PURPOSE: Less than 20% of eligible patients undergo breast reconstruction after treatment for breast cancer, despite documented quality of life benefits of the procedure.  Prior studies have demonstrated that most general surgeons do not discuss reconstructive options with their patients and that knowing about reconstructive options affects the likelihood that patients receive reconstruction.  The purpose of this study is to examine the likelihood of referral and reconstruction within a cohort of mastectomy patients and to compare rates of reconstruction between those referred (REF) and not referred (NotREF) by their breast surgeons for a plastic surgery evaluation.  Additionally, the study examines the differences between the groups in order to better understand potential factors influencing the referral decision.

METHOD: Data was collected in a retrospective review of the records of 471 consecutive female patients who underwent mastectomy between 2003 and 2007. Demographics evaluated were age, BMI, diabetes, laterality (unilateral vs. bilateral), smoking history, insurance type, and race. 

RESULTS: Of 471 patients with age median/range 61(19-94), 313 (66.4%) were referred for consultation with a plastic surgeon.  287 (91.7%) of those referred were reconstructed.  100% of those not referred were not reconstructed.  The two groups differed significantly in terms of age (51.1±11.8 in the REF group vs. 61.84±14.5 in NotREF group, p<0.0001); BMI (25.9 ± 5.6 in REF vs. 27.8±7.8 in NotREF, p<0.026); diabetes (REF 10/3.5% vs. NotREF 23/15%, p<0.0001); laterality (83/27% of REF group, vs. 23/14% of NotREF underwent bilateral mastectomies, p<0.003).  The groups did not differ significantly in terms of race, tobacco use, or insurance type.  Further, in multivariate analysis, age and diabetes were significant independent factors for referral with odds ratio 0.945, 95% CI 0.92-0.96, p<0.0001 and 0.317, 95% CI 0.13-0.75, p<0.01, correspondingly. In multivariate analysis age, BMI, diabetes and current smoking were found also to be significant independent factors for reconstruction with p values <0.0001, <0.025, <0.025, and <0.05, respectively.

CONCLUSION: Factors that influence the referral are age and diabetes whereas independent factors influencing reconstruction are age, BMI, diabetes, and current smoking. Future prospective studies are warranted to understand further both the referral decision as well as the decision for reconstruction.