Rates Of Postmastectomy Reconstruction Research Articles

Disparities in Postmastectomy Reconstruction Use among American Indian and Alaska Native Women.

American Indian/Alaska Native (AI/AN) breast cancer patients undergo postmastectomy reconstruction (PMR) infrequently relative to non-Hispanic White (NHW) patients. Factors associated with low PMR rates among AI/AN women are poorly understood. The authors sought to describe factors associated with this disparity in surgical care. A retrospective cohort study of the National Cancer Database (2004 to 2017) identified AI/AN and NHW women, aged 18 to 64, who underwent mastectomy for stage 0 to III breast cancer. Patient characteristics, annual PMR rates, and factors associated with PMR were described with univariable analysis, the Cochran-Armitage test, and multivariable logistical regression. A total of 414,036 NHW and 1980 AI/AN women met inclusion criteria. Relative to NHW women, AI/AN women had more comorbidities (20% versus 12%; Charlson Comorbidity Index ≥ 1; P < 0.001), had nonprivate insurance (49% versus 20%; P < 0.001), and underwent unilateral mastectomy more frequently (69% versus 61%; P < 0.001). PMR rates increased over the study period, from 13% to 47% for AI/AN women and from 29% to 62% for NHW women ( P < 0.001). AI/AN race was independently associated with decreased likelihood of PMR (OR, 0.62; 95% CI, 0.56 to 0.69). Among AI/AN women, decreased likelihood of PMR was significantly associated with older age at diagnosis, more remote year of diagnosis, advanced disease (tumor size >5 cm, positive lymph nodes), unilateral mastectomy, nonprivate insurance, and lower educational attainment in patient's area of residence. PMR rates among AI/AN women with stage 0 to III breast cancer have increased, yet they remain significantly lower than rates among NHW women. Further research should elicit AI/AN perspectives on PMR, and guide early breast cancer detection and treatment. Risk, II.

D124. Equity And Disparities in Access to Post-mastectomy Reconstruction: Multi-decades in New York

PURPOSE: Breast reconstruction has been shown to improve both quality of life and psychosocial wellbeing. There is a paucity of literature that examines rates of post-mastectomy reconstruction across various demographics and clinical profiles on a multi-decade, multi-institutional scale. The aim of this study is to assess the barriers in post-cancer reconstruction at our affiliate institutions. METHODS: We performed a retrospective chart review of patients who had undergone mastectomy at three institutions within the New York Presbyterian system, including Cornell (WCMC), Columbia (CUIMC), and Brooklyn Methodist (BMH) from 1979 to 2019. Patient medical history, demographics and treatments were recorded. Univariate and multivariate logistic regression were used to assess the relationship between the variables and receiving reconstruction after mastectomy. RESULTS: 4594 patients with verifiable data were included in the cohort. Older age (OR 0.9), more advanced cancer stage (OR 0.46), and being single compared to married (OR 0.66) were correlated with lower odds of pursuing reconstruction (p<0.05). Compared to their White counterparts, Asian American Pacific Islander (OR 0.21) and Black patients (OR 0.61) were significantly less likely to receive reconstruction (p<0.05). The same trend was not present for Medicare/Medicaid compared to private insurance status. CONCLUSION: The multi-decade data suggests certain racial and social factors may still pose as barriers to reconstruction access. However, efforts toward broadening insurance coverage and mandating information regarding access to reconstruction may have begun leveling the field for disadvantaged socioeconomic groups.

The State of Breast Cancer Reconstruction in Virginia: An Evidence-Based Framework for Identifying Locoregional Health Disparities.

