Introduction
In 2019, 45 experts and stakeholders attended the inaugural roundtable on breast reconstruction (BR) practice in Australia to discuss ways of addressing documented inequities in access to BR. The roundtable resulted in 10 final recommendations regarding ways of improving informed decision- making and eight recommendations for increasing funding to support wider, more timely access to BR. These recommendations have major implications for changes to operating theatre management, clinician allocations, training and education, referral processes, patient education and empowerment, transparent allocation of resources, and greater linkage between tertiary and non-tertiary hospitals and metropolitan and non-metropolitan facilities. Novel methods of funding surgical services will be needed.
Background
Breast cancer is the most common female malignancy with over 19,000 new cases in Australia in 2019.1 Approximately 40 per cent of Australian women diagnosed with breast cancer undergo mastectomy and Cancer Australia has stated that it is ‘not appropriate to perform a mastectomy without first discussing with the patient the options of immediate or delayed breast reconstruction’.2 The latest estimate of the BR rate in Australia is 18.3 per cent.3
A round table on BR practice in Australia was held on 9 October 2019 as an adjunct to the Australasian Society for Breast Disease conference at the RACV Royal Pines Resort on the Gold Coast, Queensland. The impetus for the roundtable was an agreed need among a wide range of stakeholders involved with BR, including consumers, for a forum to discuss the best ways of overcoming demonstrated inequities in access to both information about BR and to BR procedures. In a wealthy, advanced nation with a universal healthcare system, it may seem unlikely that women requiring mastectomy as part of their treatment for breast cancer, or those at high-risk of developing breast cancer choosing mastectomy as a preventive measure, would not be able to access BR. While not every woman with mastectomy would choose to have BR, it is estimated that approximately 50 per cent would choose BR if it was offered.4,5 Meanwhile, evidence of the potential physical, psychological and quality of life benefits of BR continue to grow.6–14
The roundtable represented the final stage of a large study, ‘Improving breast reconstruction equity of access through stakeholder consultation and translation into policy and practice’ (the I-BREAST project). That five-year project (2014– 2019) comprised three components. The first was geo-spatial mapping of where BR was performed using 2013 data from the Breast Surgeons of Australia and New Zealand Quality Audit. This mapping confirmed the concentration of BR services in capital city areas and along the south- eastern coastline, with a national BR rate of 18.3 per cent.3 More surprisingly, detailed analysis of this data on a state and territory basis showed the lack of BR availability even within capital city areas15 and subsequent analysis of data from the NSW Admitted Patient Data Collection confirmed these findings.16 The NSW data also revealed a similar estimated BR rate of 17.1 per cent,16 although accurate estimates are difficult to obtain in Australia.17 The Australian rate is considerably lower than those of comparable countries such as France (27.4%),18 the United States of America (26%)19 and England (23%).20
The second component of the I-BREAST project involved 90 in-depth interviews with breast and reconstructive plastic surgeons, health professionals and women with breast cancer over a two-year period. This qualitative data raised many issues surrounding access to, and satisfaction with, BR. As part of the I-BREAST project, three systematic reviews were undertaken. These explored women’s reasons for wishing to have BR,21 women’s expectations of BR22 and decisional regret associated with their choice.23 I-BREAST interview data was used to document the impact that lack of BR choice can have on women24 and as a case study of delivering patient-centred care25 The latter paper provided examples of barriers to patient-centred care as well as cases of exemplary care delivered in well-resourced settings. The I-BREAST data was also used to examine specific BR barriers in non-metropolitan areas of Australia,26 and demarcation issues between sub-specialties of breast and plastic surgeons.27
Given the findings from this large body of work, a roundtable was needed to translate these empirical results into feasible and acceptable recommendations for policy and practice changes to reduce the unwarranted variation in access to this important component of cancer survivorship. This article provides a summary of this meeting.
Preparation for the roundtable
Planning for the roundtable began in May 2019, when it was agreed to hold it as an adjunct to the Australasian Society for Breast Disease 2019 conference. Potential participants in the roundtable discussions included breast oncoplastic and breast plastic reconstructive surgeons, health professionals and consumers who had participated in the I-BREAST project, as well as representatives from breast cancer consumer and policy organisations. Invitees who were unable to attend often nominated other interested colleagues. A list of the 45 attendees is provided in Appendix A.
