those who completed reconstruction, 58% (n = 32) of patients who completed reconstruction underwent autologous-based reconstruction, whereas 42% (n = 23) underwent implant-based reconstruction. Thirteen patients failed reconstruction with TE explanation due to infection or patient request. At the time of data collection, 43 patients who completed the first stage of reconstruction were waiting for the second stage.
One hundred and six patients were included in the “surge” group. Of these, 34.0% (n = 36) of the patients underwent breast reconstruction, with 27.8% (n = 10) completing breast reconstruction within the study period. A majority of these patients (70%) underwent implant-based reconstruction, whereas the remaining 30% underwent autologous breast reconstruction. Five patients failed reconstruction and twenty-one were waiting for the second stage.
One hundred and fifty-three patients were included in the “nonsurge” group. Of these, 49.0% (n = 75) underwent breast reconstruction, with 60.0% (n = 45) completing breast reconstruction. A majority of these patients (64%) underwent autologous-based reconstruction, and the remaining 36% underwent implant-based reconstruction. Eight patients failed reconstruction and twenty-two were waiting for the second stage.
There were no significant differences between groups for race ethnicity, preferred language, or age. A trend that was approaching significance showed that patients during a nonsurge time period had an average longer time period between mastectomy and definitive reconstruction compared with patients during a surge period (261.17 days ± 157.81 vs. 178.14 days± 24.35, p = 0.059), as demonstrated in Figure 2.
Figure 2.
Days between mastectomy and definitive breast reconstruction.
Significantly fewer patients underwent initial breast reconstruction during the surge period compared with the nonsurge period (34.0% vs. 49.0%, p = 0.017). Of those who completed breast reconstruction, there was a trend toward fewer patients undergoing autologous-based breast reconstruction in the surge group compared with the nonsurge group (30.0% vs. 64.0%, p = 0.051).
Breast cancer care and reconstruction impact
Of the 259 patients that met the inclusion criteria, 86 patients participated in the COVID-19-specific survey, for a response rate of 33.2%. The average age of survey participants was 50.3 (±9.0) years old. Eighty-five percent (n = 73) of survey participants were referred to a plastic surgeon following a breast cancer diagnosis and 73.3% (n = 63) saw a plastic surgeon for a consult. There was a trend toward more patients within the surge group that did not see a plastic surgeon for a consult compared with the nonsurge group (27.3% vs. 18.9%), with referral rates being similar between the two groups (90.9% vs. 81.1%). Patients were not seen by a plastic surgeon for the following reasons: personal reasons (n = 19; 67.9%), COVID-19 restrictions (n = 4, 14.3%), and medical comorbidities (n = 3; 10.7%).
Overall, 41% (n = 35) of the patients stated that their breast reconstruction was disrupted because of the COVID-19 restrictions, with 16.3% (n = 14) of the survey respondents stating that their breast cancer care was affected “extremely much.” More patients within the surge group felt that their care was disrupted and to a greater subjective degree of an impact compared with those within the nonsurge group. At the time of their breast cancer diagnosis, 54.6% (n = 47) of the patients stated that breast reconstruction was “extremely” important to them, with 27.9% (n = 24) of the patients having concerns about breast reconstruction cross their mind “constantly.” Survey responses from the COVID-19-specific survey are demonstrated in Table 2.
Table 2.
COVID-19 specific survey results.