Age, race, socioeconomic status, and proximity to plastic surgeons have been shown to impact receipt of reconstruction after mastectomy in several national studies. Given that targeted outreach efforts and programs to address these discrepancies would occur locoregionally, investigation of these reconstructive trends on a state level is warranted. Patients diagnosed with breast cancer in Virginia between 2000 and 2018 were identified in the Virginia Department of Health Cancer Registry. Patients who underwent mastectomy breast conservation surgery, and/or breast reconstruction at the time of oncologic surgery were identified. Patient demographics were analyzed, and logistic regression analyses were used to determine the likelihood of receipt of mastectomy, receipt of mastectomy versus breast conservation surgery, receipt of mastectomy with reconstruction versus mastectomy alone, and receipt of mastectomy with reconstruction versus breast conservation surgery with respect to the demographic variables. Geographically weighted regression analyses were also performed to determine impact of geographic location on receipt of mastectomy and reconstruction after mastectomy. A total of 78,682 patients in Virginia underwent surgical treatment for breast cancer between 2000 and 2018. Living outside a metropolitan area, increased age, lower socioeconomic status, non-White race, and lower number of plastic surgeons within 50 miles were associated with decreased rates of postmastectomy reconstruction. Rural setting, lower socioeconomic status, and lower plastic surgeon supply were also associated with decreased rates of breast conservation surgery. Reconstruction after mastectomy was lowest in the northwest, central, and southwest regions of Virginia. Within the state of Virginia, programs to improve access to breast reconstruction for patients residing in rural regions, as well as non-White patients, older patients, and those in lower socioeconomic groups should be implemented. Future studies would implement and study the efficacy of such outreach programs, which could then be applied and tailored to other states or regions to address sociodemographic disparities in access to breast reconstruction.

Association of Medicaid Expansion with Post-mastectomy Reconstruction Rates.

The Affordable Care Act sought to improve access to health care for low-income individuals. This study aimed to assess whether expansion of Medicaid coverage increased rates of post-mastectomy reconstruction (PMR) for patients who had Medicaid or no insurance. A retrospective analysis performed through the National Cancer Database examined women who underwent PMR and were uninsured or had Medicaid, private insurance, or Medicare, and whose race/ethnicity, age, and state expansion status were known. Trends in the use of PMR after passage of Medicaid expansion in 2014 were evaluated. In all states and at all time periods, patients with private insurance were about twice as likely to undergo PMR as patients who had Medicaid or no insurance. In 2016, only 28.7 % of patients with Medicaid or no insurance in nonexpansion states underwent PMR (p < 0.001) compared with 38.5 % of patients in expansion states (p < 0.001). Patients in expansion states also have higher levels of education, higher income, and greater likelihood of living in metropolitan areas. Additionally, patients in all states saw an increase in early-stage disease, with a concomitant reduction in late disease, but this change was greater in expansion states than in non-expansion states. Expansion states have larger proportions of patients undergoing PMR than non-expansion states. This difference stems from significant differences in income, education, comorbidities, race, and location. Large metropolitan areas have the largest number of patients undergoing PMR, whereas rural areas have the least.

Did Medicaid Expansion Mitigate Disparities in Post-mastectomy Reconstruction Rates?

Patient and socioeconomic factors both contribute to disparities in post-mastectomy reconstruction (PMR) rates. We sought to explore PMR patterns across the US and to determine if PMR rates were associated with Medicaid expansion. The NCDB was used to identify women who underwent PMR between 2004-2016. The data was stratified by race, state Medicaid expansion status, and region. A multivariate model was fit to determine the association between Medicaid expansion and receipt of PMR. In comparison to Caucasian women receiving PMR in Medicaid expansion states, African American (AA) women in Medicaid expansion states were less likely to receive PMR (OR .96 [.92-1.00] P < .001). Patients in the Northeast (NE) had better PMR rates vs any other region in the US, for both Caucasian and AA women (Caucasian NE ref, Caucasian-South .80 [.77-.83] vs AA NE 1.11 [1.04-1.19], AA-South (.60 [.58-.63], P < .001). Interestingly, AA patients residing in the NE had the highest receipt of PMR 1.11 (1.04-1.19), even higher than their Caucasian counterparts residing in the same region (ref). Rural AA women had the lowest rates of PMR vs rural Caucasian women (.40 [.28-.58] vs .79 [.73-.85], P < .001]. Racial disparities in PMR rates persisted despite Medicaid expansion. When stratified by region, however, AA patients in the NE had higher rates of PMR than AA women in other regions. The largest disparities were seen in AA women in the rural US. Breast cancer disparities continue to be a complex problem that was not entirely mitigated by improved insurance coverage.

