Correlates of Breast ReconstructionResults from a Population-Based Study

Monica Morrow, M.D.1

Mahasin Mujahid, M.S.2

Paula M. Lantz, Ph.D.3

Nancy K. Janz, Ph.D.4

Angela Fagerlin, Ph.D.5,6

Kendra Schwartz, M.D., M.S.P.H.7

Lihua Liu, Ph.D.8

Dennis Deapen, Dr.P.H.8

Barbara Salem, M.S.W.5

Indu Lakhani, M.S.5

Steven J. Katz, M.D., M.P.H.3,5,6

1 Department of Surgical Oncology, Fox ChaseCancer Center, Philadelphia, Pennsylvania.

2 Department of Epidemiology, University of Mich-igan, Ann Arbor, Michigan.

3 Department of Health Management and Policy,University of Michigan, Ann Arbor, Michigan.

4 Department of Health Behavior and Health Edu-cation, University of Michigan, Ann Arbor, Michi-gan.

5 Department of Internal Medicine, University ofMichigan, Ann Arbor, Michigan.

6 Veterans Affairs Ann Arbor Healthcare System,Ann Arbor, Michigan.

7 Karmanos Cancer Institute, Wayne State Univer-sity, Detroit, Michigan.

8 Department of Preventive Medicine, Keck Schoolof Medicine, University of Southern California, LosAngeles, California.

Supported by a grant from the National CancerInstitute (RO1 CA8837-A1) to the University ofMichigan. This project has been funded in partwith Federal funds from the National CancerInstitute, the National Institutes of Health, theDepartment of Health and Human Services, un-der Contract No. N01-PC-35139 and N01-PC-65064. The collection of cancer incidence dataused in this publication was supported by theCalifornia Department of Health Services as part

of the statewide cancer reporting program man-dated by California Health and Safety Code Sec-tion 103885.

The ideas and opinions expressed herein are thoseof the authors, and no endorsement by the State ofCalifornia, Department of Health Services is in-tended or should be inferred.

Address for reprints: Monica Morrow, M.D., De-partment of Surgical Oncology, Fox Chase CancerCenter, 333 Cottman Avenue, Philadelphia, PA19111-2497; Fax: (215) 214-4035, E-mail:Monica.Morrow@fccc.edu

Received April 15, 2005; revision received June 6,2005; accepted June 28, 2005.

BACKGROUND . Immediate or early postmastectomy breast reconstruction is per-

formed infrequently. To the authors’ knowledge, little is known regarding surgeon

or patient perspectives on reconstruction treatment decisions. The purpose of the

current study was to identify patient attitudes and preferences associated with

breast reconstruction, and whether these differed by race.

METHODS . A sample of women age � 79 years who were diagnosed with ductal

carcinoma in situ and invasive breast carcinoma between December 2001 and

January 2003 was identified from the Surveillance, Epidemiology, and End Results

(SEER) registries of Detroit and Los Angeles. Eligible subjects completed a ques-

tionnaire at a mean of 7 months after diagnosis. The Wald chi-square test and

logistic regression were used for data analysis.

RESULTS . Of the 1844 respondents, 646 underwent a mastectomy (35.0% of the

total sample) and 245 of these patients received breast reconstruction (38.0%; of

the mastectomy group). On multivariate analysis, younger patient age, higher

educational levels, and earlier stage of disease were found to be significantly

associated with breast reconstruction. Although 78.2% of women reported that

breast reconstruction was discussed, only 11.2% correctly answered 3 basic knowl-

edge questions regarding the procedure. The desire to avoid more surgery was the

most common reason for not undergoing breast reconstruction.

CONCLUSIONS . The results of the current study found that the majority of women

were aware of breast reconstruction but choose not to undergo the procedure. Lack

of knowledge and a greater perception of barriers to the procedure were more

common among African-American patients and women with a lower education

level, suggesting a need for improved educational strategies. Cancer 2005;104:

2340 – 6. © 2005 American Cancer Society.

KEYWORDS: mastectomy, breast reconstruction, perception, African American,educational strategies.

The switch from radical mastectomy to modified radical mastec-tomy coupled with advances in plastic surgical techniques has

made immediate breast reconstruction an option for the majority ofpatients who undergo mastectomy. Despite this, relatively fewwomen receiving mastectomy undergo immediate or early (within 3months of their diagnosis of breast carcinoma) breast reconstruction.

2340

© 2005 American Cancer SocietyDOI 10.1002/cncr.21444Published online 7 October 2005 in Wiley InterScience (www.interscience.wiley.com).