| Surge (n = 33) | Non-Surge (n = 53) | All (n = 86) | |
|---|---|---|---|
| Were you referred to a plastic surgeon following a diagnosis? | |||
| Yes | 30 (91%) | 43 (81%) | 73 (85%) |
| No | 1 (3%) | 10 (19%) | 11 (13%) |
| No answer | 2 (6%) | 0 (0.0%) | 2 (2%) |
| Were you able to see a plastic surgeon following your diagnosis? | |||
| Yes | 21 (64%) | 42 (79%) | 63 (73%) |
| No | 9 (27%) | 10 (19%) | 19 (22%) |
| No answer | 3 (9%) | 1 (2%) | 4 (5%) |
| Was your breast reconstruction disrupted because of the COVID-19 restrictions? | |||
| Yes | 14 (42%) | 21 (40%) | 35 (41%) |
| No | 15 (46%) | 31 (58%) | 46 (53%) |
| No answer | 4 (12%) | 1 (2%) | 5 (6%) |
| On a scale of 1–5, how much have COVID restrictions affected breast cancer care? | |||
| 1 | 17 (52%) | 30 (56.6%) | 47 (54.7%) |
| 2 | 5 (15%) | 4 (7.6%) | 9 (10.5%) |
| 3 | 4 (12%) | 5 (9.4%) | 9 (10.5%) |
| 4 | 2 (6%) | 5 (9.4%) | 7 (8.1%) |
| 5 | 5 (15%) | 9 (17.0%) | 14 (16.3%) |
| No answer | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
| On a scale of 1–5, how important was breast reconstruction to you? | |||
| 1 | 8 (24.2%) | 9 (17.0%) | 17 (19.8%) |
| 2 | 3 (9.1%) | 3 (5.6%) | 6 (7.0%) |
| 3 | 3 (9.1%) | 7 (13.2%) | 10 (11.6%) |
| 4 | 1 (3.0%) | 4 (7.6%) | 5 (5.8%) |
| 5 | 17 (51.5%) | 30 (56.6%) | 47 (54.6%) |
| No answer | 1 (3.0%) | 0 (0.0%) | 1 (1.2%) |
| How often did concerns about breast reconstruction cross your mind? | |||
| Not at all | 14 (42.4%) | 15 (28.3%) | 29 (33.7%) |
| 1–2 times per month | 7 (21.2%) | 11 (20.8%) | 18 (20.9%) |
| Weekly | 0 (0.0%) | 3 (5.6%) | 3 (3.5%) |
| Multiple times per day | 5 (15.2%) | 7 (13.2%) | 12 (14.0%) |
| Constantly | 7 (21.2%) | 17 (32.1%) | 24 (27.9%) |
| No answer | 0 | 0 (0.0%) | 0 (0.0%) |
As for the open-ended question in the COVID-19 survey, many patients chose to discuss their experiences regarding their care during the pandemic. These responses were unique to each patient and are reviewed in the discussion.
Psychological impact
Eighty-three patients completed the HADS survey, for a response rate of 32.0%. The average age at the time of mastectomy for HADS survey participants was 50.6 (±8.9) years. Overall, 16.8% of survey respondents fell into the moderate to severe ranges for the anxiety scale, whereas 15.7% fell into the same range for the depression scale. Most patients were classified within the normal range for both the anxiety and depression scales; however, large numbers of patients fell into the mild and moderate categories, with 4.8% of patients being classified within the severe anxiety range, and 2.4%. within the severe depression range. Survey responses for the HADS scale are demonstrated in Table 3.
Table 3.
HADS survey results.
| Anxiety scoring |
Depression scoring |
|||||||
|---|---|---|---|---|---|---|---|---|
| Normal | Mild | Moderate | Severe | Normal | Mild | Moderate | Severe | |
| All (n = 83) | 54 (65.1%) | 15 (18.1%) | 10 (12.0%) | 4 (4.8%) | 59 (71.1%) | 11 (13.25%) | 11 (13.25%) | 2 (2.4%) |
| Surge (n = 30) | 19 (63.3%) | 6 (20.0%) | 3 (10.0%) | 2 (6.7%) | 21 (70.0%) | 3 (10.0%) | 5 (16.7%) | 1 (3.3%) |
| Nonsurge (n = 53) | 35 (66.0%) | 9 (17.0%) | 7 (13.2%) | 2 (3.8%) | 38 (71.7%) | 8 (15.1%) | 6 (11.3%) | 1 (1.9%) |
| Al-Ghazal et al. | 55 (45.5%) | 46 (38.0%) | 17 (14.0%) | 3 (2.5%) | 118 (97.5%) | 2 (1.7%) | 1 (0.8%) | 0 (0.0%) |
Fifty-three survey respondents were placed in the “nonsurge” group, whereas 30 respondents were in the “surge” cohort. There were no significant differences in HADS scoring between survey respondents from the surge group versus the nonsurge group. However, there was a trend toward more patients falling into the moderate and severe categories for the depression scale for survey respondents during the “surge” periods compared with those in the “nonsurge” group. A visual representation of HADS survey responses among surge groups is demonstrated in Figure 3, Figure 4.
Figure 3.
HADS anxiety scoring.
Figure 4.
HADS depression scoring.
Discussion
The COVID-19 global pandemic affected patients across all medical specialties. In the United States, moratoriums were placed on elective surgical cases in an effort to preserve sparse healthcare resources. Patients with breast cancer were able to undergo mastectomies for the treatment of their breast cancer but were unable to pursue breast reconstruction. The COVID-19 pandemic drastically affected breast cancer care.1 Plastic surgeons were prompted to choose to delay breast reconstruction to allocate strained healthcare resources, mitigate the spread of COVID-19, and avoid potential complications.15 This led to decreased rates of breast reconstruction, leaving patients without a breast mound following mastectomy until reconstruction could be performed at a later time if even performed at all.
