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A Paradigm Shift in United States Breast Reconstruction
Evan Matros, MD MMSc, Claudia R. Albornoz, MD MSc, Peter B. Bach, MD MAPP, Andrea L. Pusic, MD MHS, Colleen M. McCarthy, MD MS1, Babak J. Mehrara, MD, Joseph J. Disa, MD, Peter G. Cordeiro, MD.
Memorial Sloan Kettering Cancer Center, New York, NY, USA.

PURPOSE:
Although outcome studies initially failed to demonstrate changes in reconstructive patterns following passage of the Women Health and Cancer Rights Act, newer reports suggest shifts in U.S. breast reconstruction may be occurring. A recent population based study showed a postmastectomy reconstruction rate of 37% for 2008, compared to 15-25% in the early 2000’s. Implants were identified as the most common reconstructive technique, a reversal of prior findings. As a single year analysis, the significance of these results is unclear. The goal of the current study is to assess long-term trends of both rates and types of immediate breast reconstruction performed in the US.
METHODS:
A longitudinal analysis of patient discharges following total mastectomy was performed for 1998 through 2008 using the Nationwide Inpatient Sample (NIS) database. The NIS is a stratified sample of 20% of US hospital discharges, representing the largest available inpatient registry. Information on the number and type of mastectomy (unilateral versus bilateral), immediate reconstruction rate, and reconstruction method (autologous versus implant) were tabulated using ICD-9 procedure codes. Rates were adjusted per 1,000 mastectomies. Longitudinal trends were analyzed using Poisson regression. Associations between patient/hospital factors and reconstructive method were evaluated using multivariable analysis. Statistical analyses were performed using the statistical package Stata 11.0 ™.
RESULTS:
Immediate breast reconstruction rates increased from 20.8% in 1998 to 37.8% in 2008. This represents a 78% increase overall, with a rising significant trend of 5% per year (Incidence Rate Ratio [IRR] 1.05, p-value <0.01). Autologous reconstructions remained level (IRR 0.99, p-value=0.3) whereas implant use increased on average 11% per year (IRR 1.11, p-value <0.01). In 1998 autologous techniques were the most common reconstructive procedure; however, implants became the predominant reconstructive modality after 2003. While implant reconstructions were related to various patient/hospital factors, they were most strongly associated with patients who underwent bilateral mastectomies (OR 1.90, p-value <0.01). The number of bilateral mastectomies increased on average 17% per year (IRR 1.17, p-value <0.01). Rates of implant reconstruction increased after both bilateral and unilateral mastectomies, but were greater following bilateral mastectomies.
CONCLUSION:
Immediate reconstruction rates have risen significantly in the U.S. The increased trend correlates closely to a 200% rise in implant reconstructions. Autologous methods are no longer the preferred method of reconstruction with unchanged usage over the past decade. Since implant use is favored in bilateral mastectomies, changes in oncologic practice such as contralateral prophylactic mastectomies may contribute to reconstructive patterns. Additional reasons for the preference towards implants require further study.
Figure 1. Immediate Reconstruction trends and types of procedures.

Figure 2. Contribution of Unilateral and Bilateral Implant Reconstructions to the increased Implant Reconstruction Rate.


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