Breast Reconstruction Utilization Research Articles

Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016-2019.

Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States. Using the National Inpatient Sample, 2016-2019, the International Classification of Disease , Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling. A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Δ = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Δ = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR ( P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay ( P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242). As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility.

Regional Implicit Racial Bias and Rates of Breast Reconstruction, Complications, and Cost Among US Patients With Breast Cancer

Racial disparities influencing breast reconstruction have been well-researched; however, the role of implicit racial bias remains unknown. An analysis of the disparities in care for patients with breast cancer may serve as a policy target to increase the access and quality of care for underserved populations. To identify whether variations in implicit racial bias by region are associated with the differences in rates of immediate breast reconstruction, complications, and cost for White patients and patients from minoritized racial and ethnic groups. This cohort study used data from the National Inpatient Sample (NIS) from 2009 to 2019. Adult female patients with a diagnosis of or genetic predisposition for breast cancer receiving immediate breast reconstruction at the time of mastectomy were included. Patients receiving both autologous free flap and implant-based reconstruction were included in this analysis. US Census Bureau data were extracted to compare rates of reconstruction proportionately. The Implicit Association Test (IAT) was used to classify whether implicit bias was associated with the primary outcome variables. Data were analyzed from April to November 2022. IAT score by US Census Bureau geographic region. Variables of interest included demographic data, rate of reconstruction, complications (reconstruction-specific and systemic), inpatient cost, and IAT score by region. Spearman correlation was used to determine associations between implicit racial bias and the reconstruction utilization rate for White patients and patients from minoritized racial and ethnic groups. Two-sample t tests were used to analyze differences in utilization, complications, and cost between the 2 groups. A total of 52 115 patients were included in our sample: 38 487 were identified as White (mean [SD] age, 52.0 [0.7] years) and 13 628 were identified as minoritized race and ethnicity (American Indian, Asian, Black, and Hispanic patients and patients with another race or ethnicity; mean [SD] age, 49.7 [10.5] years). Implicit bias was not associated with disparities in breast reconstruction rates, complications, or cost. Nonetheless, the White-to-minoritized race and ethnicity utilization ratio differed among the regions studied. Specifically, the reconstruction ratio for White patients to patients with minoritized race and ethnicity was highest for the East South Central Division, which includes Alabama, Kentucky, Mississippi, and Tennessee (2.17), and lowest for the West South Central Division, which includes Arkansas, Louisiana, Oklahoma, and Texas (0.75). In this cohort study of patients with breast cancer, regional variation of implicit bias was not associated with differences in breast reconstruction utilization, complications, or cost. Regional disparities in utilization among racial and ethnic groups suggest that collaboration from individual institutions and national organizations is needed to develop robust data collection systems. Such systems could provide surgeons with a comparative view of their care. Additionally, collaboration with high-volume breast centers may help patients in low-resource settings receive the desired reconstruction for their breast cancer care, helping improve the utilization rate and quality of care.

Improvement in Breast Reconstruction Disparities following Medicaid Expansion under the Affordable Care Act.

Under the Affordable Care Act, Medicaid expansion effective 1 January 2014 aimed to increase access to health care. We sought to determine the association of Medicaid expansion with disparities in utilization of breast reconstruction. Non-Hispanic Black (NHB) and White (NHW) breast cancer patients undergoing mastectomy +/- reconstruction between 2010 and 2017 were selected from the National Cancer Database. Annual trends for utilization of breast reconstruction by race, income, and education were evaluated by Medicaid expansion status using difference-in-differences regression analyses. Medicaid expansion was categorized by expansion date as early (2010-2013), 2014 (1/2014), late (after 1/2014), or no expansion. Of 443,607 patients, 36.3% (n = 161,128) underwent reconstruction, 13.1% (n = 58,249) were NHB, 16.8% (n = 74,430) had median income < $40,227, and 17.1% (n = 75,718) were in the lowest education quartile. In non-expansion states, lower proportions of NHB patients underwent reconstruction than NHW patients in all years, with the smallest disparity (NHB% - NHW%) (-6.4%) in 2017. Decreases in disparities between NHB and NHW patients were seen with the smallest difference observed in 2014 (-2.5%) in early-expansion states, in 2017 (-0.7%) in 1/2014 expansion states, and in 2017 (-4.5%) in late-expansion states. Similar findings for convergence of reconstruction utilization rates for the lowest two education levels and lowest two income quartiles were found with Medicaid expansion, with no convergence seen in non-expansion states over the study period. Some improvement in breast reconstruction disparities followed Medicaid expansion. Failure to improve parity without Medicaid expansion should be a consideration with any modifications to Medicaid access.