Breast reconstruction is an essential component of comprehensive breast cancer care. Compared with women undergoing mastectomy alone, those undergoing breast reconstruction report higher levels of satisfaction.16 Currently within the United States, more patients are opting for bilateral mastectomy with breast reconstruction instead of breast conserving surgery for early-stage breast cancers.17 Following the Women’s Health and Cancer Rights Act of 1998, which increased access to breast reconstruction by mandating insurance coverage of all breast reconstructive procedures, there has been an increase in the uptake of breast reconstruction surgeries.18, 19
This study demonstrated an overall breast reconstruction rate of 42.9%, with significantly fewer patients in the surge group undergoing breast reconstruction compared with the nonsurge group (34.0% vs. 49.0%, p = 0.0167). This is a decreased overall trend compared with the institution’s historical data from 2016 to 2019, which showed a breast reconstruction rate of 66%.20 In addition, more patients within the surge group stated that they did not see a plastic surgeon for a consult following their diagnosis compared with survey participants from the nonsurge group, although referral rates between the two groups remained similar.
Breast reconstruction following mastectomy has consistently been associated with increased psychological well-being and satisfaction.21 Rosenberg et al. demonstrated that patients with unilateral or bilateral mastectomy with reconstruction experience less discomfort postoperatively compared with mastectomy alone.21 Patients undergoing breast reconstruction outperform those undergoing mastectomy alone on a multitude of psychological and emotional well-being questionnaires and scales.22 Most importantly, breast satisfaction and psychological well-being have been found to be higher in those undergoing breast reconstruction compared with those undergoing mastectomy alone.22
The timing of breast reconstruction is also an important consideration. Psychosocially, lower levels of anxiety and depression are associated with patients who undergo immediate breast reconstruction compared with those who undergo delayed breast reconstruction.3, 4, 5, 23 During the COVID-19 pandemic, many plastic surgeons were encouraged to delay breast reconstruction procedures.15 As demonstrated by the survey results, the majority of the patients (54.6%, n = 47) felt that breast reconstruction was “extremely important” to them, and for 27.9% (n = 24) of the patients, thoughts about breast reconstruction crossed their mind “constantly.” However, despite breast reconstruction being this important to patients, many patients (40.7%, n = 35) felt that their care was disrupted during the COVID-19 global pandemic.
The type of breast reconstruction also has a significant effect on patient satisfaction. When compared with other reconstructive modalities, patients undergoing autologous, abdominal-based breast reconstruction have consistently demonstrated higher rates of satisfaction compared with those undergoing implant-based reconstruction.16, 24, 25, 26, 27 In this study, patients undergoing mastectomy during the COVID-19 surge periods demonstrated decreased rates of autologous breast reconstruction compared with those within the nonsurge period. In the early stages of the pandemic, autologous breast reconstruction was paused to preserve limited healthcare resources including intensive care unit beds, healthcare providers, and personal protective equipment.1 The respondents of a global survey proposed an Enhanced Recovery After Surgery pathway for microsurgical breast reconstruction to balance COVID-19 risks while reinstating autologous breast reconstruction.28 Surgeons began offering immediate implant-based reconstruction as a temporary solution to the COVID-19 restrictions, as this decreased the length of stay in the hospital as well as decreased the number of procedures needed for completion of breast reconstruction, thus decreasing exposure to COVID-19 and also preserving hospital resources.1, 29, 30
This study demonstrated that the well-being of patients with breast cancer was negatively impacted by the COVID-19 pandemic, as demonstrated by the trend toward more patients falling into the “mild” and “moderate” categories for the HADS depression scale within the study cohort compared with the previously published literature.4 The study cohort also demonstrated a trend toward more patients falling within the “severe” category for both the anxiety and depression sections of the HADS survey.4 This patient cohort exhibited higher scores on the HADS survey in the depression domains compared with previously published data (5.47 vs. 3.3) with comparable anxiety scores (6.12 vs. 6.1), although statistical significance cannot be determined.22
Most survey respondents did not undergo breast reconstruction, a trend opposing what is typically seen at our institution. Reasons for not undergoing breast reconstruction within the study population varied among patients. Some women did not desire to undergo multiple surgeries. Other patients desired to return to work and did not have time for additional operations. For some, because their referral to plastic surgery was delayed due to the COVID-19 restrictions, breast reconstruction became less important to them. These trends correlate with previous data demonstrating that fear, practicality, and the desire to avoid additional surgeries are all themes seen with women choosing to not undergo breast reconstruction following mastectomy.31, 32 However, the COVID-19 pandemic restrictions did not give patients nor surgeons a choice on whether they pursued immediate or delayed breast reconstruction. During the surgical moratoriums and other time periods of COVID-19 surges, hospitals mandated the delay of all elective procedures, which included postmastectomy breast reconstruction.
