Abstract PD08-02: Disparities in the Utilization of Reconstruction after Mastectomy: The California Teachers Study

Abstract

Abstract Background: For breast cancer patients undergoing mastectomy, factors such as insurance status, race/ethnicity, age, and type of hospital influence whether post-mastectomy reconstruction (PMR) is performed. This study was undertaken to determine if additional patient variables and clinicopathologic features also influence the utilization of PMR using the California Teachers Study (CTS). Methods: Patients were identified from the CTS, a cohort of approximately 133,000 female public school teachers and administrators, followed prospectively from 1995 forward to investigate exposures associated with incident cancer and other outcomes. All in situ and invasive breast cancers were identified through linkage with the California Cancer Registry, as well as with the California Office of Statewide Health Planning and Development (OSHPD) hospital discharge database to determine the rates of mastectomy with and without reconstruction. Patterns in PMR rates were examined by calendar year, age, race/ethnicity, type of insurance, type of hospital, tumor stage, body mass index (BMI), family history of breast cancer (FH), smoking history, physical activity, and prior breast implant status using a chi-square test. Univariable and multivariable-adjusted odds ratios (OR) with 95% confidence intervals (CI) were estimated for relative odds of immediate reconstruction vs. mastectomy only. Results: During follow-up, 1,253 CTS participants with incident breast cancer underwent mastectomy with (N = 368) and without (N = 885) reconstruction. In multivariable stepwise logistic regression analyses, calendar year, age, type of insurance, tumor stage, and prior breast implant were statistically significantly associated with use of reconstruction. The proportion of patients undergoing immediate PMR increased from 21.8% during 1995–1999 to 26.4% during 2005–2009. A statistically significant dose-response was apparent between older age at surgery and decreased likelihood of post-mastectomy reconstruction (Ptrend<0.001). Race/ethnicity was not significantly associated with the use of PMR because the majority of patients were non-Hispanic white (89.5%). Most participants either had private insurance (56.8%) or Medicare (42.4%); those with private insurance were twice as likely to undergo PMR compared to patients with Medicare (OR 2.23: 95%CI 1.25–4.00, p = 0.01). Compared to participants with in situ and stage I breast cancer combined, participants with stage II or stage III breast cancer had one-third to one-half lower odds of postmastectomy reconstruction relative to mastectomy only (ORstageII = 0.67, 95% CI = 0.49–0.90, p = 0.01; ORstageIII=0.47, 95% CI=0.29–0.77, p = 0.002). Participants with a prior history of a breast implant were 7 times more likely to undergo PMR than participants with no such history (OR 7.14: 95%CI 2.38–21.41, p < 0.001). Conclusions: In the CTS population, having a prior breast implant and lower tumor stage were additional variables associated with increased odds of PMR. This study validates previous studies which have shown that private insurance and younger age are associated with the use of reconstruction after mastectomy. Patient and health care provider education is warranted to ensure that all patients undergoing mastectomy are offered and have access to PMR. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD08-02.