The Impact of the COVID-19 Pandemic on Breast Reconstruction Practices in the United States

Discussion

The COVID-19 pandemic has changed the landscape of medicine, as we once knew it. Breast and plastic surgeons across the US could have never predicted that elective surgeries would be cancelled and surgery centers would close down at the hands of a virus. We could have never predicted that something so fundamental as a woman’s right to breast reconstruction after mastectomy would be in jeopardy. Over the course of the pandemic, thousands of women in the US were diagnosed with breast cancer, many of whom were forced to delay or even forego their breast reconstruction. And along with these women who were dealt this misfortune, their plastic surgeons, too, were left to make decisions that often diverted from their typical practices for the sake of their patients’ safety. As such, we thought it would be of paramount importance to deconstruct the effect that the COVID-19 pandemic has had on breast reconstruction practices across the US and how those effects would vary by geographic region and practice type.

To date, our study on COVID-19 and our survey data represent the largest cohort of responses pertaining to a specific set of procedures from the largest plastic surgery society in our country, the ASPS. Of note, the ASPS represents a broad spectrum of practices among Board Certified plastic surgeons, providing a realistic and accurate representation of plastic surgeons in the US. Strikingly, nearly half (44.2%) of the responders indicated that breast reconstruction – in any capacity – was not occurring at their institutions during the pandemic, whether that was via delay of all oncologic treatment, hormone/chemotherapy alone, or mastectomy alone. It remains to be seen whether or not this aberration from standard treatment protocols will have an effect on future oncologic outcomes for these patients.

Our data show that a majority (58.9%) of surgeons reported that restrictions on surgeries performed at their respective institutions were instated during the middle third of the month of March, which appropriately corresponds to the rising number of cases across the US (Figure 1). Temporally, this also corresponds with the ACS Statement on Recommendations for Management of Elective Procedures on March 13^th, 2020, and with the ASPS Statement on Breast Reconstruction in the face of the COVID-19 Pandemic issued on March 24^th, 2020, which encouraged delayed reconstruction, advised against any autologous reconstruction, and recommended that implant-based reconstruction be examined on a case-by-case basis (1, 12). In an ACAPS survey study by Sarac et al., 95% of their respondents reported adhering to the ASPS recommendations, unless otherwise guided by direct state or intuitional policies (7). Interestingly, academic practices had the highest percentage of restrictions instated as late as April (16.7%). Furthermore, on approximately April 6^th, the US number cases of COVID-19 had reached an initial peak, and at this point in time, 93.9% of plastic surgeons reported that restrictions had been instated. Cases across the United States remained relatively high throughout the month of April as much of the country attempted to “flatten the curve.” Over this time, at institutions where breast reconstruction after mastectomy was permitted, immediate implant-based reconstruction was the most common practice reported among plastic surgeons (47.7%). This finding is consistent with other recent studies (7, 11, 13).

It was not until the beginning of May that case numbers began to fall, and as such, we found that during the first third of May, a majority (19.8%) of plastic surgeons reported that the restrictions at their institutions had been lifted (Figure 2). When these data were broken down by geographic region, a vast majority of the practices in the South and West were more aggressive with their re-openings (majority in May), whereas in the Northeast and the Midwest, a more conservative approach to re-opening was taken and the lifting of restrictions was more likely to occur in June.

Despite such variation in approaches taken by different institutions across the country, an overwhelming majority of plastic surgeons (81.6%) responded that they either agreed or strongly agreed with their respective institutions policies. Nonetheless, 11.3% either disagreed or strongly disagreed. In a published commentary by Kumar et al., the authors assert that immediate autologous reconstruction was unfairly restricted, citing the inherent decreased infection risk, in-person office visits, and overall increased psychosocial satisfaction as compared with implant-based reconstruction (14).

While our study examined the effects of the COVID-19 pandemic on breast reconstruction practices across the country, the study was limited in its ability to highlight the impact on the patients themselves. In future studies, we hope to examine the cohort of patients at our institution whose breast cancer care was affected by COVID-19 and prospectively follow both their oncologic and reconstructive outcomes. We also plan on using the BREAST-Q to assess the psychosocial effect on these patients with COVID-19 as an added variable in their treatment course. Lastly, due to the timing of survey distribution, our study did not fully delineate the impact of the 2nd rise in COVID-19 cases observed from mid-July.

In conclusion, despite the geographic variability in case numbers, breast and plastic surgeons across our nation were forced to modify their breast reconstruction practices in order to conserve personal protective equipment, protect our healthcare workers, protect themselves, and protect their patients. Many surgeons reported a complete hiatus of both surgical oncologic treatment and reconstructive procedures. Overall, institutional restrictions appropriately correlated with rising case numbers, and subsequently, resumption of cases was appropriately timed with a down-slope in the case curve. An overwhelming majority of respondents were satisfied with the institutional actions taken in regard to the practice of breast reconstruction.