Patients expressed fears about additional clinic, hospital, and operative room visits because of their fear of contracting COVID-19. A national survey demonstrated that patients fear of COVID-19 prevented them from seeking appropriate medical care; 40% of the respondents felt that going to the doctor’s office during COVID-19 was not safe.33 Local hospitals in Taiwan experienced a significant reduction in elective orthopedic surgeries and clinic visits despite not having any restrictions placed, a trend attributed by the authors to the fear of COVID-19.34 The fear of COVID-19 may have played a significant role in the decreased rates of breast reconstruction seen within this patient cohort, as patients may have neglected to seek out appropriate medical care.
Perhaps one of the most important and interesting components of this study was asking patients to describe their experiences with their care during the COVID-19 pandemic. When asked an open-ended question regarding their breast cancer care during the COVID-19 pandemic, respondents provided a wide array of responses. One woman felt that COVID-19 prevented her breast reconstruction, which “made [her] feel depressed.” Another woman felt that the delays because of the COVID-19 restrictions “made everyday living more difficult.” Some patients felt that things were rushed, whereas others felt they had to wait for a long time for their care. Some patients stated that it was very difficult going to appointments and surgeries without visitors because of the pandemic restrictions. On the other hand, when faced with delays and rescheduling, patients were grateful for the system “being careful.” Others felt they received great care during this difficult time and that the team was available to them and cared for them.
In conclusion, the COVID-19 pandemic has impacted the breast cancer pattient population in unique ways. Our institution exhibited decreased breast reconstruction rates compared with prepandemic times. Patients undergoing mastectomy during COVID-19 surge periods demonstrated significantly decreased rates of overall breast reconstruction and lower rates of autologous breast reconstruction. Many patients chose not to pursue breast reconstruction during the pandemic for reasons including the fear of contracting COVID-19 at the hospital, no desire to undergo additional surgeries, and the need to return to work quickly being some of the more common reasons. The importance of breast reconstruction within the breast cancer patient population cannot be emphasized enough; it is a vital component of comprehensive breast cancer care.
This study is not without limitations. The surveys were retrospectively administered, which can induce inherent error and bias. The response bias must be considered as the members of the research team contacted patients via telephone calls, patients may have been reluctant to share honest opinions about their intimate breast cancer journey. Shorter follow-up time may also skew survey responses and patient perspectives. Without a control group of similar patients to compare this study cohort to, it is difficult to quantify the impact of the COVID-19 pandemic on this patient population. Future studies are warranted to continue to study the psychosocial impact of the COVID-19 pandemic on this unique population of patients with breast cancer.
Conclusion
Breast reconstruction is a necessary component of comprehensive breast cancer care. Many patients were faced with difficulties accessing breast reconstruction during the COVID-19 global pandemic because of various restrictions imposed on elective surgeries and clinic visits. In the future, psychosocial benefits of breast reconstruction must be considered when hospital resources allocation is considered.
Ethical Approval
Institutional Review Board Approved. IRB STU062018–062.
Funding Statement
No funding was utilized for the completion of this project.
Declaration of Competing Interest
The authors have no conflicts of interest to disclose.
Footnotes
Presented at Plastic Surgery The Meeting 2022 in Boston, MA, and at the 11th Congress of the World Society of Reconstructive Microsurgery in Cancún, Mexico, as oral presentations.