Differences in post mastectomy reconstruction rates between Asian and Caucasian patients: A 5 year institutional review

Differences in post mastectomy reconstruction rates between Asian and Caucasian patients: A 5 year institutional review

The Relationship Between Geographic Access to Plastic Surgeons and Breast Reconstruction Rates Among Women Undergoing Mastectomy for Cancer.

Despite a national health care policy requiring payers to cover breast reconstruction, rates of postmastectomy reconstruction are low, particularly among minority populations. We conducted this study to determine if geographic access to a plastic surgeon impacts breast reconstruction rates. Using 2010 inpatient and ambulatory surgery data from 10 states, we identified adult women who underwent mastectomy for breast cancer. Data were aggregated to the health service area (HSA) level and hierarchical generalized linear models were used to risk-standardize breast reconstruction rates (RSRR) across HSAs. The relationship between an HSA's RSRR and plastic surgeon density (surgeons/100,000 population) was quantified using correlation coefficients. The final cohort included 22,997 patients across 134 HSAs. There was substantial variation in plastic surgeon density (median, 1.4 surgeons/100,000; interquartile range, [0.0-2.6]/100,000) and the use of breast reconstruction (median RSRR, 43.0%; interquartile range, [29.9%-62.8%]) across HSAs. Higher plastic surgeon density was positively correlated with breast reconstruction rates (correlation coefficient = 0.66, P < 0.001) and inversely related to time between mastectomy and reconstruction (correlation coefficient = -0.19, P < 0.001). Non-white and publicly insured women were least likely to undergo breast reconstruction overall. Among privately insured patients, racial disparities were noted in high surgeon density areas (white = 79.0% vs. non-white = 63.3%; P < 0.001) but not in low surgeon density areas (34.4% vs 36.5%; P = 0.70). The lack of geographic access to a plastic surgeon serves as a barrier to breast reconstruction and may compound disparities in care associated with race and insurance status. Future efforts to improve equitable access should consider strategies to ensure access to appropriate clinical expertise.

Trends in Post-Mastectomy Reconstruction in an Asian Population: A 12-Year Institutional Review.

Post-mastectomy breast reconstruction is an integral component of breast cancer treatment. It is often perceived that women in Asian countries have a lower rate of post-mastectomy reconstruction than Western populations. This study describes trends in timing and types of breast reconstruction performed in the largest healthcare provider in Singapore, over a period of 12 years. It also reports on the oncological outcomes and surgical safety. A retrospective review of all patients who underwent post-mastectomy reconstruction from January 2001 to December 2012 at the National Cancer Centre Singapore and Singapore General Hospital was performed. Six hundred and twenty post-mastectomy reconstructions were performed in 579 patients. The proportion of reconstructions increased from 4% in 2001 to 18% in 2012. Younger patients (<50 years old) and those with early stage cancer were more likely to undergo reconstruction. Immediate breast reconstruction was favored by more than 90% of patients. Postoperatively, 9% developed acute surgical complications that were treated surgically; 6% had additional surgery for late complications. Only 4% had delay of adjuvant chemotherapy. At median follow-up of 63 months (range 3-166), loco-regional recurrence was 4%, and distant metastases 8%. Post-mastectomy reconstruction for breast cancer is increasingly performed in our institution. Both younger age and lower stage disease were associated with choice for reconstruction in our study. Low rates of delay to adjuvant therapy were noted, and it may safely be offered to suitable women undergoing mastectomy.

