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1.
Dempsey K, Brennan ME, Spillane A. Inaugural roundtable on breast reconstruction practice in Australia: background, process and recommendations. AJOPS. 2022;5(1):17-23. doi:10.34239/ajops.v5n1.287

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).

Table 1.Ranking of priority issues, based on median score
Type of barrier Issue Number of responses Median Mean Range (%) Priority ranking
Resource Lack of experienced BR surgeons 30 72.0 70 35–100 16
Lack of experienced operating theatre staff and specialised BR equipment 27 66.0 63 21–100 18
Lack of operating time 30 72.5 69 25–100 15
Lack of funding 28 78.0 70 17–100 9
Lack of MDT support 25 80.0 72 35–100 6
Lack of mentoring of junior/isolated surgeons 30 75.0 70 28–100 11
Attitudinal Some breast surgeons do not discuss BR options 29 92.0 86 40–100 2
Some breast surgeons are opposed to BR 24 90.5 76 7–100 3
Some breast reconstructive surgeons do not work in public hospitals 19 55.0 63 24–100 23
Some breast reconstructive surgeons do not work outside major cities 19 74.0 71 31–100 12
Some breast surgeons do not keep up with the latest evidence on BR 25 65.0 67 23–100 20
Some breast surgeons have poor communication and mentoring skills 20 71.0 70 26–100 17
Some breast surgeons do not work with other subspecialty surgeons 16 58.5 61 22–100 21
Access No access to BR discussion 27 98.0 87 24–100 1
Inadequate BR information is provided 25 74.0 74 23–100 13
BR decision-making is rushed 15 85.0 74 30–100 5
Women cannot afford BR (even with private health insurance) 22 90.5 87 46–100 4
Long waiting times for BR in public hospitals 24 79.5 75 42–100 8
Long distances to travel for BR 17 73.0 71 39–100 14
Some hospitals will not accept ‘out of area’ referrals for BR 24 55.5 62 20–100 22
Inadequate practical support for women seeking/having BR 23 54.0 61 21–100 24
Inadequate emotional support for women seeking/having BR 22 65.5 63 18–100 19
Inadequate continuity of care postoperatively 22 50.0 54 5–100 25
Inadequate targeted assistance for culturally and linguistically diverse and low literacy women 21 80.0 67 22–100 7
Women are not able to participate in clinical trials that may benefit them 21 76.0 65 6–100 10

BR=breast reconstruction; MDT=multidisciplinary team
Highlighted rows=nine highest ranked issues; orange highlighted rows=informed decision-making; green highlighted rows=funding

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

  • Brief background overview on the issue of unwarranted variation in uptake of BR.

  • 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

  • Summary of feedback from session 1, to derive two agreed lists of proposals that were generally supported or not supported

  • Brief presentation about different possible models of care for BR.

  • 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.

  • 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

  • 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.

  • 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).

Box 1.Improving informed decision-making
Recommendations
  1. Encourage discussion of all relevant BR options with clinically eligible and interested patients prior to mastectomy as a minimum standard of care and routine practice (as per the 2016 Cancer Australia statement Influencing best practice in breast cancer).
  2. Appoint breast and plastic surgeons who are skilled in BR to new positions in public cancer services organisations, as members of their credentialled multidisciplinary team.
  3. Promote and disseminate widely BR information for GPs from existing resources to inform their referral practices.
  4. Promote and disseminate widely, prior to mastectomy, a generic package of BR information for patients based on information available from existing resources.
  5. Use a simple and comprehensive online or paper-based BR discussion prompt list, to aid discussion between patients and surgeons or patients and BCNs/specialist BR nurses.
  6. Recommend health professionals follow a BR referral pathway to ensure patients have access to informed discussion and referral to a specialist BR surgeon in line with patient preferences.
  7. Include BR discussion and referral as a performance indicator for membership of Breast Surgeons of Australia and New Zealand.†
  8. Develop a register of hospitals of where BR is available and what types (with some measure of quality assessment) by government department/surgical representative societies.
  9. Consider preoperative MDT discussion of potential immediate BR patients to aid BR decision-making with plastic/oncoplastic surgeons attending.
  10. Introduce a formal ‘mentor system’ between hospitals to provide inexperienced surgeons with advice on patient selection for specific BR procedures, access to MDT discussion and the establishment of regular referral patterns (supported by telemedicine).