References
- 1.Hemal K., Boyd C.J., Bekisz J.M., Salibian A.A., Choi M., Karp N.S. Breast reconstruction during the COVID-19 Pandemic: A systematic review. Plast Reconstr Surg Glob Open. 2021;9(9) doi: 10.1097/gox.0000000000003852. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Sokas C., Kelly M., Sheu C., et al. Cancer in the shadow of COVID: Early-stage breast and prostate cancer patient perspectives on surgical delays due to COVID-19. Ann Surg Oncol. 2021;28(13):8688–8696. doi: 10.1245/s10434-021-10319-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Heimes A.-S., Stewen K., Hasenburg A. Psychosocial aspects of immediate versus delayed breast reconstruction. Breast Care. 2017;12(6):374–377. doi: 10.1159/000485234. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Al-Ghazal S.K., Sully L., Fallowfield L., Blamey R.W. The psychological impact of immediate rather than delayed breast reconstruction. Eur J Surg Oncol. 2000;26(1):17–19. doi: 10.1053/ejso.1999.0733. [DOI] [PubMed] [Google Scholar]
- 5.Wellisch D.K., Schain W.S., Noone R.B., Little J.W., 3rd. Psychosocial correlates of immediate versus delayed reconstruction of the breast. Plast Reconstr Surg. 1985;76(5):713–718. doi: 10.1097/00006534-198511000-00010. [DOI] [PubMed] [Google Scholar]
- 6.Dauplat J., Kwiatkowski F., Rouanet P., et al. Quality of life after mastectomy with or without immediate breast reconstruction. Br J Surg. 2017;104(9):1197–1206. doi: 10.1002/bjs.10537. [DOI] [PubMed] [Google Scholar]
- 7.van Bommel A.C.M., de Ligt K.M., Schreuder K., et al. The added value of immediate breast reconstruction to health-related quality of life of breast cancer patients. Eur J Surg Oncol. 2020;46(10 Pt A):1848–1853. doi: 10.1016/j.ejso.2020.06.009. [DOI] [PubMed] [Google Scholar]
- 8.Harris P.A., Taylor R., Minor B.L., et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inf. 2019;95 doi: 10.1016/j.jbi.2019.103208. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Harris P.A., Taylor R., Thielke R., Payne J., Gonzalez N., Conde J.G. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381. doi: 10.1016/j.jbi.2008.08.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Kronowitz S.J., Hunt K.K., Kuerer H.M., et al. Delayed-immediate breast reconstruction. Plast Reconstr Surg. 2004;113(6):1617–1628. doi: 10.1097/01.Prs.0000117192.54945.88. [DOI] [PubMed] [Google Scholar]
- 11.Zigmond A.S., Snaith R.P. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361–370. doi: 10.1111/j.1600-0447.1983.tb09716.x. [DOI] [PubMed] [Google Scholar]
- 12.Hedman E., Ljótsson B., Blom K., et al. Telephone versus internet administration of self-report measures of social anxiety, depressive symptoms, and insomnia: Psychometric evaluation of a method to reduce the impact of missing data. J Med Internet Res. 2013;15(10):e229. doi: 10.2196/jmir.2818. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Vodermaier A., Linden W., Siu C. Screening for emotional distress in cancer patients: A systematic review of assessment instruments. J Natl Cancer Inst. 2009;101(21):1464–1488. doi: 10.1093/jnci/djp336. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.IBM SPSS Statistics for Mac. Version 28. IBM Corp; 2021.
- 15.Chetta M.D., Schoenbrunner A.R., Lee C.N. Postmastectomy breast reconstruction in the time of the novel coronavirus disease 2019 (COVID-19) pandemic. Plast Reconstr Surg Glob Open. 2020;8(6) doi: 10.1097/gox.0000000000002967. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Atisha D.M., Rushing C.N., Samsa G.P., et al. A national snapshot of satisfaction with breast cancer procedures. Ann Surg Oncol. 2015;22(2):361–369. doi: 10.1245/s10434-014-4246-9. [DOI] [PubMed] [Google Scholar]
- 17.Albornoz C.R., Matros E., Lee C.N., et al. Bilateral mastectomy versus breast-conserving surgery for early-stage breast cancer: The role of breast reconstruction. Plast Reconstr Surg. 2015;135(6):1518–1526. doi: 10.1097/prs.0000000000001276. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Hernandez-Boussard T., Zeidler K., Barzin A., Lee G., Curtin C. Breast reconstruction national trends and healthcare implications. Breast J. 2013;19(5):463–469. doi: 10.1111/tbj.12148. [DOI] [PubMed] [Google Scholar]
- 19.Women’s Health and Cancer Rights Act of 1998, 1998. 〈https://www.cms.gov/Regulations-and-Guidance/Health-Insurance-Reform/HealthInsReformforConsume/downloads/WHCRA_Statute.pdf〉.
