Annelotte van Bommel

79 Organizational factors affect the use of immediate breast reconstruction INTRODUCTION Current surgical treatment of breast cancer patients consists of either breast conserving surgery or mastectomy. A mastectomy is performed in about 40% of invasive breast cancer patients and in approximately 33% of patients with a ductal carcinoma in situ. 1–3 An increasing number of patients desire restoration of their breast contour following mastectomy and consequently breast reconstruction has become an integral part of breast cancer treatment. 4 The breast can be reconstructed during the initial operation followingmastectomy (immediate breast reconstruction (IBR)) or at a later time (delayed breast reconstruction). 2 IBR has proven to be safe in terms of local recurrence and long-term survival rates compared tomastectomy only. 5,6 Moreover, IBRofferswomen psychological benefits in terms of recovery and improved quality of life and is associated with superior esthetic results compared to delayed breast reconstruction. 5–7 Guidelines emphasize the importance of reconstruction after mastectomy and recommend clinicians to discuss the possibility of IBR with every patient undergoing mastectomy. 2,8,9 Despite the benefits of IBR, the percentage of patients with DCIS or invasive breast cancer actually undergoing IBR after mastectomy is approximately 20% in the Netherlands. Large hospital variation in the use of IBR was found previously, ranging from0 to 64% for invasive breast cancer and 0–83% for DCIS. 10 Comparable IBR rates were shown in other international studies; IBR was performed in 21% of the postmastectomy patients in the United Kingdom and 24% in the United States. 2,11,12 Literature has demonstrated that patient and tumor factors such as age, social economic status, multifocality, tumor type, clinical tumor stage, clinical lymph node stage, grade and previous breast surgery are predictors of the use of IBR. 10,11,13–17 However, these patient and tumor factors do not fully explain the large variation between hospitals in the Netherlands. 10 Theaimofthepresentstudywastoinvestigatewhichhospitalandhospitalorganizational factors affect theuseof IBRaftermastectomy forDCISand invasivebreast cancer in the Netherlands andwhether these factors account for the variation seen. 5