BCN=breast care nurse; BR=breast reconstruction; GP=general practitioner; MDT=multidisciplinary team
† Five of the six groups supported this recommendation. The remaining group did not support the proposal on the grounds that it was not possible to accurately capture BR discussion. They suggested that recording individual surgeons’ BR rates, as an endpoint proxy for BR discussion and referral, was a more feasible alternative.

Box 2.Recommendations for increasing funding to support wider, more timely access to BR
Recommendations
  1. Provide incentives for surgeons to operate in the public system and/or for hospitals to provide BR services.
  2. Provide designated BR theatre lists.
  3. Lobby for more realistic government reimbursement of operating time through review of Medicare item number payments for longer surgery and percentage funding of subsequent procedures (disincentive for IBR, especially LD flaps).
  4. Consider bundling of BR-related surgical and postoperative costs.
  5. Lobby private health funds for recognition of BR as part of breast cancer treatment (not cosmetic) and for higher reimbursement of BR-related costs.
  6. Lobby industry for lower costs for implants, mesh etc.
  7. Improve waiting list management.
  8. Encourage breast cancer clinicians to collect BR data to provide an evidence-base for quality assurance and improvement and to advocate for more funding.

IBR=immediate BR; LD flaps=latissimus dorsi flaps

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

Accepted: March 12, 2021 AEST

References

1.
Cancer Australia. Breast Cancer in Australia Statistics. Australian Government; 2019. Accessed January 29, 2020. https://breast-cancer.canceraustralia.gov.au/statistics
2.
Cancer Australia. Influencing Best Practice in Breast Cancer, Practice 11. Australian Government; 2016. Accessed January 29, 2020. https://canceraustralia.gov.au/publications-and-resources/cancer-australia-publications/influencing-best-practice-breast-cancer
3.
Flitcroft K, Brennan M, Costa D, Spillane A. Documenting patterns of breast reconstruction in Australia: The national picture. Breast. 2016;30:47-53. doi:10.1016/j.breast.2016.08.013
Google Scholar
4.
Brennan ME, Spillane AJ. Uptake and predictors of post-mastectomy reconstruction in women with breast malignancy – a systematic review. Eur J Surg Oncol. 2013;39(6):527-541. doi:10.1016/j.ejso.2013.02.021
Google Scholar
5.
Matrai Z, Kenessey I, Savolt A, Ujhelyi M, Bartal A, Kásler M. Evaluation of patient knowledge, desire, and psychosocial background regarding postmastectomy breast reconstruction in Hungary: a questionnaire study of 500 cases. Med Sci Monitor. 2014;20:2633-2642. doi:10.12659/msm.891072
Google ScholarPubMed CentralPubMed
6.
Ananian P, Houvenaeghel G, Protiere C, et al. Determinants of patients’ choice of reconstruction with mastectomy for primary breast cancer. Ann Surg Oncol. 2004;11(8):762-771. doi:10.1245/aso.2004.11.027
Google Scholar
7.
National Clinical Audit Support Programme. A National Audit of Provision and Outcomes of Mastectomy and Breast Reconstruction Surgery for Women in England, Fourth Annual Report. The Information Centre (NHS); 2011. Accessed July 3, 2019. https://digital.nhs.uk/catalogue/PUB02731
8.
Gieni M, Avram R, Dickson L, et al. Local breast cancer recurrence after mastectomy and immediate breast reconstruction for invasive cancer: a meta-analysis. The Breast. 2012;21(3):230-236. doi:10.1016/j.breast.2011.12.013
Google Scholar
9.
Howes BHL, Watson DI, Xu C, Fosh B, Canepa M, Dean NR. Quality of life following total mastectomy with and without reconstruction versus breast-conserving surgery for breast cancer: a case-controlled cohort study. J Plast Reconst Aesth Surg. 2016;69(9):1184-1191. doi:10.1016/j.bjps.2016.06.004
Google Scholar
10.
Türk KE, Yilmaz M. The effect on quality of life and body image of mastectomy among breast cancer survivors. Eur J Breast Health. 2018;14(4):205-210. doi:10.5152/ejbh.2018.3875
Google ScholarPubMed CentralPubMed
11.
Chen W, Lv X, Xu X, Gao X, Wang B. Meta-analysis for psychological impact of breast reconstruction in patients with breast cancer. Breast Cancer. 2018;25(4):464-469. doi:10.1007/s12282-018-0846-8
