27 March 2018
- New Breast Cancer Now report finds 47 out of 208 (22.6%) CCGs in England have introduced policies to restrict NHS breast reconstruction services for non-clinical reasons, with a further 30 CCGs (14.4%) having draft, informal or unclear guidelines in place
- Patients’ long-term body confidence and quality of life at risk as restrictive policies begin to limit the number of surgeries allowed, enforce time-frames and deny balancing surgery to the unaffected breast – leading to widespread variation in NHS care across England
- Breast Cancer Now, the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) launch new guidelines calling for CCGs to ensure all patients have access to the reconstructive services they need
- Baroness Delyth Morgan: “Reconstructive surgery has profound benefits for those that choose it, helping give many their confidence and their lives back after breast cancer. These arbitrary restrictions represent a backward step and are categorically not in the best interests of patients.”
- Mr Mark Sibbering, President of the Association of Breast Surgery: “The Breast Cancer Now report confirms concerns raised by both ABS and BAPRAS members that in some areas restrictions are being placed on access to this important part of breast cancer management.”
Hundreds of breast cancer patients are being denied or rushed into the reconstructive surgeries they need, following the introduction of “arbitrary” policies in some areas of England to restrict NHS breast reconstruction services, a new report by leading charity Breast Cancer Now has found.
‘Rebuilding My Body: Breast Reconstruction Surgery in England’ compiles evidence from Freedom of Information (FOI) requests conducted by the charity in 2017, and shows that 47 out of 208 (22.6%) Clinical Commissioning Groups (CCGs) in England have established policies to restrict reconstruction services for non-clinical reasons – with a further 30 CCGs (14.4%) having draft, informal or unclear guidelines in place.
The emerging policies – which have been described by the charity as “totally unacceptable” and “not in the best interest of patients” – include limiting the number of surgeries women are allowed, enforcing a time-frame on their completion and denying ‘balancing surgery’ to the unaffected breast to achieve symmetry with the reconstruction, resulting in widespread variation in care across England.
All breast cancer patients requiring a mastectomy can opt to have breast reconstruction if they want to, either immediately or sometime in the future (known as delayed reconstruction). While the majority choose not to have reconstruction, for the significant number of women that do, it is an essential part of their treatment and plays an instrumental role in their recovery and ongoing quality of life – often helping restore their body confidence, self-esteem and sexuality[1].
It is estimated that around 11,500 of the 42,000 women diagnosed with breast cancer each year in England undergo a mastectomy [2] – with around 2,400 (21%) of these patients opting to have immediate breast reconstruction, and around 1,100 (10%) having delayed reconstruction.
For most, reconstruction is a process requiring multiple procedures, depending on the patient and method chosen. There are two main types of reconstruction: patients can have an implant inserted, or they can have a breast shape recreated using tissue from another part of their body, usually the back or abdomen.
Where the reconstructed breast may not match a patient’s unaffected breast, clinical guidelines recommend that they are also offered ‘balancing surgery’ to increase, decrease or change the shape of their remaining breast to help them achieve symmetry.
With research and clinical progress in recent decades seeing best-practice guidelines become well-established in the UK, Europe and North America to recommend patients be offered reconstruction at the right that’s time for them, the policies also directly contravene recent clinical advice issued by NHS England’s Breast Cancer Clinical Expert Group in 2017 which states: “patients make decisions at very different speeds so delayed reconstruction or further operative procedures to optimise symmetry should be available without time restrictions.”
With the policies emerging in geographical clusters in the West Midlands (17 CCGs), London (12), the East (8), the South West (5) and Yorkshire & Humber (4), and a further 14.4% of CCGs (30 of 208) being found to have draft, informal or unclear policies in place [4], experts are concerned that, unless urgently addressed, the number of women being affected by these restrictions will only continue to increase.
While the reasons for the policies remain unclear, the NHS is facing unprecedented financial pressures, and, with patients and clinicians alike wanting all appropriate reconstructive options to be available, it begs the question whether the restrictions may have been introduced to help make efficiency savings.
Breast Cancer Now’s new report calls for an immediate end to the restrictive policies, urging CCGs to ensure patients are provided with photos of a range of surgical outcomes by their surgeons to help inform their decisions – using ‘shared decision-making’ tools – and to ensure all patients are offered appropriate and timely support and counselling to help make the best choice for them.
