Postmastectomy Breast Reconstruction: An Exigent Need for the Impetus

Postmastectomy breast reconstruction is integral to the management of breast cancer. Despite the apparent benefits of psychosocial well-being, positive body image, and overall quality of life, the number of women receiving breast reconstruction is alarmingly low. Less than half of all women who require mastectomy in the United States are offered breast reconstruction surgery, and fewer than 20% elect to undergo immediate reconstruction. 1 In India, it is estimated that less than 1% of women undergoing mastectomies receive breast reconstruction, albeit breast cancer is the most common cancer, accounting for 14% of all new cases of malignancies. 2

Younger Women with Breast Cancer

The demography of affected Indian women is distinctly different from the west. The average age of affected women is a decade younger than in the west. 3 Women in their mid-forties, premenopausal, living in urban areas tend to have a higher risk of developing breast cancer. Further, the young women with breast cancer under 40 constitute ∼17%, with challenges of aggressive disease and associated psychosocial and economic issues. 4 In a study from Tata Memorial Hospital of young women with a median age of 36 years, only ∼10% underwent reconstruction following mastectomy, all with microsurgical flaps. 4 Despite these women in the most eligible age group in a dedicated tertiary cancer hospital with a multidisciplinary team, the percentage of reconstructions remains low. The reasons mentioned were “patient's reluctance, irrational fears of delay in treatment, additional cost, and other logistic issues.” It is pertinent to evaluate all such factors closely and rectify them.

Oncoplastic Breast Surgery

The gold standard in breast cancer surgery remains total mastectomy offering the best chances for disease-free survival. Lately, breast conservation surgery (BCS) followed by radiotherapy for early-stage diseases showed overall disease-free survival rates equal to mastectomy. 5 When the excision in BCS exceeds 20% breast volume, reconstruction is necessary. Oncoplastic breast surgery (OBS) was evolved in the early 1990s to achieve wider excision margins without compromising aesthetic outcomes. 6 In partial mastectomy defects, the reconstruction is based on either volume displacement of the remaining breast tissue or volume replacements with local flaps or autologous fat grafting. Association of Breast Surgeons of India Practical Consensus Statement recommends oncoplastic procedure if the volume loss is >20% in BCS and immediate breast reconstruction for total mastectomy. 7

OBS is rapidly gaining acceptance as a standard of care in breast cancer management worldwide. The procedures of OBS in developing countries are in a nascent stage, with the vast majority of the population lacking its availability, accessibility, and awareness about these procedures. There is an emergence of trained surgeons performing both tumor resection and reconstruction, taking a dual role in oncoplastic procedures. This serves a limited purpose where reconstructive surgeons are not available. However, this is not ideal, where the reconstructive challenges of larger defects may influence tumor resection and compromise margins. It is always preferable to perform sequential procedures by two teams with a competent plastic surgeon taking over the reconstruction part following wide resections.

Barriers in the Utility of Plastic Surgery Services

Indeed, there is a substantial paucity of reconstructive surgeons for a large population with its geographical distribution; Notwithstanding, the utility of available expertise certainly meets several barriers. The role of a primary physician in informing and guiding the patient plays a pivotal role. Any reluctance to offer reconstruction deprives a woman of her only chance. The primary surgeon's concerns about the reconstructive procedures, complications, additional time, and adjuvant therapies should be addressed. Often, a woman cannot decide by herself and is perhaps unwilling to speak about reconstruction in a patriarchal society with diverse socioeconomic and cultural differences. However, more than 75% of women in India prefer reconstruction if offered. 8

Affordability of additional cost is a significant hurdle for reconstructive procedures. Unfortunately, health insurances consider this a cosmetic procedure. There is no clear package for breast reconstruction in the government-run free health scheme Ayushman Yojana (PM-JAY) as well. In an analysis by the National Health Authority on the utility of PM-JAY scheme services for breast cancer, among the 138 procedure packages for breast cancer, only 12% is for surgical procedures and the rest for medical (58%) and radiation oncology (30%). Further, 92% of patients were admitted to medical oncology services, and only 4% were in general surgery. 9 The most common surgical procedures were excision of lumps that included reconstructions, though the data for each was not precise. As private hospitals provide >50% of the services, a comprehensive and reasonable cost package for multidisciplinary management is necessary for a vast number of poor patients.

Breast Reconstruction Awareness Campaign

The Breast Reconstruction Awareness (BRA) campaign educates, engages, and empowers women to make the reconstruction decision that is best for them. 10 First launched in 2011 in Canada, the “BRA-Day” is held annually on the third Wednesday of October in association with American and Canadian societies of plastic surgeons and several other groups involved in breast cancer treatment and support. 11

With the number of new cases of invasive carcinoma approaching 300,000 annually in the United States, at least 20% of women who do not undergo breast reconstruction are unaware of the procedure. 12 This is despite the Women's Health and Cancer Rights Act of 1998, which mandates insurance cover for reconstructive procedures and prostheses. With plastic surgeon's efforts, the USA passed the Breast Cancer Patient Education Act, which informs women of their right to breast reconstruction under federal law and provides them with information about breast reconstruction and prostheses. 12

An Exigent Need for the Impetus in India

At every 4 minutes, a woman in India is diagnosed with breast cancer, and one succumbs to the disease at every 13 minutes, making this the most prevalent disease among women. With over 210,000 new diagnoses every year, Indian women have a cumulative risk of 1 in 29 getting breast cancer during their lifetime. 13 Most of them report late, with advanced disease resulting in the highest mortality per case in the world.

The awareness about cancer and its early detection among the general population is seriously lacking. While the priority remains disease-free survival, the reconstruction must not be ignored. Acknowledging that breast reconstruction is a critical and integral part for every woman is the first step toward awareness. Unless all stakeholders, service providers, government schemes, and health insurances recognize and integrate into the management, the largest health sector remains unaddressed. This is an opportunity for the Association of Plastic Surgeons of India to launch an awareness campaign and take the lead.