Google Scholar
12.
Fanakidou I, Zyga S, Alikari V, Tsironi M, Stathoulis J, Theofilou P. Mental health, loneliness, and illness perception outcomes in quality of life among young breast cancer patients after mastectomy: the role of breast reconstruction. Qual Life Res. 2018;27(2):539-543. doi:10.1007/s11136-017-1735-x
Google Scholar
13.
Platt J, Zhong T. Patient-centered breast reconstruction based on health-related quality-of-life evidence. Clin Plast Surg. 2018;45(1):137-143. doi:10.1016/j.cps.2017.08.011
Google Scholar
14.
Retrouvey H, Kerrebijn I, Metcalfe KA, et al. Psychosocial functioning in women with early breast cancer treated with breast surgery with or without immediate breast reconstruction. Ann Surg Oncol. 2019;26(8):2444-2451. doi:10.1245/s10434-019-07251-9
Google Scholar
15.
Flitcroft KL, Brennan ME, Costa DSJ, Spillane AJ. Regional variation in immediate breast reconstruction rates in Australia. BJS Open. 2017;1(4):114-121. doi:10.1002/bjs5.19
Google ScholarPubMed CentralPubMed
16.
Feng Y, Flitcroft K, van Leeuwen MT, Elshaug AG, Spillane A, Pearson SA. Patterns of immediate breast reconstruction in New South Wales, Australia: A population-based study. ANZ J Surg. 2019;89(10):1230-1235. doi:10.1111/ans.15381
Google ScholarPubMed CentralPubMed
17.
Flitcroft K, Brennan ME, Spillane AJ. The difficulties of sourcing Australian health data: The case of breast reconstruction. ANZ J Surg. 2016;86(7-8):537-539. doi:10.1111/ans.13590
Google Scholar
18.
Régis C, Le J, Chauvet MP, Le Deley MC, Le Teuff G. Variations in the breast reconstruction rate in France: a nationwide study of 19,466 patients based on the French medico-administrative database. The Breast. 2018;42:74-80. doi:10.1016/j.breast.2018.07.009
Google Scholar
19.
Sisco M, Du H, Warner JP, Howard MA, Winchester DP, Yao K. Have we expanded the equitable delivery of postmastectomy breast reconstruction in the new millennium? Evidence from the national cancer data base. J Am Coll Surg. 2012;215(5):658-667. doi:10.1016/j.jamcollsurg.2012.07.008
Google Scholar
20.
Jeevan R, Mennie JC, Mohanna PN, O’Donoghue JM, Rainsbury RM, Cromwell DA. National trends and regional variation in immediate breast reconstruction rates. Br J Surg. 2016;103(9):1147-1156. doi:10.1002/bjs.10161
Google Scholar
21.
Flitcroft K, Brennan M, Spillane A. Making decisions about breast reconstruction: a systematic review of patient-reported factors influencing choice. Qual Life Res. 2017;26(9):2287-2319. doi:10.1007/s11136-017-1555-z
Google Scholar
22.
Flitcroft K, Brennan M, Spillane A. Women’s expectations of breast reconstruction following mastectomy for breast cancer: a systematic review. Support Care Cancer. 2017;25(8):2631-2661. doi:10.1007/s00520-017-3712-x
Google Scholar
23.
Flitcroft K, Brennan M, Spillane A. Decisional regret and choice of breast reconstruction following mastectomy for breast cancer: a systematic review. Psychooncology. 2018;27(4):1110-1120. doi:10.1002/pon.4585
Google Scholar
24.
Flitcroft KL, Brennan ME, Spillane AJ. The impact on Australian women of lack of choice of breast reconstruction options: a qualitative study. Psychooncology. 2019;28(3):547-552. doi:10.1002/pon.4974
Google Scholar
25.
Flitcroft K, Brennan M, Spillane A. Principles of patient-centred care for cancer services and barriers to their implementation: a case study of breast reconstruction in Australia. Support Care Cancer. 2020;28(4):1963-1981. doi:10.1007/s00520-019-04978-9
Google Scholar
26.
Flitcroft K, Brennan M, Salindera S, Spillane A. ncreasing access to breast reconstruction for women living in under-serviced non-metropolitan areas of Australia. Support Care Cancer. 2020;28(6):2843-2856. doi:10.1007/s00520-019-05130-3
Google Scholar
27.
Flitcroft K, Brennan M, Spillane A. On the frontiers of change: breast surgeons’ views on demarcation between surgical sub-specialties in Australia. ANZ J Surg. 2020;90(3):317-324. doi:10.1111/ans.15580
Google Scholar
28.
Kennedy D, Wheeler J, Walker M. Re: On the frontiers of change: Breast surgeons’ views on demarcation between surgical subspecialities in Australia. ANZ Journal of Surgery. 2020;90(10):2143-2144. doi:10.1111/ans.16193
Google Scholar