In a study using a large convenience sample from theNational Cancer Database, Morrow et al. found thatonly 8.3% of 68,348 women undergoing mastectomybetween 1994 –1995 had immediate or early breastreconstruction.1 A population-based study using 1998data from the Surveillance, Epidemiology, and EndResults (SEER) Registry Program found that 15% ofmastectomy patients underwent breast reconstructionwithin 4 months of mastectomy.2 Both of the studiesdemonstrated variations in the use of reconstructionon the basis of age, race, and geographic region.1,2

It has been suggested that large variations in pat-terns of surgical treatment for breast carcinoma areevidence of the failure to involve women in the surgi-cal decision-making process.3,4 However, to ourknowledge, little is known regarding the way decisionsregarding breast reconstruction are made. To ourknowledge, mastectomy with breast reconstructionhas never been compared with mastectomy alone in aprospective, randomized trial, and data regarding can-cer outcomes are derived primarily from single-insti-tution studies, the majority of which are retrospec-tive.5–7 Low rates of early breast reconstruction couldreflect surgeons’ concerns that immediate or earlyreconstruction might delay the use of postoperativesystemic therapy or hinder the detection of local dis-ease recurrence. Alternatively, low rates of breast re-construction could be an indication of either patientreluctance to undergo an extra surgical procedure at atime when they are coping with a new diagnosis of apotentially life-threatening disease, or a lack of aware-ness of the availability of reconstruction.

To improve our understanding of breast recon-struction treatment decisions, we conducted a large,population-based survey of women who were recentlydiagnosed with breast carcinoma in Detroit and LosAngeles. These cities were chosen because they aremultiethnic urban environments that have popula-tion-based cancer registries able to identify mostwomen with breast carcinoma shortly after diagnosis.The objectives of the current study were to explorepatient perceptions about involvement in the breastreconstruction decision, to determine whether partic-ular patient attitudes and preferences were associatedwith the receipt of reconstruction, and to determinewhether involvement in the decision to undergobreast reconstruction and attitudes toward the proce-dure differed by race.

MATERIALS AND METHODSStudy PopulationWomen age � 79 years who were diagnosed withductal carcinoma in situ (DCIS) and invasive diseaseand identified by the SEER Registries of the greater

metropolitan areas of Detroit and Los Angeles duringa 14-month period between December 2001 and Jan-uary 2003 were eligible for the current study.

Database and SamplingInvestigators from both registries identified the studysample and implemented the mailing of a self-admin-istered survey based on a uniform protocol. Womenwith breast carcinoma were identified and initial pa-thology reports were collected within 6 weeks of diag-nosis for 90% of patients in Detroit and nearly 100% ofpatients in Los Angeles. Eligible patients underwent adefinitive surgical procedure, resided in the catch-ment area of the SEER site, and were able to completea questionnaire in English or Spanish. All Asianwomen and all U.S.-born women age � 50 years whowere diagnosed with invasive disease in Los Angelesduring our study period were excluded because thesewomen already were being enrolled in other studies.Women with a diagnosis of lobular carcinoma in situwere excluded because the natural history of and rec-ommended treatment for this diagnosis differ fromthat for DCIS.

We prospectively selected all patients of DCIS anda random sample of invasive patients meeting thestudy criteria (oversampling African-Americanwomen) each month into the preliminary study sam-ple (n�2647). Approximately 90% of all accrued pa-tients were eligible for the study (n � 2382). The sur-vey was completed by 77.4% of eligible patients (92.4%of whom completed a written survey and 7.6% ofwhom completed an abbreviated telephone survey [n� 1844]). Compared with survey respondents, nonre-spondents were of a similar age, but were less likely tobe white (69.4% vs. 76.6%; P � 0.001), were more likelyto have American Joint Committee on Cancer (AJCC)Stage II disease (25.2% vs. 20.4%; P � 0.034), and weremore likely to have undergone a mastectomy (34.7%vs. 30.0 %; P � 0.021). The sample selected for theanalyses in the current study was the 646 respondents(35.0%) who underwent a mastectomy.

Data Collection and ManagementPhysicians were notified of our intent to contact pa-tients. An introductory letter was sent to all potentialsubjects approximately 3 months after diagnosis fol-lowed by a telephone call to assess eligibility. A ques-tionnaire and gift worth $10 were mailed to all eligiblewomen who agreed to participate and to people whocould not be reached by telephone (approximately14% of potential respondents) on a monthly basis. TheDillman survey method was used to encourage re-sponse.8

SEER clinical data from hospital-based sources

Correlates of Breast Reconstruction/Morrow et al. 2341

were merged with survey data for 98.2% of patients.The study protocol was approved by the InstitutionalReview Boards of the University of Michigan, the Uni-versity of Southern California, and Wayne State Uni-versity.