The objective of the roundtable was to reach some consensus on what can and should be done to improve BR access nationally and reduce unwarranted variation.
The I-BREAST project identified 25 specific areas of concern raised by the 90 participants (Table 1). Prior to the roundtable, invitees were emailed a survey to rank items for discussion. A link to this online survey was sent to 37 confirmed attendees as well as 17 interested non-attendees (54 surveys distributed, with an overall response rate of 70.4%). Participants were asked to rank each item out of 100. The nine top-ranked items (those with median scores of 78 or above) were then grouped by the I-BREAST research team into two major priority issues: (1) informed decision-making and (2) funding (Table 1).
The roundtable process
Participants were allocated to one of six tables to maximise the variation in professional expertise and personal experience. There were three parts to the roundtable:
Session 1
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Brief background overview on the issue of unwarranted variation in uptake of BR.
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Table discussion of issues relating to informed decision-making. Participants were asked to discuss a list of 10 proposals for potential solutions within 30 minutes. These proposals were generated from the I-BREAST data. Each table reported their discussion back to the whole group.
Session 2
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Summary of feedback from session 1, to derive two agreed lists of proposals that were generally supported or not supported
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Brief presentation about different possible models of care for BR.
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Second round of table discussions, using the same format as the first session, to consider 10 funding issues. An eleventh issue, concerning appropriate funding for multidisciplinary team (MDT) meetings, was added during discussion.
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Presentation of nine case studies of different models of care, including one on referral directories. This enabled participants to hear about the variation in models of BR services, their advantages and limitations, and the possibility of adapting such models across different settings.
Session 3
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Reporting of summary of table discussions on funding issues to all participants for further clarification and agreement on which proposals were worthwhile and which should not be pursued.
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General discussion of issues raised by the participants.
All three sessions generated robust and enthusiastic discussion. There were instances when participants expressed opposing views on the feasibility of particular proposals but discussions were respectful and participants remained engaged and collegial throughout.
Subsequent confirmation of roundtable recommendations
A draft report of all stages of the roundtable process listed above was prepared as well as a summary of the case studies presented. This draft also included revised recommendations based on the discussion held throughout the afternoon. Each revised recommendation was accompanied by implementation notes and a list of organisations that the recommendation should be sent to. The final recommendations often represented a compromise between differing views and consensus was reached on a surprisingly large number of revised recommendations.
The draft report was emailed to all roundtable participants and comments were invited (and encouraged). Participants were given several weeks to respond. Feedback was received from six participants and these comments were incorporated into the final version of the roundtable report.
Recommendations
Ten final recommendations were made regarding ways of improving informed decision- making (Box 1) and a further eight focused on recommendations for increasing funding to support wider, more timely access to BR (Box 2).
Conclusion
This roundtable on BR practice in Australia was the first to bring an interested and diverse group of stakeholders together to discuss documented inequities in access to BR. The next logical step is to disseminate the report and its recommendations as widely as possible to encourage further discussion with those who have the ability (and in some instances, the responsibility) to make these changes happen.
When evidence suggests that up to 50 per cent of women would choose to have BR if it were offered to them, an estimated national BR rate of 18 per cent demonstrates a very substantial unmet need for this procedure, which has been shown to improve the physical and psychological wellbeing of women requiring mastectomy.
We hope that with adequate financing and goodwill, organisations and individuals will be able to work together to improve access to BR and provide a better long-term quality of life for women with breast cancer. We are encouraged in this pursuit by the support of the presidents of the Australian Society of Plastic Surgeons, the New Zealand Association of Plastic Surgeons and the Breast Surgeons of Australia and New Zealand.28 Breast Reconstruction is not a cosmetic luxury, but an important component of quality of life and survivorship.
Acknowledgements
The authors wish to acknowledge the generous support of the Friends of the Mater Foundation, Sydney, which funded the I-BREAST project from 2014–2019. We are also grateful to the roundtable participants who provided their expertise and support.
Disclosure
The authors have no financial or commercial conflicts of interest to disclose.
Funding declaration
The authors received no financial support for the research, authorship, and/or publication of this article