Appendix.A: Roundtable participants

Roundtable Convenors (Breast and Surgical Oncology at The Poche Centre)

Kathy Flitcroft, Research Fellow
Andrew Spillane, Oncoplastic Surgeon
Meagan Brennan, Breast Physician

Breast Oncoplastic Surgeons

Sanjay Warrier, Royal Prince Alfred Hospital, Sydney
Kylie Snook, The Mater Hospital, Sydney
Elisabeth Elder, Westmead Breast Cancer Institute, Sydney
Peter Chin, Tauranga, New Zealand
Meron Pitcher, Western Health, Victoria
James French, Westmead Breast Cancer Institute, Sydney
Shehnarz Salindera, Coffs Harbour, NSW
Chris Pyke, The Mater Hospital, Brisbane
Nita Bartlett, Rockhampton, Queensland
Prath Nakka (Fellow), The Mater Hospital, Brisbane
Wen Chan Yeow, Fiona Stanley Hospital, Perth
Kerrie Lewis, Maitland, NSW
David Littlejohn, Wagga Wagga, NSW
Kim Isaacs (Fellow), Gold Coast, Queensland
Manimaran Sinnathamby, Darwin, Northern Territory

Plastic Reconstructive Surgeons

Dean Trotter, Royal Melbourne Hospital, Victoria
Anna Goodwin-Walters, Fiona Stanley Hospital, Perth
Andrew Campbell-Lloyd, Southport Specialist Suites, Queensland
Nicola Dean, Flinders Hospital, South Australia

Breast Care Nurses

Lee Millard-Newton, Coffs Harbour, NSW
Clare John, The Mater Hospital, Sydney
Jo Lovelock, Clinical Leader at the McGrath Foundation
Leanne Storer, Ballarat, Victoria
Mary Sweeney, Launceston, Tasmania

Consumers

Louise Turner, Central Coast, NSW
Kristen Diemer, Melbourne, Victoria
Cancer Policy representatives,
Megan Varlow, Cancer Council Australia
Ms Katrina Anderson, Cancer Australia
Kirsten Pilatti, BCNA, Breast Cancer Network Australia, Melbourne
Danielle Spence, Cancer Vic
Victoria Walton, Cancer Institute NSW, Sydney

Radiation And Medical Oncologists

Penny MacKenzie, Rad Onc, Toowomba
Gillian Lamoury, Rad Onc, Sydney
Susan Carroll, Rad Onc, Sydney
Marita Morgia, Rad Onc, Sydney
Nicola Lowrey, Rad Onc, Brisbane
Lina Pugliano, Med Onc, Sydney

Industry Representatives (Observer Status)

Fallen Guthrie, GenesisCare, Patient Experience Specialist
Beverley Blakeway, GenesisCare, Referrer Engagement Manager
Joanne Mitchell, GenesisCare, Referrer Engagement Rep.
Rachel Koster, Mentor, Marketing Manager
Megan Lynch, Mentor, Product Specialist