MeasuresThe main dependent variable was the receipt of re-construction, constructed as a dichotomous variable.Self-report of local therapy, including receipt of breastreconstruction after mastectomy, was used in all pa-tients except those in which the self-report was am-biguous or missing (n�26), in which case SEER datawere used. Similar to other studies,9 we found thatself-report of definitive surgical treatment and SEERdata yielded the same surgical procedure for 96.3% ofpatients in the current study sample. Excluding thosepatients in which there was a conflict between theself-report and the SEER data did not change theresults. Patients who had started or finished breastreconstruction were classified as having undergonereconstruction. Those who were planning, consider-ing, or not considering breast reconstruction werecoded as not having undergone breast reconstruction.

The principle independent variables were age atdiagnosis (age � 50 yrs, 50 – 64 yrs, and � 65 yrs), race(white, African American, and other ethnicity), educa-tion (some high school, high school graduate, somecollege, college graduate, and unknown), income(� $20,000, $20,000 –$69,999, � $70,000, and un-known), marital/domestic partner status (currentlyliving with partner or not), disease stage, number ofcomorbidities (0, 1, or 2 or more as derived from a listin the questionnaire of 6 common medical comorbidi-ties), and the presence of a clinical contraindication tobreast-conserving treatment. The summary cancerstage was classified using the AJCC TNM staging sys-tem for breast carcinoma (DCIS or invasive carcinomaof Stages I–III).10

Patients were asked whether their surgeon ex-plained breast reconstruction to them or referredthem to a plastic surgeon for a discussion about re-construction. Patients who reported that they werenot considering breast reconstruction were asked toidentify the reasons for the decision from a checklistthat included choices such as not wanting to undergomore surgery, not feeling that a new breast was im-portant, a lack of availability of breast reconstructionlocally, or concerns about interference with the detec-tion of recurrent breast carcinoma at the surgical site.Finally, patients were asked three true-false questionsto determine their level of knowledge about breastreconstruction. The items were: 1) breast reconstruc-tion often involves more than one surgery (true); 2)

having breast reconstruction can make it difficult todetermine whether breast disease has returned to abreast (false),11,12 and 3) a breast that has been recon-structed has sensation or feeling (false).

Statistical AnalysisWe calculated the proportions of patients who under-went breast reconstruction using sociodemographicand clinical variables. The Wald chi-square test wasused to test for bivariate associations between breastreconstruction and each of the independent variables.Sample weights were included to adjust for designeffects resulting from our differential sampling acrossethnicity and stage. We then used logistic regressionto calculate adjusted odds ratios for the associationbetween the receipt of breast reconstruction and in-dependent variables. Second-order interactions be-tween selected covariates were evaluated, particularlygeographic site and other covariates, but none werefound. We also examined patient reports of their com-munication with their surgeon(s) about breast recon-struction, the patients’ knowledge about breast recon-struction, and their reasons for not undergoingreconstruction. Point estimates were adjusted for de-sign effects using a sample weight that accounted fordifferential selection by stage, ethnicity, and nonre-sponse. All analyses were performed using SAS soft-ware (version 8.2; SAS Institute Inc., Cary, NC).

RESULTSSample CharacteristicsTable 1 shows characteristics of the sample patientdistribution. The mean patient age was 58.3 years, and64.3% of the patients were white. Approximately 54.8%had some college or were college graduates and 20.6%had family incomes of � $70,000. Of the patients stud-ied, 42.1% had DCIS or Stage I invasive breast carci-noma, and 53.4% had 1 or more comorbidities. Table1 also shows the distribution of the receipt of breastreconstruction by variable categories. Compared withpatients who did not undergo breast reconstruction,patients who did undergo reconstruction were morelikely to be younger and white, and to have somecollege education, a higher income, and an earlierstage of disease.

Factors Associated with Breast ReconstructionTable 2 shows the independent associations betweencovariates and receipt of breast reconstruction basedon a logistic regression model. Younger age, whiterace, and earlier stage of disease remained significantcorrelates of the receipt of breast reconstruction. Al-though there was a trend toward a greater use ofreconstruction with both higher levels of education

2342 CANCER December 1, 2005 / Volume 104 / Number 11

and income, these independent associations were notfound to be statistically significant.

