One in nine Canadian women will develop breast cancer in their life time. The growth of screening programs means that breast cancer is being caught and treated earlier. Often, treatment involves surgery – lumpectomy or mastectomy.
Increasingly, women are also choosing to undergo breast reconstruction surgery following treatment.
However, only some of these breast cancer surgeries are deemed a priority and given special funding to improve access.
Growth in preventative mastectomy & reconstruction
Traditionally, preventative surgery and reconstruction have not been given the same priority as cancer treatment.
Ontario has a cancer system and medical professionals who treat cancer with powerful chemotherapy drugs, radiation and surgery. Sometimes, this system is focused on ’the fight against cancer’, but not dealing with its aftermath.
Florianne Yeung was first diagnosed with breast cancer at the age of 39 and following treatment, which included radiation and surgery, underwent breast reconstruction surgery.
She says “reconstruction was a very important part of my journey … I can forget that I had breast cancer, even with my scars, I am back to normal life.”
Opting for preventative surgery and reconstruction is a personal choice.
Research shows that women who have not yet had a cancer diagnosis but are at high risk of cancer, and younger women, are more likely to choose breast reconstruction surgery.
Kim Winchcombe, diagnosed with breast cancer at the age of 42, describes how she advocated for a second mastectomy and reconstruction after her initial diagnosis. “It’s my body and is what I wanted” she says.
Nancy Baxter, a surgeon at St. Michael’s Hospital says that increasingly people in her field are “seeing reconstruction as part of oncology care.”
“There is an increasing awareness of the need to maintain quality of life, and while research demonstrates that reconstruction isn’t for everyone, it can be an important part of recovery for some women” says Baxter.
Growing evidence for breast reconstruction surgery
Often, women with the BRCA1/2 genetic mutation choose to undergo both prophylactic mastectomy and breast reconstruction surgery at the same time.
Women with a diagnosis of breast cancer are also increasingly undergoing preventative surgery, removing not only the identified cancer, but the other breast as well, to reduce further recurrence.
A United States study published in 2009 found that the rate of preventative surgery for these women doubled in ten years. A Canadian report also found that the rate of preventative mastectomy is increasing.
Kelly Metcalfe, professor at the University of Toronto Bloomberg Faculty of Nursing highlights the increase in preventative surgery for some women, once breast cancer is diagnosed. She says “if we can save a woman from the first breast cancer, it doesn’t make sense not to want to prevent cancer from happening in the future.”
Breast reconstruction surgery is usually delayed until after all treatment for the cancer, including radiation, is complete.
While the number of women opting for preventative surgery and breast reconstruction has grown, there are gaps in knowledge and information around how, where, when and why patients are accessing breast reconstruction surgery.
Waiting for surgery
The Ontario Ministry of Health and Long-Term Care provides special priority funding to ensure that women who need surgery as part of cancer treatment get it in a timely way. This was first put in place in 2004, in response to higher than optimal wait times for breast cancer surgery.
Timely access to surgery is critical when a cancer needs to be removed, because longer waits can mean that the breast cancer can grow and possibly spread to other parts of the body.
The current target for breast cancer surgery waits in Ontario is 84 days (meaning that 90% of women get their surgery within 84 days). Many centers across Ontario achieve lower wait times than the target. There is no information available on the average national wait times or targets.
However, preventative mastectomies for those who have received a cancer diagnosis, and those women at high risk, are not funded through priority dollars.
As such, waits for these procedures are much longer since the need is not immediate or urgent. Similarly, breast reconstruction is not funded through priority dollars. These surgeries are funded through hospital global budgets and reflect hospital priorities for surgery, as well as the supply of operating rooms and surgical staff.
Dr. Laura Snell, a plastic surgeon at Sunnybrook Health Sciences Center, acknowledges the challenges of funding all surgeries under tight budgets. “It’s hard to prioritize prophylactic surgery and reconstruction with limited resources in the system” she says.
Pilot program at the Ottawa Hospital
The Ottawa Hospital has recently set up a program at its Riverside site that offers same day mastectomy and reconstruction surgery. It is targeted at improving access for high risk women who choose preventative surgery.
This program runs two operating rooms side by side with a surgical oncologist doing mastectomies, and a plastic surgeon doing breast reconstruction surgeries. This means that more patients will be able to have both surgeries in one day.
Dr. James Watters, medical director of the Women’s Breast Health Centre at the Ottawa Hospital says this program keeps women who are getting preventative surgery “from competing for Operating Rooms and resources in other streams with patients who have active cancers.”
Access to reconstruction after mastectomy
There is no provincial data available on wait times for immediate breast reconstruction, which is done in conjunction with a mastectomy. However, a 2010 study of 57 women seeking breast reconstruction surgery at St. Joseph’s Health Centre in London, Ontario found an average of 98 days wait time for immediate reconstruction, and a 359 days wait for delayed reconstruction.
The target wait time in Ontario for delayed breast reconstruction is 182 days, and but the actual wait times at Ontario hospitals range from under 90 days to over 650 days.
This wait is measured from the time that the patient meets with the surgeon to the actual date of surgery.
Often, patients wait to schedule breast reconstruction surgery for important medical reasons such as allowing scars from the mastectomy to heal and having radiation treatment following surgery.
Snell suggests “resource availability” of both surgeons and operating room time is a significant cause of waits once surgery is booked. “We cannot accommodate all of the women who want delayed reconstruction” she says, noting that “reconstruction is not considered a cancer operation, with no additional funds for hospitals which treat these women.”
Further, there is tremendous geographic variation in who has these surgeries. Women in the Toronto area are twice as likely to undergo breast reconstruction as those in the rest of the province.
This is in part due to the availability of plastic surgeons who do breast reconstruction surgery. Dr. Baxter notes that when patients undergo breast reconstruction, a plastic surgeon is working in collaboration with cancer surgeons and providers. “It involves coordination of care. Unless there is a systems approach to do it, it will be hard to increase availability” she says.