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Only one in 10 eligible breast cancer patients gets the chance to have reconstruction at the time of mastectomy
Despite recommendations from the National Institute for Health and Clinical Excellence (Nice) in 2002 that breast reconstruction should be available to all, only one in 10 breast cancer patients has the opportunity at the time of mastectomy.
Today's study, by the Royal College of Surgeons and the NHS Information Centre on behalf of the Healthcare Commission, also found that a fifth of trusts in England performing breast cancer surgery do not employ a consultant radiologist, pathologist or oncologist specialising in breast cancer diagnosis or treatment.
The report noted that the number of women diagnosed with breast cancer has risen steadily in recent years. It accounts for almost 30% of all cases of cancer in women in England and Wales. There were 39,301 new cases of breast cancer among women in England and Wales in 2004, an increase of 27% on 10 years earlier.
Stark statistics
A total of 10,969 women died from the disease in 2005. Such statistics have led to a 37% rise in the number of operations carried out between between 1997 and 2006, but also increased pressure on NHS units, the study said.
"There are considerable pressures upon service providers,'' it said. "These include the need to provide more operations because of the rising incidence of breast cancer and the requirement to provide a higher proportion of women with reconstructive options after mastectomy.
"Service providers in the English NHS responded to these pressures by increasing the number of operations performed from 24,684 to 33,814 over the period 1997 to 2006, a 37% increase.
"The number of immediate reconstruction procedures provided by the English NHS almost doubled between 1997 and 2006. However, the proportion of all women undergoing mastectomy who received an immediate reconstruction increased only from 7% to 11%.
"This indicates that there have been difficulties in implementing guidance that immediate reconstruction should be made available to all women undergoing mastectomy.''
Finances
The report suggested reasons for the low number of women getting reconstruction at the same time as mastectomy, including the current NHS financial climate acting as a disincentive.
"There is a perception that the current funding climate within the NHS creates disincentives to increase access to breast reconstruction.
"Some service commissioners may create barriers to the availability of breast reconstruction by, for example, insisting upon a psychological evaluation.
"Some service providers have responded to resource shortages by ring-fencing hospital beds for breast cancer patients.''
The study also noted "considerable variation'' between and within the NHS and private sector over offering patients chemotherapy before surgery to enable immediate reconstruction to go ahead.
It said: "55% of NHS Trusts would provide the option of such therapy to a woman with metastatic disease while 45% would not. 72% of private hospitals said they would provide this option to women with metastatic disease. The variation observed is likely to create inequities in access to immediate breast reconstruction.''
Little improvement in services
John Browne, senior lecturer in health services research at the Royal College of Surgeons Clinical Effectiveness Unit, said: "This audit of breast cancer surgery shows that a good service is available in England, despite the health services being under pressure.
"However, over the last 10 years we have seen little improvement in access to immediate reconstruction after mastectomy. Current funding arrangements in the NHS, cancer waiting list targets and problems with the information and support provided to patients while making their decision about breast reconstruction may have contributed to this lack of progress.''
Jonathan Boyce, head of clinical audits at the Healthcare Commission, said: "It is important that women with breast cancer who have a mastectomy are offered the choice of breast reconstruction at the time of their operation. This can help reduce the number of operations needed as well as minimise the psychological impact of a mastectomy.''
Better results
Chris Caddy, consultant plastic surgeon and member of the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS), said: "For many patients, reconstruction is felt to be the final step in their recovery. Currently, most women have reconstructive surgery some time after their mastectomy.
"Whilst immediate breast reconstruction has a longer anaesthetic and recovery time, it tends to achieve better cosmetic results, smaller breast scars and only one hospital stay.
"BAPRAS believes the NHS needs to do more to ensure that women have all the information they need to access immediate reconstruction and understand the benefits it has for their recovery.''
"Unacceptable" statistics
Anna Wood, head of policy and campaigns for Breast Cancer Care, said it was "totally unacceptable'' that only one in 10 women got access to reconstruction at the time of mastectomy.
"While some patients we talk to have chosen to delay reconstructive surgery until much later after their initial treatment, the option of immediate reconstruction should be offered to all throughout England, as set out under existing Nice guidelines.
"That a fifth of English NHS Trusts performing breast cancer surgery are said not to employ a specialist team must be urgently addressed. Every breast cancer patient, as the report recommends, should be managed by a multi-disciplinary team.
"Anyone with breast cancer should be able to expect the highest standards of treatment and care, whenever they need it, wherever they may live.''
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