Understanding Disparities in Post-Mastectomy Breast Reconstruction Utilization in the Rural State of Nevada

Purpose: Despite federally mandated insurance coverage and clear benefits of breast reconstruction after mastectomy, reported rates remain low at 23-63%. We hypothesize that rates and types of reconstruction would be disproportionately lower in the rural state of Nevada. The goal of this study was to identify and understand disparities in breast reconstruction utilization in Nevada compared to the nation. Methods: Breast cancer patient information (2008-2013) was aggregated from AHRQ’s HCUP Nationwide Inpatient Sample (NIS) and the Nevada State Inpatient Database (NV SID). Chi-square analysis for two population proportions was used to determine differences between the NV SID (n=7,466) and NIS (n=1,231,428) mastectomy and breast reconstruction cases with statistical significance considered p<.05. Autologous reconstruction was further separated into pedicled and free tissue transfer for analysis. Results: The percentage of mastectomies performed in Nevada per patient with breast cancer was compared to nationwide values. Nevada was significantly lower in overall reconstruction at only 38.8% compared to 47.2% nationwide (p<.001). Subgroup analysis of autologous reconstructions demonstrates that free tissue transfer accounts for 51.3% of cases performed nationally compared to only 9.3% of cases performed in Nevada. Conclusion: Utilization of breast reconstruction in Nevada is significantly lower compared to the rest of the nation. Perhaps more striking is the fact that less than 10% are autologous free flap reconstructions despite increasing national trends. The results of this study will be essential in highlighting the disparities in rural states such as Nevada and developing programs to improve outreach and delivery of optimal post-cancer breast reconstruction.

Abstract A126: Rural-urban differences in breast reconstruction utilization following mastectomy

Abstract Background: Healthcare disparities in rural women are well-defined, however little is known about breast reconstruction (BR) utilization in this population, especially rural Kentucky. The goal of this study was to determine if disparities in BR exist among post-mastectomy rural female patients in Kentucky. Methods: The Kentucky Cancer Registry was used to identify patients diagnosed with breast cancer and treated with mastectomy from 2006-2015. Patients were subdivided into mastectomy-only and mastectomy plus BR groups. 2013 Beale codes were used to stratify patients according to urban, near-metro or rural status. Chi-square tests were used to examine the association of BR along the rural-urban continuum. A multivariate logistic regression model controlling for patient, disease and treatment factors was used to predict BR. The likelihood of undergoing BR was reported in odds ratios (OR) using a 95% confidence interval (CI). Results: Overall, 12,036 patients underwent mastectomy. Of these patients, 2,822 (23.4%) also underwent BR. The rate of BR among urban, near-metro and rural patients was 32.4%, 23.1% and 14.7%, respectively. Multivariate analysis revealed that women from near metro (OR 0.56, CI 0.50-0.63; p &amp;lt; 0.001) and rural areas (OR 0.38, CI 0.33-0.43; p &amp;lt;0.001) were less likely to undergo BR than women from urban areas. Conclusion: Although BR benefits are well documented, women from rural areas undergo BR at lower rates and are less likely to receive BR than their urban and near-metro counterparts. While multiple factors contribute to this disparity, future efforts should seek to improve comprehensive breast cancer care which includes access to a reconstructive breast surgeon. Citation Format: Robert-Marlo F. Bautista, Ryan C. DeCoster, Jack C. Burns, Robert W. Edmunds, Adam J. Dugan, Brian J. Rinker, Matthew Webster, Henry C. Vasconez. Rural-urban differences in breast reconstruction utilization following mastectomy [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A126.

Rural-Urban Differences in Breast Reconstruction Utilization Following Oncologic Resection.

Breast reconstruction (BR) is the reconstructive surgical technique that focuses on restoring normal form and function to the breast following oncologic resection. The goal of this study was to determine if BR disparities exist among rural female patients in Kentucky. A retrospective (2006-2015), population-based cohort study was conducted on breast cancer patients (stages I-III) treated with mastectomy with or without BR. We used 2013 Beale codes to stratify patients according to geographic status. Chi-square tests were used to examine the association of BR along the rural-urban continuum. A multivariate logistic regression model controlling for patient, disease, and treatment factors was used to predict BR. The likelihood of BR was reported in odds ratios (OR) using a 95% confidence interval (CI). Overall, 10,032 patients met study criteria. Of those, 2,159 (21.5%) underwent BR. The rate of BR among urban, near-metro, and rural patients was 31.1%, 20.4%, and 13.4%, respectively (P < .001). Multivariate analysis revealed that women from near metro (OR 0.54, CI: 0.47-0.61; P < .001) and rural areas (OR 0.36, CI: 0.31-0.41; P < .001) were less likely to undergo BR than women from urban areas. Although BR benefits are well documented, women from rural Kentucky undergo BR at lower rates and are less likely to receive BR than their urban counterparts. Efforts should seek to promote equitable access to BR for all patients, including those from rural areas.