Abstract P4-14-08: Race as an independent factor affecting post-mastectomy reconstruction in Asian women

Abstract BACKGROUND: Racial disparities exist in many areas of breast cancer treatment. Multiple factors influence whether Asian women with breast cancer undergo immediate reconstruction after mastectomy. This study aims to evaluate breast reconstruction trends at a comprehensive cancer center and to determine whether race is an independent predictor of breast reconstruction. METHODS: Using an IRB-approved, prospectively maintained database, post-mastectomy reconstruction rates were determined for 2003 to 2013. This database was compiled from three university-affiliated hospitals serving a diverse urban population. A total of 5379 patients were identified who were treated for breast cancer during the 10-year period. The odds-ratio for immediate breast reconstruction was compared among different races. The data was examined to identify factors influencing the decision for post-mastectomy reconstruction, including age, stage of presentation, marital status, and family history of breast cancer. RESULTS: Thirty percent (n=1614) of women treated for breast cancer underwent mastectomy, while seventy percent (n=3765) received breast-conserving therapy. In the mastectomy group, a unilateral procedure was performed in 93.1% (n=1503) of women and a bilateral procedure in 6.9% (n=111). The immediate reconstruction rate after mastectomy was 70% (n=1130), with only 30% (n=484) of women not undergoing reconstruction. Of the women undergoing mastectomy, 58.5% were white, 14.9% were black, 13.1% were Hispanic, 7.5% were Asian and 6% of women did not report race. Of the women who underwent breast reconstruction after mastectomy, 60.5% were white women, 13.4% were black women, 13% were Hispanic women, 6.9% were Asian women and 6.2% of women did not report race. The immediate reconstruction rate by race was 72.2% for white women, 63.2% for black women, 69.8% of Hispanic for women, and 64.8% for Asian women. The remainder did not receive breast reconstruction. The unadjusted odds ratio (OR) for immediate breast reconstruction, including both unilateral and bilateral cases, for black versus white women was 0.62 (95% confidence interval 0.46-0.84; P=0.001). The OR for breast reconstruction for Hispanic versus white women was 0.88 (95% confidence interval; 0.63-1.22; .P=0.45). The OR for unilateral breast reconstruction for Asian versus white women was 0.66 (95% confidence interval 0.44-0.99; P=0.04.) CONCLUSION: Reconstruction rates vary by race, with Asian women being less likely to undergo immediate breast reconstruction after mastectomy. Compared to white women, Asian and black women were both significantly less likely to have immediate breast reconstruction following mastectomy. Many variables may contribute to this disparity in breast cancer care. Language and cultural beliefs may be unique factors that influence Asian women’s decision for post-mastectomy reconstruction and warrant further study. Citation Format: Carmen F Fong, Alyssa Gillego, Theresa Shao, Erika Reategui, Catherine Campo, Sarah Cate, Christopher Mills, Mark L Smith, Gina Aharonoff, Susan K Boolbol. Race as an independent factor affecting post-mastectomy reconstruction in Asian women [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-14-08.

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

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&amp;lt;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 &amp;lt; 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.

Invited Commentary

Invited Commentary

Disparities in Reconstruction Rates after Mastectomy for Ductal Carcinoma in Situ (DCIS): Patterns of Care and Factors Associated with the Use of Breast Reconstruction for DCIS Compared with Invasive Cancer