Following the report’s publication, Breast Cancer Now, the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) have today launched new guidelines, calling for CCGs across England to ensure all patients to have access to the services they need, regardless of where they live.
The new guidelines include:
- that all patients should be able to choose to return for breast reconstruction surgery at any point following their diagnosis and initial treatment
- that a full range of symmetry and adjustment procedures should be available, including surgery on the unaffected breast
- that clear communication is needed between surgeons and their patients in treatment planning to ensure patients have realistic expectations of what reconstruction can achieve
With a clinical consensus still to be developed regarding the number of surgeries likely to be required using newer techniques, the new guidelines suggest that for most patients, a satisfactory result should be possible within 2-3 surgeries but state that for those for whom this is not achieved or those that experience complications, further corrective surgery should not be restricted or denied.
Baroness Delyth Morgan, Chief Executive at Breast Cancer Now, which led the report, said:
“Whether to have reconstructive surgery is a very personal decision – one which is never taken lightly and which many women need time to think about.
“Following their diagnosis and as they undergo long-term treatment, many women are going through some of the most gruelling months and years of their lives. That any patient is being denied the reconstructive surgery they need or rushed into potentially life-changing decisions, at such a difficult time, is totally unacceptable.
“Reconstructive surgery has profound benefits for those that choose it, helping give many their confidence and their lives back after breast cancer. These arbitrary restrictions in some areas of the country therefore represent a backward step in treatment and are categorically not in the best interests of patients.
“The reasons for these restrictions remain unclear, but with the NHS facing unprecedented pressures, their introduction despite clear clinical advice begs the question whether they are being driven by a desire to reduce costs. For those that want it, reconstruction must not be dismissed as a cosmetic or dispensable part of breast cancer treatment.
“If we are to achieve the Government’s ambition of world-class NHS cancer care, all patients must be fully involved and supported in making decisions about their treatment – with their doctors, at their own pace. We hope these new guidelines will be practice-changing, ensuring all patients have access to the services they need and enabling more to live well beyond breast cancer.”
Mr Mark Sibbering, President of the Association of Breast Surgery, which led on the development of the new guidelines for Clinical Commissioning Groups said:
“The option of breast reconstruction surgery, with balancing surgery when appropriate, is an essential part of the care of a patient treated for breast cancer. It is not cosmetic surgery, but part of their treatment. It should be available to all patients equitably.
The Breast Cancer Now report confirms concerns raised by both ABS and BAPRAS members that in some areas restrictions are being placed on access to this important part of breast cancer management.
We hope that the joint guidelines on ‘Commissioning of Oncoplastic Breast Surgery’ will help provide a framework for CCGs to use that will ensure appropriate and equitable access for all breast cancer patients regardless of where they live.”
ENDS
For more information or to arrange an interview, please contact Jamie Lederhose or Rachel Tyler on 020 7749 4115 or press@breastcancernow.org (if out-of-hours, please ring 07436107914).
Notes to Editors:
- The National Mastectomy and Breast Reconstruction Audit (2011) found that 60% of women who had immediate or delayed reconstruction felt confident sexually most or all of the time, compared to 34% of women who had a mastectomy only. The audit covered 16,487 women who had a mastectomy, with 21% having immediate reconstruction and 10% having delayed reconstruction.
- These are estimates based on data from:
The NHS Information Centre, 2011: National Mastectomy and Breast Reconstruction Audit 2011, Available at: https://digital.nhs.uk/catalogue/PUB02731
- CCGs with unclear policies include those who responded to the Freedom of Information request referring to a generic policy (such as an ‘Individual Funding Request’ policy or a ‘Procedures of Limited Clinical Value’ policy) that either explicitly do not apply to breast cancer patients or give no indication of whether they apply to breast cancer patients. 12 CCGs responded referring to these types of policies and it is therefore unclear whether patients being treated by these CCGs face restrictions. CCGs with informal policies include those who responded to the Freedom of Information request stating that although they do not have a formal policy, they would view requests received some years after treatment as ‘cosmetic’ and this surgery would not be funded. These decisions would be made on case by case basis. 11 CCGs responded saying they had informal policies.
Breakdown of responses:
Formal policies restricting breast reconstruction: 47 CCGs
Draft policies: 7
Informal policies restricting breast reconstruction: 11 CCGs
Unclear policies e.g. referred to general policy 2 CCGs
Did not hold information on reconstruction policies: 7 CCGs
Referred to another organisation: 3 CCGs
No restrictions: 131 CCGs