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Evans TA, Duquette S, Soleimani T, et al. Trends in Surgical Treatment of Breast Cancer in the Veterans Affairs System. JAMA Surg. 2017;152(3):305–306. doi:https://doi.org/10.1001/jamasurg.2016.3191
One in 8 women will be diagnosed as having invasive breast cancer during their lifetime.1 The demand for women’s health services and the rapidly growing body of knowledge of breast cancer has led to numerous advances in diagnosis, treatment, and reconstruction. Women will make up approximately 10% of the Veterans Affairs (VA) health care system by 2020 and 15% by 2030.2 As more of these women become military veterans, the need for women’s health services, including breast cancer treatment, in the VA health care system will grow. Oncologic resection and reconstruction are critical components in breast cancer therapy, and different approaches in surgical treatment will continue to evolve. Being at the forefront of innovation and improvement in breast cancer treatment will allow the VA health care system to provide quality care to all veterans. This study was designed to investigate the increasing need for breast surgery in the VA and trends in surgical approaches.
Using the VHA Services Support Center database, a review was conducted including veteran patients undergoing mastectomy or reconstructive breast procedures from 2007 to 2014. The database was part of a quality improvement initiative, containing no patient identifiers, and was therefore exempt from institutional review board approval and patient consent. Current Procedural Terminology codes 19300-19307 were used for mastectomy procedures, and Current Procedural Terminology codes for tissue expander placement (19537), free-flap reconstruction (19364), latissimus dorsi (19361), and pedicle transverse rectus abdominis myocutaneous flap (19367-9) were used for reconstructive procedures. Frequencies of procedures and trends were analyzed. Regression analysis was accomplished using SAS, version 9.4 (SAS Institute Inc).
A total of 5673 mastectomies and 2223 reconstructive procedures were performed between 2007 and 2014. The Figure shows the mastectomy and reconstruction trends. The total number of breast operations increased by a mean (SD) of 63 (7.6) cases per year, which was significant (P < .001). Mastectomy procedures increased significantly by a mean (SD) of 35 (5.7) cases per year (P = .001), while breast reconstructions increased significantly by a mean (SD) of 28 (2.4) cases per year (P < .001). Free-flap reconstruction also significantly increased (mean [SD], 2 [0.26]; P = .003). The rate of reconstruction after mastectomy was 25% to 42% between 2007 and 2014. Partial mastectomies and simple mastectomies showed a significant rise (mean [SD], 6 [2.0]; P = .02 and mean [SD], 17 [3.2]; P = .002, respectively); however, modified radical mastectomies showed a decreased trend, although this trend was not significant (P = .06). Partial mastectomies were used in 30% to 50% of all mastectomies.
Breast cancer treatment continues to evolve, helping to improve survival and quality of life in affected patients. As of 2012, the incidence of breast cancer accounted for 1% of cancers within the VA3; however, the incidence of breast cancer will continue to increase as the female veteran population grows. A 2015 study by Kummerow et al4 showed increasing trends nationwide in mastectomies and breast reconstructions during the past decade.4 This also showed that breast-conserving surgery was used in 65% of early-stage cancers, while only 35% were modified radical mastectomies. The results of our study showed significant increases in both mastectomies and reconstructive procedures among the veteran population, correlating with the previous study. Simple mastectomies and breast-conserving operations significantly increased, although a lower overall proportion of partial mastectomies was seen comparatively. Modified radical mastectomies rates showed a decreased trend, although this was not statistically significant. The modest decrease in modified radical mastectomies may represent a lag in progressive treatment or lack of access, associated with delayed treatment requiring more aggressive resection.
Systems with multidisciplinary breast cancer programs have shown reconstruction rates of approximately 50% to 60%.5 There are only 7 VA hospitals providing oncologic breast surgery, with reconstruction rates ranging from 26% to 42% since 2007. Although reconstruction rates are increasing, expanding designated breast oncology/surgery programs with multidisciplinary approaches to treatment within the VA may be necessary to meet rising demands and decrease the number of “fee out” services. Free-flap breast reconstructions are also rising in academia, shown by Kadle et al.6 Interestingly, there was an increase in free-flap reconstructions performed in the VA, although the number remained quite low. With the technical difficulty of microsurgical reconstruction, increasing the number of microsurgical trained plastic surgeons in the VA should be considered.
As the number of women in the military rises, it will be crucial to improve breast cancer treatment and reconstruction for veterans. Initiatives to expand access to breast oncologic and reconstructive surgeons, enhancing facilities, and improving women’s services will be essential in providing future quality care.
Corresponding Author: Sunil S. Tholpady, MD, PhD, Division of Plastic Surgery, Department of Surgery, Indiana University, 705 Riley Hospital Dr, RI 2514, Indianapolis, IN 46202 (firstname.lastname@example.org).
Published Online: November 30, 2016. doi:10.1001/jamasurg.2016.3191
Author Contributions: Drs Tholpady and Evans had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Evans, Duquette, Christensen, Cohen, Tholpady.
Acquisition, analysis, or interpretation of data: Evans, Soleimani, Munshi, Tholpady.
Drafting of the manuscript: Evans, Tholpady.
Critical revision of the manuscript for important intellectual content: All Authors.
Statistical analysis: Evans, Soleimani, Tholpady.
Administrative, technical, or material support: Duquette, Munshi, Cohen, Tholpady.
Study supervision: Tholpady.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This paper was presented at the 2016 Association of VA Surgeons Annual Meeting; April 10-12, 2016; Virginia Beach, Virginia.
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