Many factors influence whether breast cancer patients undergo reconstruction after mastectomy. This study was undertaken to determine the patterns of care and variables associated with the use of reconstruction for ductal carcinoma in situ (DCIS) and to compare previous results for invasive carcinoma. Postmastectomy reconstruction rates were collected from the California Office of Statewide Health Planning and Development (OSHPD) for 2003-2007. International Classification of Disease-9 codes were used to identify patients undergoing reconstruction after mastectomy. Variations in reconstruction rates were examined by type of breast cancer (DCIS vs. invasive), calendar year, age, type of insurance, type of hospital, and race/ethnicity. Univariate and multivariate odds ratios (OR) with 95% confidence intervals (CI) were estimated for relative odds of immediate reconstruction versus mastectomy only. For multivariate analysis, age, race/ethnicity, type of insurance, and type of hospital were significantly associated with the use of reconstruction for DCIS patients. DCIS patients were twice as likely to undergo reconstruction as patients with invasive cancer (odds ratio (OR) = 1.93, 95% confidence interval (CI) = 1.75-2.13). DCIS patients with private insurance were nine times more likely to undergo reconstruction as patients with Medicaid (OR = 8.84, 95% CI = 5.92-13.21). Both Hispanic white and Asian patients were one-fifth as likely to undergo reconstruction compared with non-Hispanic white patients (OR = 0.18, 95% CI = 0.1-0.3; OR = 0.17, 95% CI = 0.09-0.31). Postmastectomy rates for DCIS were twice those for invasive cancer mostly because stage was not a limiting factor. However, significant factors remain that limit the use of reconstruction in this breast cancer population: age, race/ethnicity, type of hospital, and type of insurance.

Disparities in Reconstruction Rates After Mastectomy: Patterns of Care and Factors Associated with the Use of Breast Reconstruction in Southern California

Many factors influence whether breast cancer patients undergo reconstruction after mastectomy. We sought to determine the patterns of care and variables associated with the use of breast reconstruction in Southern California. Postmastectomy reconstruction rates were determined from the California Office of Statewide Health Planning and Development (OSHPD) inpatient database from 2003 to 2007. International Classification of Disease-9 codes were used to identify patients undergoing reconstruction after mastectomy. Changes in reconstruction rates were examined by calendar year, age, race, type of insurance, and type of hospital using a chi-square test. Univariate and multivariate odds ratios (OR) with 95% confidence intervals (95% CI) were estimated for relative odds of immediate reconstruction versus mastectomy only. In multivariate analysis, calendar year, age, race, type of insurance, and type of hospital were statistically significantly associated with use of reconstruction. The proportion of patients undergoing reconstruction rose from 24.8% in 2003 to 29.2% in 2007. Patients with private insurance were 10 times more likely to undergo reconstruction than patients with Medi-Cal insurance (OR 9.95, 95% CI 8.46-11.70). African American patients were less likely (OR 0.58, 95% CI 0.46-0.73) and Asian patients one-third as likely (OR 0.37, 95% CI 0.29-0.47) to undergo reconstruction as Caucasians patients Most reconstructive procedures were performed at teaching hospitals and designated cancer centers. Although the rate of postmastectomy reconstruction is increasing, only a minority of patients undergo reconstruction. Age, race, type of insurance, and type of hospital appear to be significant factors limiting the use of reconstruction.

A Multi-Institutional Analysis of the Socioeconomic Determinants of Breast Reconstruction

To determine the rate of postmastectomy reconstruction and investigate the impact of socioeconomic status on the receipt of reconstruction. The National Comprehensive Cancer Network (NCCN) Outcomes Project is a prospective, multi-institutional database that contains data on all newly diagnosed breast cancer patients treated at one of the participating comprehensive cancer centers. The study cohort consisted of 2174 patients with DCIS and stage I, II, and III invasive breast cancer who underwent mastectomy at one of 8 NCCN centers. Rates of reconstruction were determined. Logistic regression analyses were used to evaluate whether socioeconomic characteristics are associated with breast reconstruction. Overall, 42% of patients had breast reconstruction following mastectomy. Patients with Medicaid and Medicare were less likely to undergo reconstruction than those with managed care insurance; however, there was no difference for indemnity versus managed care insurance. Homemakers and retired patients had fewer reconstructions than those employed outside the home. Patients with a high school education or less were less likely to have reconstruction than those with more education. Race and ethnicity were not significant predictors of reconstruction. The reconstruction rate in this study (42%) is markedly higher than those previously reported. The type of insurance, education level, and employment status of a patient, but not her race or ethnicity, appear to influence the use of breast reconstruction. Because all patients were treated at an NCCN institution, these socioeconomic differences cannot be explained by access to care.