To examine those factors influencing the use ofbreast reconstruction further, all women were askedwhether the procedure was explained by their surgeonor whether they were referred to a plastic surgeon todiscuss treatment options. These variables were com-bined in an analysis to determine the proportion ofwomen who were aware of breast reconstruction as asurgical option. Overall, 78.2% of patients reportedsuch discussions and no significant differences wereobserved based on race or study site.

Despite the high proportion of women who re-ported provider discussions about breast reconstruc-tion, knowledge about the procedure was very low.Only 11.2 % of women correctly answered the 3 knowl-edge questions (the need for multiple surgeries withreconstruction, the impact of breast reconstruction onthe detection of disease recurrence, and sensorychanges in the reconstructed breast). The lack of im-pact of breast reconstruction on the detection of localdisease recurrence, a critical factor in the decision toundergo reconstruction, was recognized by only 25.1%of responding patients.

TABLE 1Sample Characteristics

Variable n � 646

Patientdistribution(%)

Receivedreconstruction(%) P value

Study siteLos Angeles 294 44.7 28.1 0.002Detroit 352 55.3 34.2

Age (mean, 58.3 yrs; SD, 11.8)� 50 yrs 165 24.1 53.0 � 0.00150–64 yrs 281 43.8 36.6� 65 yrs 200 32.1 8.3

Ethnicitya

White 383 64.3 48.3 � 0.001African-American 159 20.9 30.9Other 98 14.8 31.5

EducationSome high school 93 15.2 15.2 � 0.001High school graduate 124 20.2 20.0Some college 213 32.2 35.5College graduate 151 22.6 48.8Unknown 65 9.8 27.5

Income� $20,000 140 22.6 14.3 � 0.001$20,000–$69,999 244 37.8 33.1� $70,000 139 20.6 56.8Unknown 123 19.0 23.1

Married/domestic partnerb

Yes 374 56.1 38.0 � 0.001No 270 43.9 23.4

AJCC stage0 199 16.5 51.6 � 0.001I 151 25.6 36.2II 167 31.3 28.8III 106 22.5 16.2Unknown 23 4.1 25.6

No. of comorbidities0 299 46.6 40.7 � 0.0011 166 25.7 30.8� 2 181 27.7 16.7

SD: standard deviation; AJCC: American Joint Committee on Cancer. Percentages are weighted to

account for differential selection by stage of disease, ethnicity, and nonresponse.

P values test differences in the receipt of breast reconstruction for each set of variables.aUnknowns (n � 6) not included.bUnknowns (n � 2) not included.

TABLE 2Multivariate Analysis of Significant Correlates of the Receipt of BreastReconstruction

Variable OR 95% CI

Study siteLos Angeles 0.9 0.4–1.5Detroit 1.0 —

Age� 50 yrs 8.8 4.0–19.350–64 yrs 4.5 2.4–8.7� 65 yrs 1.0 —Wald chi-square test 51.5 P � 0.001

EthnicityOther 0.5 0.3–1.2African American 0.5 0.2–1.0White 1.0 —Wald chi-square test 3.92 P � 0.048

EducationSome high school 0.4 0.2–1.1High school graduate 0.6 0.2–0.9Some college 0.8 0.5–1.4College graduate 1.0 —Wald chi-square test 6.81 P � 0.146

Income� $20,000 0.5 0.1–1.0$20,000– $69,999 0.7 0.3–1.2� $70,000 1.0 —Wald chi-square test 4.60 P � 0.203

Married/domestic partnerNo 1.0 —Yes 1.2 0.6–1.7

AJCC stage0 7.9 3.7–16.9I 4.7 2.4–9.3II 2.9 1.5–5.7III 1.0 —Wald chi-square test P � 0.001

No. of comorbidities0 1.0 0.5–1.91 1.1 0.6–2.0� 2 1.0 —Wald chi-square test 4.06 P � 0.541

OR: odds ratio; 95% CI: 95% confidence interval; AJCC: American Joint Committee on Cancer.

Coefficients were weighted to account for differential selection by stage of disease, ethnicity, and

nonresponse.

