INTRODUCTION

Primary surgical treatment options for early stage invasive, intraductal (ductal carcinoma in situ, DCIS), and some locally advanced breast cancers include breast conserving surgery or mastectomy. The type of breast surgery impacts the need for breast reconstruction. A woman undergoing lumpectomy or quadrantectomy usually does not require reconstruction unless she is left with a significant deformity after breast conservation therapy.

The growing population of breast cancer survivors serves as a motive for clinicians and researchers to address the multifaceted needs of those living with and beyond a cancer diagnosis. Common sequelae that disrupt the psychosocial aspects of life for adult breast cancer survivors who have undergone mastectomy include poor body image [1-4], severe depression, feelings of diminished self-worth, and disturbances in social and occupational functioning [3-6]. Over the past 30 years, several studies have documented the psychological, social, emotional, and functional benefits of breast reconstruction, including improved psychological health, self-esteem [7-9], sexuality, body image [5,6,10-12], and reduced concern for cancer recurrence [13-15]. The literature provides support for offering postmastectomy reconstruction, as this is an important determinant of long-term health and wellbeing for breast cancer patients.

This topic review will discuss the different methods of breast reconstruction and the factors that influence the timing of reconstructive surgery. Primary surgical treatment of breast cancer and surgical options for women with an inherited predisposition to breast cancer are discussed elsewhere. (See "Breast conserving therapy" and "Mastectomy" and "Management of hereditary breast and ovarian cancer syndrome and patients with BRCA mutations", section on 'Mastectomy'.)

UTILIZATION AND PATTERNS OF CARE

Outcomes research on quality of life (QOL) improvements and psychosocial benefits associated with breast reconstruction served as the driving force for the 1998 Women's Health and Cancer Rights Act, which mandated health care payer coverage for breast and nipple reconstruction, contralateral procedures to achieve symmetry, and treatment for the sequelae of mastectomy [16]. This was followed in 2001 by additional legislation imposing penalties on noncompliant insurers. Whether passage of these laws has contributed to changes in clinical practice is unclear.

Although the rate of breast reconstruction has increased, the number of women who undergo reconstruction after mastectomy remains low [17,18]. Data collected from the American Society of Plastic Surgeons showed that the number of breast reconstructions performed annually increased from 29,609 in 1992 to 78,832 in 2000, a 166 percent increase [17]. However, a review of US women undergoing mastectomy for breast cancer from 1998 to 2002 who were identified using the Surveillance, Epidemiology and End Results (SEER) database reported that only 17 percent had breast reconstruction [18]. Geographic variation was prominent; adjusted regional rates ranged from 4.5 percent in Alaska to 34.7 percent in Atlanta, Georgia. Markedly higher rates were reported in a study of 2174 women from the National Comprehensive Cancer Network (NCCN), 42 percent had breast reconstruction [19]. Rates were significantly higher for women covered by managed care payers (compared with Medicare or Medicaid recipients), those with more than a high school education, and for women employed outside of the home. Race and ethnicity did not influence rates of reconstruction, although other reports suggest otherwise [20].