National Breast Reconstruction Utilization in the Setting of Postmastectomy Radiotherapy.

Background Immediate breast reconstruction (IBR) is often deferred, when postmastectomy radiotherapy (PMRT) is anticipated, due to high complication rates. Nonetheless, because of robust data supporting improved health-related quality of life associated with reconstruction, physicians and patients may be more accepting of tradeoffs. The current study explores national trends of IBR utilization rates and methods in the setting of PMRT, using the National Cancer Database (NCDB). The study hypothesis is that prosthetic techniques have become the most common method of IBR in the setting of PMRT. Methods NCDB was queried from 2004 to 2013 for women, who underwent mastectomy with or without IBR. Patients were grouped according to PMRT status. Multivariate logistic regression was used to calculate odds of IBR in the setting of PMRT. Trend analyses were done for rates and methods of IBR using Poisson regression to determine incidence rate ratios (IRRs). Results In multivariate analysis, radiated patients were 30% less likely to receive IBR (p < 0.05). The rate increase in IBR was greater in radiated compared with nonradiated patients (IRR: 1.12 vs. 1.09). Rates of reconstruction increased more so in radiated compared with nonradiated patients for both implants (IRR 1.15 vs. 1.11) and autologous techniques (IRR 1.08 vs. 1.06). Autologous reconstructions were more common in those receiving PMRT until 2005 (p < 0.05), with no predominant technique thereafter. Conclusion Although IBR remains a relative contraindication, rates of IBR are increasing to a greater extent in patients receiving PMRT. Implants have surpassed autologous techniques as the most commonly used method of breast reconstruction in this setting.

Disparate British Breast Reconstruction Utilization: Is Universal Coverage Sufficient to Ensure Expanded Care?

Summary:Our intent is to improve the understanding of the ability of healthcare providers to deliver high-quality care as we approach an era of universal coverage. We adopted 2 unique vantage points in this article: (1) the mandated coverage for immediate breast reconstruction (IBR) surgery as a microcosmic surrogate for universal coverage overall and (2) we then scrutinized the respective IBR utilization rates in a contemporaneous system of 2 healthcare delivery models in the United Kingdom, that is, the public National Health Service trust versus private-sector hospitals. A literature review was performed for IBR rates across public trust and private-sector hospitals in the United Kingdom. The IBR rate among public trust hospitals was 17% compared with 43% in the private sector. In the trust hospital setting, the enactment of 2 government mandates, intended to increase the access to cancer care, seemed to fall short in maximizing the ability of surgical practitioners to deliver quality care to patients. Among women who did not receive IBR, 65% felt that they had received the sufficient amount of information to appropriately inform their decision. In addition, only 46% of this same cohort reported a consultation with a reconstructive surgeon preoperatively. Private-sector hospitals delivered better IBR care because of the likely presence of infrastructure and financial incentives for physicians. These results serve as a call for a better alignment between policy initiatives designed to expand care access and the perogatives of physicians to ensure an optimized delivery of the expanded care such policy mandates.

Geographic Variation Immediate and Delayed Breast Reconstruction Utilization in Ontario, Canada and Plastic Surgeon Availability: A Population-Based Observational Study.

Utilization of breast reconstruction (BR) is low in many jurisdictions. We studied the geographical and surgical workforce factors that contribute to access and use of BR using a small area analysis approach with a geographical unit of analysis. We linked administrative data from Ontario Canada to calculate the age-standardized rates for immediate BR (IBR) (same time as mastectomy) between 2002 and 2011, and delayed BR (DBR) (within 3 years of mastectomy) for each county. The influence of plastic surgeon access on variation in county rates of BR was examined using Poisson random effects models. 12,663 women underwent mastectomy in Ontario; 2,948 had BR within 3 years (23.3%). Over 50% of the counties had no access to any plastic surgeon. County IBR rates ranged from 0 to 21.5%; plastic surgeon access explained 46% of geographic variation (p<0.0001). IBR rates in counties with very low, low, and moderate access to plastic surgeons were significantly less than counties with high access (relative rate [RR] 0.48 [95% confidence interval (CI) 0.35-0.66], RR 0.61 [CI 0.43-0.87] and RR 0.70 [CI 0.52-0.96], respectively) after adjusting for age and county socioeconomic characteristics. For DBR, while there was less geographic variation, very low access counties demonstrated reduced rates (RR 0.60 [CI 0.47-0.76]). Geographic access to a plastic surgeon is a major determinant of BR. Targeted interventions for regions without high access to plastic surgeons may improve overall rates and reduce geographic disparities in care, particularly for IBR.

