Sunday, December 28, 2008

Breast Reconstruction article in the NYT - there's really nothing "hidden" about it

Being someone who did advanced fellowship training in breast reconstruction, I was interested in the article in today's New York Times, "Some Hidden Choices in Breast Reconstruction".

I came away somewhat disappointed. The article tangentially discusses the issue of some advanced breast reconstruction techniques and how they aren't always offered or discussed by surgeons. It mostly centers around some of the more advanced microsurgical breast reconstructions using what are called "perforator flaps", which are much more laborious then traditional muscle flap surgeries or implant based reconstruction techniques. Those operations are very elegant, lengthy, and complex cases whose "true value" is hard to demonstrate either in outcome data or to bean counters (who just pay attention to how much things cost). The editorial tone is basically suggesting that there's some conspiracy to not talk about these procedures to patients and that these advanced procedures are the most ideal reconstruction.

I have a few thoughts on this

1. I touched upon the resources and cost to the system of demanding the most exotic types of surgeries for all comers last October 2007 entitled "A Breast Reconstruction Lawsuit - Can We afford Cadillacs for all?" which involved a patient suing her insurer for NOT covering a redo operation with one of the perforator microsurgical flaps discussed in the article.

I asked the question then:
In a scenario like the one involved here (lawsuit over non-coverage), should someone have the right to demand complex and expensive surgery when less expensive options are available?

I'm conflicted here. It does not seem completely outrageous to me for this company to deny this request or at least ask the patient to pay part of the balance difference given the particulars as I understand them. She had an acceptable reconstruction with implants, and needs a quick & relatively inexpensive surgery to maintain her result. In other countries with state-funded ("universal") health care programs, I suspect there's no way in hell this would be approved. In an era of cost-containment, all health care costs are going to be scrutinized and there will be hard choices to make. Luxuries like exotic breast reconstruction almost two decades after the initial surgery seem hard to justify in that context

We just cannot afford the most exotic procedures and technologies for every indication in every patient. Complicating this issue with breast surgery is that these types of procedures are arguably cosmetic procedures rather then functional surgeries (ie. a reconstructed breast reproduces a secondary sex characteristic but does not lactate). As a society in the US, we've come treat this topic differently through legislation guaranteeing breast reconstruction after mastectomy. This did not however, promise funding however, and the savaging of reimbursement for the long procedures and large amount of aftercare have functionally served to ration patients access to breast reconstruction.

2. Surgeries involving your own tissue have significantly more morbidity up front then tissue expander/implant procedures. They are not appropriate for everyone, particularly the very fit, smokers, obese patients, or the elderly. The complications from these operations can be MUCH more spectacular then expander procedures.

In general, I think TRAM, DIEP, and other described flaps are best reserved for young patients with small-medium breasts who are only having one sided mastectomies. The benefit in them is the natural "aging" of the flap more like the remaining breast. For bilateral mastectomies I (and most surgeons) think it is an absolute no-brainer to use tissue expanders in most patients in terms of recovery, cost, and symmetric result of the reconstruction. The improvements in implant designs that we should have available this winter make this an even stronger recommendation for most patients. Surgeon's who

I'm trained in just about everything, but I do implant based reconstruction on probably 7 or 8 out of ten patients as it's the best choice for most people. Keep in mind, that's coming from someone (me) who's favorite operations are TRAM's and Latissimus breast reconstruction. IF you look at the rest of the world, similar % of patients are reconstructed in this fashion which I think represents a collective pragmatic balancing of costs and benefits.



Scott Sattler MD FACS said...

Rob, after reading the NYT article on reconstruction, I did not conclude that the author was concerned about a conspiracy of silence regarding completely and thoroughly informing patients about complex autologous breast reconstruction options. The author recognizes the diminishing insurance reimbursement rates for these procedures, and pointed out that the lack of reimbursement on a dollar/hour basis might have something to do with the trend toward implant based reconstruction. Despite making this point, the thrust of the argument appeared to be that it is greed amongst plastic surgeons that decides who gets what reconstructive procedure. No where was the point made that the source of the problem is truly the insurance companies, who, if they had their choice in the matter, would never pay for the reconstruction of a 'secondary sex characteristic' of any type. Attention, anger and activism should be directed squarely at the insurance companies that scrape by on procedure reimbursement to surgeons, while paying seven figure salaries to insurance company managers. Until plastic surgeons are fairly compensated for their efforts, no patient should be surprised that she was not offered a 'Cadillac' reconstruction. Sadly, in this current environment, we could go even going a step further: no patient should despair about the type of reconstruction offered to her unless she is putting up some of her own money to fund the procedure.

Dr. Rob Oliver Jr. said...

Agree completely.

There was this faux outrage conjured up in the article which was kind of dismissive of the costs of those kinds of procedures. Unless you're subsidized by either the feds (in terms of paying for upper level resident assistance/coverage) or by the patient (by asking them to fund large parts of the fees themselves) there is no way DIEPS, free TRAMS,etc... are a sustainable procedure for most (any?) surgeons.

Anonymous said...

Last month I had a bilateral mastectomy. Since then, I've closely followed website discussions posted by survivors. I am aghast at the percentage of women who have complications following autologous reconstruction. Often this is done following failed implants.

I did consult with a plastic surgeon prior to my surgery, but opted to pass on both implants and reconstruction. IMHO the fairest allocation of resources would be to greatly increase the funding of research on breast cancer.

Single payer systems don't waste money on seven-figure salaries to insurance company managers. That is TRUE waste. No value there, from what I see.

Anonymous said...

I understand that it is not cost-efficient for many Plastic Surgeons to offer complicated reconstruction options to their patients. Certainly they can make more money doing 10 procedures in the amount of time it takes to do 1 procedure. It's a business decision and probably lifestyle as well. Also, it's perfectly understandable and no one should fault them for it.

The point is that SOME surgeons don't even educate patients about other options available even if the PS in question (for many valid reasons) doesn't do the procedure him/herself. The patient is paying the consultant for knowledge of options available and to withhold that knowledge is to fail the patient.

Whether or not a woman is an appropriate candidate for DIEP should be evaluated by a surgeon who actually offers the procedure and performs it regularly. The woman can weigh the cost, recovery, and potential complications for herself. It's her decision.

Dr. Rob Oliver Jr. said...

"Whether or not a woman is an appropriate candidate for DIEP should be evaluated by a surgeon who actually offers the procedure and performs it regularly"

I'd disagree. You don't have to do that particular surgery to be able to have an informed discussion about it.

Seattle Plastic Surgery on Lake Union said...

I disagree as well. Most recently trained plastic surgeons have a good understanding of what goes into a perforator flap reconstruction.

What's really interesting about the anonymous poster's comment about DIEP flaps is that there are substantial number of surgeons offering this complex reconstructive procedure as a fee-for-service procedure- no insurance accepted.

So while I applaud the technical expertise and sheer grit that DIEP surgeons have, I'd argue that some DIEP surgeons negatively impact patient access to the broad range of reconstructive procedures by limiting the DIEP procedure to only patients that can pay for it out of pocket.

Think I'm exaggerating? Ask yourself who the DIEP surgeons are in the country (we all know the names...) and then ask if these surgeons accept insurance for the procedure. The answer in many cases (especially in my own town...) is NO, cash only.

We may not all offer the procedure, but at least I'm able to discuss a DIEP flap, along with the other available reconstructive options, with ANY patient that comes into my office.