Correlates of Breast Reconstruction/Morrow et al. 2343

Women who reported that they did not undergoor were not considering breast reconstruction (n� 362) were asked a series of questions regardingbarriers to the use of the procedure. The only com-monly endorsed barrier to breast reconstruction forwomen of all races was the desire to avoid more sur-gery or the belief that breast reconstruction was notimportant (77.8% of respondents). Other barriers toreconstruction were endorsed by many fewer respon-dents and included: 1) the belief that the surgeon didnot recommend the procedure or actively discouragedit (17.5%) and 2) not knowing about breast reconstruc-tion (5.4%). Other barriers to reconstruction (includ-ing lack of availability, concern about the appearanceof the reconstructed breast, and length of surgicalrecovery) were endorsed by only 3.7 % of women.Figure 1 shows that there were ethnic variations in thepatient report about reasons for not undergoing orconsidering breast reconstruction. White womenwere somewhat more likely to report that recon-struction was not important or that they did notwant to undergo more surgery; whereas nonwhitewomen were more likely to believe that the proce-dure was not recommended or was discouraged bytheir surgeon. Black patients were somewhat morelikely to report that they did not know enough aboutbreast reconstruction. Racial differences in knowl-edge were persistent after controlling for age, edu-cation, and stage of disease. For example, the ad-justed odds ratio (OR) for getting any of the threeknowledge questions correct was 0.5 for African-American women compared with white women(95% confidence interval [95% CI], 0.3– 0.7; Waldchi-square test for racial groups, 16.0 [P � 0.001]).Education was also found to be positively associatedwith knowledge (adjusted OR of 2.6; 95% CI, 4.0 –7.7

for high school graduate, some college, and collegegraduate vs. less than high school; Wald chi-squaretest, 32.7 [P � 0.001])

DISCUSSIONThe results of the current study suggest that comparedwith earlier reports, the use of immediate and earlypost-mastectomy breast reconstruction has increased.Morrow et al. noted that only 3.4% of 155,463 patientswith breast carcinoma reported to the National Can-cer Database between 1985–1990 underwent breastreconstruction; this figure increased to 8.3% in 1994 –1995.1 In a SEER registry study from 1998, breast re-construction was performed in 15% of patients2

whereas the results of the current study documented a30% rate of breast reconstruction among women un-dergoing mastectomy between December 2001 andJanuary 2003. Both the studies by Morrow et al.1 andAlderman et al.2 found that younger age, white race,and a diagnosis of in situ carcinoma were significantpredictors of undergoing breast reconstruction. Al-though the overall use of breast reconstruction washigher in the current study, age, race, and stage ofdisease remained significant predictors of its use.

The selection of younger patients with early-stagedisease for breast reconstruction is in part a reflectionof sound medical judgment. A recent prospective,multiinstitutional study of complication rates afterbreast reconstruction reported a 52% rate of compli-cations after immediate reconstruction with tissue ex-panders/implants or transverse rectus myocutaneous(TRAM) flaps, with major complications reported tooccur in approximately 30% of patients.13 Awarenessthat postreconstruction complications may delay theadministration of adjuvant systemic therapy, coupledwith concerns about prolonged surgery and recoveryin older patients with comorbid conditions, may mo-tivate surgeons to selectively offer immediate or earlypostmastectomy breast reconstruction to patientsthey perceive will have a favorable risk/benefit ratiofor the procedure. This is consistent with the findingsfrom a survey of 376 consultant breast surgeons in theU.K. and Ireland, in which 88% of respondents indi-cated that they “usually” or “always” discussed breastreconstruction with patients undergoing mastectomy,but the majority (57%) preferred delayed reconstruc-tion because of concerns about “interference with ad-juvant therapy.”14

The results of the current study suggest that vari-ations in patient preferences play a role in the heter-ogeneous patterns of treatment that were observed. Incontrast to prior studies, which to our knowledge onlyexamined the correlation between demographic fac-tors, tumor factors, and the use of breast reconstruc-

FIGURE 1. Self-reported reasons why patients did not undergo breast

reconstruction among women who did not undergo or were not considering

reconstruction (n � 362). The figures were weighted to account for differential

selection by stage of disease, ethnicity, and nonresponse.