- 20.Meade A.E., Cummins S.M., Farewell J.T., et al. Breaking barriers to breast reconstruction among socioeconomically disadvantaged patients at a large safety-net hospital. Plast Reconstr Surg Glob Open. 2022;10(7) doi: 10.1097/gox.0000000000004410. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Rosenberg S.M., Dominici L.S., Gelber S., et al. Association of breast cancer surgery with quality of life and psychosocial well-being in young breast cancer survivors. JAMA Surg. 2020;155(11):1035–1042. doi: 10.1001/jamasurg.2020.3325. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Retrouvey H., Kerrebijn I., Metcalfe K.A., et al. Psychosocial functioning in women with early breast cancer treated with breast surgery with or without immediate breast reconstruction. Ann Surg Oncol. 2019;26(8):2444–2451. doi: 10.1245/s10434-019-07251-9. [DOI] [PubMed] [Google Scholar]
- 23.Dean C., Chetty U., Forrest A.P. Effects of immediate breast reconstruction on psychosocial morbidity after mastectomy. Lancet. 26 1983;1(8322):459–462. doi: 10.1016/s0140-6736(83)91452-6. [DOI] [PubMed] [Google Scholar]
- 24.Yueh J.H., Slavin S.A., Adesiyun T., et al. Patient satisfaction in postmastectomy breast reconstruction: A comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg. 2010;125(6):1585–1595. doi: 10.1097/PRS.0b013e3181cb6351. [DOI] [PubMed] [Google Scholar]
- 25.Duraes E.F.R., Schwarz G.S., de Sousa J.B., et al. Factors influencing the aesthetic outcome and quality of life after breast reconstruction: A cross-sectional study. Ann Plast Surg. 2020;84(5):494–506. doi: 10.1097/sap.0000000000002157. [DOI] [PubMed] [Google Scholar]
- 26.Eltahir Y., Krabbe-Timmerman I.S., Sadok N., Werker P.M.N., de Bock G.H. Outcome of quality of life for women undergoing autologous versus alloplastic breast reconstruction following mastectomy: A systematic review and meta-analysis. Plast Reconstr Surg. 2020;145(5):1109–1123. doi: 10.1097/prs.0000000000006720. [DOI] [PubMed] [Google Scholar]
- 27.Santosa K.B., Qi J., Kim H.M., Hamill J.B., Wilkins E.G., Pusic A.L. Long-term patient-reported outcomes in postmastectomy breast reconstruction. JAMA Surg. 2018;153(10):891–899. doi: 10.1001/jamasurg.2018.1677. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Ali S., Ibrahim N., Warwick J., Boyce D., Ghattaura A. COVID-19 microsurgical breast reconstruction national practise survey: A survey of BAPRAS members and proposal of COVID-19 specific perioperative and ERAS pathways. J Plast Reconstr Aesthetic Surg. 2021;74(3):644–710. doi: 10.1016/j.bjps.2020.10.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Perez-Alvarez I.M., Bartholomew A.J., King C.A., et al. Breast surgery in the time of global pandemic: Benefits of same-day surgery for breast cancer patients undergoing mastectomy with immediate reconstruction during COVID-19. Plast Reconstr Surg. 2020;146(4):522–523. doi: 10.1097/prs.0000000000007269. [DOI] [PubMed] [Google Scholar]
- 30.Specht M., Sobti N., Rosado N., et al. High-efficiency same-day approach to breast reconstruction during the COVID-19 crisis. Breast Cancer Res Treat. 2020;182(3):679–688. doi: 10.1007/s10549-020-05739-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Flitcroft K., Brennan M., Spillane A. Making decisions about breast reconstruction: A systematic review of patient-reported factors influencing choice. Qual Life Res. 2017;26(9):2287–2319. doi: 10.1007/s11136-017-1555-z. [DOI] [PubMed] [Google Scholar]
- 32.Morrow M., Li Y., Alderman A.K., et al. Access to breast reconstruction after mastectomy and patient perspectives on reconstruction decision making. JAMA Surg. 2014;149(10):1015–1021. doi: 10.1001/jamasurg.2014.548. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Grines C.L. SCAI COVID 19 updated consumer survey shows continued concern of patients, especially among underserved populations. Catheter Cardiovasc Inter. 2021;98(3):414–415. doi: 10.1002/ccd.29788. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Shih C.L., Huang P.J., Huang H.T., Chen C.H., Lee T.C., Hsu C.H. Impact of the COVID-19 pandemic and its related psychological effect on orthopedic surgeries conducted in different types of hospitals in Taiwan. J Orthop Surg. 2021;29(1) doi: 10.1177/2309499021996072. [DOI] [PubMed] [Google Scholar]