6th Leura International Breast Cancer Conference, Sydney, Sept 2008.

The 6TH Leura International Breast Cancer Conference was held in Sydney during September 2008. Held every four years, the Leura conference was the first multidisciplinary breast cancer conference in Australia designed to offer comprehensive clinical sessions to address current issues in a variety of disciplines including surgery, radiation oncology, medical oncology, pathology, radiology and breast care nursing. The conference attracted more than 700 international and local delegates with a strong contingent of breast cancer survivors.

A presentation on breast reconstruction after mastectomy covered factors influencing the use of breast reconstruction. These factors relate to both access and uptake, and include patient, tumour and surgeon factors. Access to breast reconstructive surgery has been shown both in the USA and Australia to be inequitably distributed across socio-demographic groups. Women, who are younger, and in less socially disadvantaged groups are very much more likely to receive breast reconstructive surgery, as are women in metropolitan areas. Women with private health insurance or treated in a private hospital at the time of their primary breast cancer surgery are also more likely to receive breast reconstructive surgery, even after adjustment for other co-variates, and this relates both to availability and potential treatment delay. Tumour stage is also a factor, with women with early stage disease more likely to undergo reconstruction than those with more advanced disease. Surgeon factors associated with higher reconstruction rates are “women” surgeons and “high-volume breast” surgeons.

The effects of social status on the uptake of breast reconstructive surgery are profound, with a 40% reduction between the least disadvantaged group and most disadvantaged groups. There are several reasons why women from lower socioeconomic backgrounds are less likely to have breast reconstruction. The lack of an available service is certainly one of the main initial barriers. Women of lower income may be less aware of reconstructive options, less likely to obtain care in a hospital with qualified reconstructive surgeons, or have less time and money to devote to their body image in general, making them less likely to pursue reconstruction. J Am Coll Surg, 2001.

A reduced uptake of breast reconstruction in women from lower socioeconomic groups is however only partly due to deficiencies in the availability of service. Studies have shown that disadvantaged and less affluent groups are more likely to present with more advanced and aggressive disease, potentially making immediate reconstruction clinically less appropriate. They are also more likely to have significant medical co-morbidities. Cigarette smoking is a factor in reducing reconstruction rates and it is internationally well recognized and accepted that smoking correlates very strongly with low socioeconomic status. It contributes to cardiovascular and respiratory related comorbidity that can strongly influence anaesthetic and surgical decision making. In addition, smoking may compromise flap survival and wound healing following free tissue transfer and microvascular techniques. In some centres cigarette smoking is considered an absolute contraindication to advanced reconstructive techniques.