National trends in immediate and delayed post-mastectomy reconstruction procedures in England: A seven-year population-based cohort study.

Little is known about post-mastectomy reconstruction procedural trends in women diagnosed with breast cancer in England. Our aim was to examine patterns of immediate and delayed reconstruction procedures over time and within regions. Women with breast cancer who underwent unilateral index immediate or delayed post-mastectomy reconstruction between 2007 and 2014 were identified using the National Hospital Episode Statistics database. Women were grouped into categories based on the type of reconstruction procedure. Adjusted rates of implant and free flap reconstructions were then calculated across regional Cancer Networks using a regression model to adjust for age, disease, comorbidities, ethnicity, and deprivation. Between 2007 and 2014, 21 862 women underwent immediate reconstruction and 8653 delayed reconstruction. Immediate implant reconstruction increased from 30% to 54%, and immediate free flap reconstruction from 17% to 21%. Adjusted immediate implant and free flap proportions ranged from 17 to 68% and 9-63%, respectively, across regions. Free flaps became more common in the delayed setting, rising from 25% to 42%. However, adjusted rates ranged from 23% to 74% across regions. Networks with high/low rates of free flaps for immediate tended to have high/low rates for delayed reconstruction. There has been a substantial increase in the use of immediate implant reconstruction in England. In comparison, there has been an increasing use of autologous free flap reconstruction for delayed procedures. Significant regional variation exists in the type of reconstruction performed, and these patterns need to be examined to determine if variation is related to service provision and/or capacity barriers

National trends and regional variation in immediate breast reconstruction rates.

BACKGROUND: Previous studies have identified variation in immediate reconstruction (IR) rates following mastectomy for breast cancer across English regions during a period of service reorganization, a national audit and changing guidelines. This study analysed current variations in regional rates of IR in England. METHODS: Patient-level data from Hospital Episode Statistics were used to define a cohort of women who underwent primary mastectomy for invasive or in situ breast carcinoma in English National Health Service (NHS) hospitals between April 2000 and March 2014. A time series of IR rates was calculated nationally and within regions in 28 cancer networks. Regional IR rates before and after the national audit were compared, using logistic regression to adjust for patient demographics, tumour type, co-morbidity and year of mastectomy. RESULTS: Between 2000 and 2014, a total of 167 343 women had a mastectomy. The national IR rate was stable at around 10 per cent until 2005; it then increased to 23·3 per cent by 2013-2014. Preaudit (before January 2008), adjusted cancer network-level IR rates ranged from 4·3 to 22·6 per cent. Postaudit (after April 2009) adjusted IR rates ranged from 13·1 to 36·7 per cent, with 20 networks having IR rates between 15 and 24 per cent. The degree of change was not greatest amongst those that started with the lowest IR rates, with four networks with the largest absolute increase also starting with relatively high IR rates. CONCLUSION: The national IR rate increased throughout the study period. Substantial regional variation remains, although considerable time has elapsed since a period of service reorganization, guideline revision and a national audit