Utilization of the National Cancer Database (NCDB) to Access Postmastectomy Breast Reconstruction

The treatment of breast cancer is a multidisciplinary effort. Breast surgical oncologists, medical oncologists, and radiation oncologists work to create a comprehensive cancer treatment plan specific for each patient. Each plan is dependent on the stage of the disease, patient age, patient family history, while also taking into account patient preference. Increasingly, plastic surgeons are included as part of the multidisciplinary team to offer women planning for postmastectomy breast reconstruction (PMBR).  Since the passage and implementation of the Women’s Health and Cancer Rights Act of 1998, which ensures insurance coverage of reconstruction after mastectomy, the rate of PMBR has been increasing over the last decade.^1,2 PMBR improves satisfaction and psychological outcomes for women,³ thus it is important that PMBR be studied in the context of breast cancer patients.

The National Cancer Data Base (NCDB) was established in 1989 as a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. The NCDB is a nationwide, facility-based, clinical surveillance resource oncology database that captures 70% of all newly diagnosed malignancies in the US annually.⁴ One of the first PMBR-specific studies that utilized the NCDB to determine national patterns of care for the use of breast reconstruction and to identify factors that predict the use of PMBR.⁵ Morrow and colleagues compared patients who underwent a mastectomy between 1985-1990 and those who did between 1994-1995, and found that 3.4% of mastectomy patients had early or immediate reconstruction increasing to 8.3% in 1994-5. Patient age, income, location, type of hospital where treatment occurred, and tumor stage influenced the use of reconstruction. This analysis study revealed that PMBR was an underused option in breast cancer management at that time.⁵ In 2012, Sisco et al. re-examined the NCDB to evaluate the trends in post mastectomy immediate and early delayed breast reconstruction. A total of 452,903 breast cancer patients between 1998 and 2007 were assessed and the study revealed that PMBR increased from 13% to 26% from 1998 to 2007, though racial and socioeconomic disparities persist.⁶

In this last decade, the NCDB has continued to be utilized to investigate PMBR. An article by Albornoz et al. was published in 2015 in Plastic and Reconstructive Surgery that analyzed the NCDB and found that since 2005, an increasing proportion of patients with early-stage breast cancer have been choosing mastectomy over breast-conserving surgery for surgical treatment. This is thought to be attributable to a shift towards bilateral mastectomy with contralateral prophylactic mastectomy and wider PMBR access and acceptance.⁷ The NCDB has been applied to assess both regional variation in breast cancer surgery and reconstruction,⁸ and PMBR in the setting of post-mastectomy radiotherapy.⁹ Most recently there has been a focus specifically on breast reconstruction for cancer in the elderly. An increasing number of elderly (defined as either >65 years old or >70 years old) women are having PMBR, and readmission and postoperative mortality rates are overall low and comparable to that of younger patients.^10,11

The NCDB is an immensely useful resource for the treatment of breast cancer patients. With its national reach and comprehensive approach, the NCDB is a database to continually review to investigate breast surgical treatment, including PMBR.

References

1. Farhangkhoee H, Matros E, Disa J. Trends and concepts in post-mastectomy breast reconstruction. J Surg Oncol. 2016;113(8):891–94. doi: 10.1002/jso.24201.
2. Garfein ES. The privilege of advocacy: legislating awareness of breast reconstruction. Plast Reconstr Surg. 2011;128(3):803–4. doi: 10.1097/PRS.0b013e3182221501.
3. Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg 2000;106:1014–25; discussion 1026–7. doi: 10.1097/00006534-200010000-00010.
4. Bilimoria KY, Stewart AK, Winchester DP, Ko CY. The National Cancer Data Base: a powerful initiative to improve cancer care in the United States. Ann Surg Oncol. 2008;15(3):683–90. doi: 10.1245/s10434-007-9747-3.
5. Morrow M, Scott SK, Menck HR, Musteo TA, Winchester DP. Factors influencing the use of breast reconstruction postmastectomy: a national cancer database study. J Am Coll Surg. 2001;192(1):1-8. doi: 10.1016/s1072-7515(00)00747-x.
6. Sisco M, Du H, Warner JP, Howard MA, Winchester DP, Yao K. Have we expanded the equitable delivery of postmastectomy breast reconstruction in the new millennium? Evidence from the National Cancer Data Base. J Am Coll Surg. 2012;215(5):658-66. doi: 10.1016/j.jamcollsurg.2012.07.008.
7. Albornoz CR, Matros E, Lee CN, et al. Bilateral mastectomy versus breast-conserving surgery for early-stage breast cancer: The role of breast reconstruction. Reconstr. Surg.2015;135(6):1518-26. doi: 10.1097/PRS.0000000000001276.
8. Chiu AS, Thomas P, Killelea BK, Horowitz N, Chagpar AB, Lannin DR. Regional variation in breast cancer surgery: Results from the National Cancer Database (NCDB). Am J Surg. 2017;214(5):907-13. doi: 10.1016/j.amjsurg.2017.07.008.
9. Razdan SN, Cordeiro PG, Albornoz CR, et al. National breast reconstruction utilization in the setting of post-mastectomy radiotherapy. J Reconstr Microsurg. 2017;33(5):312-17. doi: 10.1055/s-0037-1598201.
10. Gibreel WO, Day CN, Hoskin TL, Boughey JC, Habermann EB, Hieken TJ. Mastectomy and immediate breast reconstruction for cancer in the elderly: A National Cancer Data Base study. J Am Coll Surg. 2017;224(5):895-905. doi: 10.1016/j.jamcollsurg.2016.12.051.
11. Cortina CS, Bergom CR, Kijack J, Thorgerson AA, Huang CS, Kong AL. Postmastectomy breast reconstruction in women aged 70 and older: an analysis of the National Cancer Database (NCDB). 2021;170(1):30-38. doi: 10.1016/j.surg.2021.03.033.