The influence of race/ethnicity and place of service on breast reconstruction for Medicare beneficiaries with mastectomy.

Racial disparities in breast reconstruction for breast cancer are documented. Place of service has contributed to disparities in cancer care; but the interaction of race/ethnicity and place of service has not been explicitly examined. We examined whether place of service modified the effect of race/ethnicity on receipt of reconstruction.We included women with a mastectomy for incident breast cancer in SEER-Medicare from 2005–2009. Using Medicare claims, we determined breast reconstruction within 6 months. Facility characteristics included: rural/urban location, teaching status, NCI Cancer Center designation, cooperative oncology group membership, Disproportionate Share Hospital (DSH) status, and breast surgery volume. Using multivariable logistic regression, we analyzed reconstruction in relation to minority status and facility characteristics.Of the 17,958 women, 14.2% were racial/ethnic women of color and a total of 9.3% had reconstruction. Caucasians disproportionately received care at non-teaching hospitals (53% v. 42%) and did not at Disproportionate Share Hospitals (77% v. 86%). Women of color had 55% lower odds of reconstruction than Caucasians (OR = 0.45; 95% CI 0.37-0.55). Those in lower median income areas had lower odds of receiving reconstruction, regardless of race/ethnicity. Odds of reconstruction reduced at rural, non-teaching and cooperative oncology group hospitals, and lower surgery volume facilities. Facility effects on odds of reconstruction were similar in analyses stratified by race/ethnicity status.Race/ethnicity and facility characteristics have independent effects on utilization of breast reconstruction, with no significant interaction. This suggests that, regardless of a woman’s race/ethnicity, the place of service influences the likelihood of reconstruction.

An Analysis of Immediate Postmastectomy Breast Reconstruction Frequency Using the Surveillance, Epidemiology, and End Results Database

Mastectomy is used to treat one third of the nearly 180,000 women diagnosed with breast cancer in the United States annually. In this study, we use population-level data from multiple years of the Surveillance, Epidemiology, End Results (SEER) database to further define patient, tumor, and geographic characteristics associated with immediate and early-delayed breast reconstruction. Population level de-identified data for the years 1998 to 2002 were extracted from the National Cancer Institute's (NCI) SEER cancer database. All female patients who were treated with mastectomy for a diagnosis of ductal and/or lobular breast cancer (including Paget disease) were included. The primary end point of interest was odds of reconstruction. Multivariate analysis was performed to control for patient demographic and oncologic characteristics. A total of 52,249 patients met the inclusion criteria. Reconstruction was performed in 8,446 patients (16.2%). Odds of reconstruction varied by region from 0.60 (Seattle) to 2.81 (Atlanta). African Americans were noted to have a significantly lower likelihood of reconstruction when compared with Caucasian patients (OR 0.60 versus 1.00). Patients living in nonmetropolitan regions were also significantly less likely to undergo reconstruction. Receipt of radiation therapy was also negatively correlated with likelihood of reconstruction. In this multicenter, multiyear analysis of factors associated with immediate or early-delayed reconstruction after mastectomy, we demonstrate that younger age, white race, metropolitan locale, and lower stage disease were all independently associated with higher likelihood of reconstruction. This information provides insight into breast reconstruction utilization and will help guide future studies to understand how these factors affect patient and physician decision-making.

Local Recurrence of Breast Cancer 52 Years after Halsted Mastectomy: Is There a Role for More Aggressive Ipsilateral Surveillance?

We present the longest reported case of breast cancer recurrence, 52 years after initial diagnosis, in a patient initially treated with Halsted mastectomy. Observation and palpation of the chest wall resulted in late presentation, and this patient went on to demonstrate metastatic disease. Current surveillance guidelines lack specific recommendations regarding monitoring of the ipsilateral chest wall. In addition, the growing utilization of breast reconstruction poses an additional challenge to surveillance strategies of the ipsilateral breast. However, the emergence of MRI may present a new opportunity to identify ipsilateral recurrence. The changing landscape of breast cancer therapy warrants guidance from groups of national import such as ASCO, in the surveillance of breast cancer patients.

Breast Reconstruction Practices in North America: Current Trends and Future Priorities

The Women's Health and Cancer Rights Act (WHCRA) became federal law on January 1, 1999, mandating health care payer coverage for postmastectomy breast reconstruction. Despite passage of this legislation, breast reconstruction rates in the United States remain low. The Surveillance, Epidemiology and End Results (SEER) database for mastectomy patients in 11 regions across the United States show overall rates for immediate and early delayed reconstruction (performed within 4 months of mastectomy) of 15.4% for 1998 and 18.0% for 2000. Reconstruction rates vary significantly by region as well as by patient age, race, and income. The paper examines potential etiologies for low utilization of breast reconstruction and outlines possible remedies.