2344 CANCER December 1, 2005 / Volume 104 / Number 11

tion, we directly surveyed patients to determinewhether reconstruction was discussed as a surgicaloption, and the reasons why they did not to undergothe procedure. We identified a high level of awarenessabout breast reconstruction, and it appears that it waspatient preference rather than physician advice thatwas the most common reason for not undergoing theprocedure. However, we found variation in the treat-ment experience by race, with African-Americanwomen undergoing breast reconstruction less fre-quently than their white counterparts, even after con-trolling for age, level of education, and stage of dis-ease. African-American women were somewhat morelikely to endorse barriers to breast reconstruction, in-cluding not knowing about the procedure or feelingthat their surgeon discouraged them from undergoingit. These findings are consistent with our previousobservations regarding decision making for breast car-cinoma surgical treatment, including reports by Afri-can-American women of receiving less informationregarding breast-conserving surgery and fewer sur-geon recommendations for the procedure.15

Investigators from the M. D. Anderson CancerCenter in Houston, Texas, examined their institutionalexperience with immediate breast reconstruction in1004 women who underwent a mastectomy betweenJanuary 2001 and December 2002. Breast reconstruc-tion was performed in approximately 40.0% of whitewomen compared with 20.2% of African-Americanwomen. The rates of reconstruction for Hispanicwomen were similar to those reported in white wom-en.16 After adjustment for age, stage of disease, andbody mass index, the OR for immediate breast recon-struction in African-American women was 0.34 (95%CI, 0.18 – 0.62) compared with white women. Alder-man et al.2 also found that African-American womenwere significantly less likely than white women toundergo breast reconstruction (OR of 0.48). Paradox-ically, in those African-American women choosing toundergo breast reconstruction, the more physicallydemanding autogenous tissue reconstructions wereused significantly more often than in white women,who were more likely to undergo implant or expanderreconstruction.2 These findings, in combination withthose of the current study, suggest that less knowledgeabout breast reconstruction, a greater perception ofbarriers to the procedure, and preferences or recom-mendations for a type of reconstruction that signifi-cantly lengthens the time of surgery and postoperativerecovery all may contribute to the lower rates of breastreconstruction performed among African-Americanwomen.

LimitationsSeveral caveats apply to our observations. We onlyassessed patient perspectives regarding the decisionto undergo breast reconstruction. Clinician perspec-tives may vary, especially with regard to oncologicconcerns about reconstruction. We did not have ade-quate information regarding some patient, provider,and organizational attributes that may affect treat-ment and treatment experience. In particular, infor-mation concerning medical insurance was limited be-cause only approximately 2% of patients in the currentstudy sample reported no insurance and we did nothave specific information regarding coverage forbreast carcinoma treatments such as reconstruction.We may have failed to identify some women whounderwent breast reconstruction later in their courseof treatment. Indeed, approximately 14.0% of womenwho underwent mastectomy reported they were plan-ning or considering breast reconstruction. Includingthese women in our analyses as having undergonebreast reconstruction did not change the results. Ofthe 623 women who opted not to undergo reconstruc-tion in the M. D. Anderson Cancer Center study, only8% elected to undergo the procedure between 15–27months after mastectomy,16 indicating that the resultsof the current study are unlikely to change signifi-cantly with further follow-up. The study was retro-spective in design and patient recall of their encoun-ters with clinicians may vary with the passage of timeor because of posttreatment experiences. However,the average time from treatment to completion of thequestionnaire was 7 months (range, 1-14 mos) andthere was no association noted between the time fromdiagnosis to the completion of the questionnaire andthe findings described in the current study. Finally,although our study was population based, we had toexclude all Asian women and all U.S.-born women age� 50 years with invasive carcinoma at the Los Angelessite because of participation in other studies. There-fore, the findings of the current study may not begeneralizable to these groups. However, the results didnot change when we restricted a secondary analysis towomen age � 50 years.

ConclusionsThe current study results suggest that rates of imme-diate and early breast reconstruction after mastec-tomy continue to increase. The majority of patientsare aware of breast reconstruction as a treatment op-tion, but many choose not to undergo the procedure.The optimal proportion of mastectomy patients whoshould undergo reconstruction is unknown. The cur-rent study suggests that although women have a high

Correlates of Breast Reconstruction/Morrow et al. 2345

level of awareness about breast reconstruction, theiractual knowledge about what reconstruction entailsand its effect on cancer outcomes is quite limited. Thisis particularly true among African-American patients.Considering our observation that it appears to be pa-tient preference, not physician advice, that is the mostcommon reason for not undergoing breast reconstruc-tion, this lack of knowledge about the procedure isparticularly noteworthy. Making sure that newly diag-nosed breast carcinoma patients are aware of theavailability of breast reconstruction that the proce-dure does not have an adverse impact on diseaseoutcomes, and that different methods of breast recon-struction are available is a reasonable goal. Whetherthe lack of knowledge about breast reconstruction isbecause of a lack of interest in the procedure or afailure to be provided with comprehensive informa-tion should be the subject of further study.

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