Health insurance status affected likelihood of having reconstructive surgery after breast cancer

San Antonio Breast Cancer Symposium

SAN ANTONIO — Having health insurance was linked to an increased likelihood of undergoing breast reconstruction after mastectomy, according to findings presented here.

Dawn L. Hershman, MD,of the departments of medicine and epidemiology at Columbia University in New York, said the aim of the study was to determine factors that influenced the decision to undergo post-mastectomy reconstructive surgery.

“Immediate reconstructive surgery is associated with improved psychological health, self-esteem and body image,” Hershman said.

The researchers evaluated demographic-, hospital-, physician- and insurance-related factors in the decision to have immediate breast reconstruction.

Data for ICD-9 procedure codes for 108,992 women who underwent mastectomy for invasive breast cancer and 14,710 women with ductal carcinoma in situ from 2000 to 2010 were pulled from a database that includes 500 acute care hospitals in the United States.

“Health insurance carriers that cover mastectomy also should cover reconstruction,” Hershman said.

The final analysis showed that 23.4% of the women who had invasive cancer underwent immediate reconstruction, and for women with ductal carcinoma in situ, it was 36.4%. The reconstruction rate increased from 15% in 2000 to 33.3% in 2010. The largest increases were observed in women who had commercial insurance (25.3% to 54.6%) and women aged younger than 50 years (29% to 60%). The reconstructive surgery rate was 67.5% among women aged younger than 50 years with commercial insurance in 2010.

Multivariate analysis results indicated that the following factors were linked to a decreased likelihood of reconstruction:

• Increasing age.
• Black race (OR=0.66).
• Rural hospital location (OR=0.48).
• Non-teaching hospital (OR=0.82).
• More than two comorbid conditions (OR=0.72).

“Caucasian women had higher rates of reconstruction than African-American women,” Hershman said.

Factors associated with increased odds of reconstructive surgery included commercial (OR=2.7) and public (OR=1.6) insurance (compared with self-pay), bilateral mastectomies (OR=2.5), being single (OR=1.09) and increased hospital mastectomy volume (OR=1.94).

“The influence of insurance coverage on immediate reconstruction rates has increased over time, while the cost has almost tripled over the 10-year period,” she said.

There was a small link between reconstruction and breast surgeon volume. Similar associations were seen in the subgroup of women aged younger than 50 years, according to the results.

“Prolonged length of stay was greater for women undergoing reconstruction (3.5 days vs. 1.6 days),” the researchers wrote. However, in-hospital complication rates were similar between the two groups.

“Public policy should ensure that access to reconstructive surgery is available to all women, regardless of insurance type,” Hershman said.

Earn CME this spring at the HemOnc Today Breast Cancer Review & Perspective meeting to be held March 23-24, 2012 at the Hilton San Diego Bayfront. See details at HemOncTodayBreastCancer.com.

Patricia Ganz

Many women are reluctant to undergo a second operation for reconstruction. However, if it is possible to offer mastectomy and reconstruction simultaneously, that is appealing to women. Women in urban areas or higher volume may be more likely to have a surgeon available to handle the cosmetic surgery immediately. It is an access issue, but, in this case, we are talking about access in terms of availability of surgery combined with insurance coverage.

Having lived through the time when there was no reconstruction offered, even if women don’t want it, it is important that there is a discussion, and that the surgery is offered. What we are seeing is a disparity in what is offered.

Patricia Ganz, MD
Jonsson Comprehensive Cancer Center at the University of California at Los Angeles

For more information:

• Hershman D. #S6-3. Presented at: 2011 CTRC-AACR San Antonio Breast Cancer Symposium; Dec. 6-10, 2011; San Antonio.

Follow HemOncToday.com on Twitter.