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Disparities identified among women who undergo immediate breast reconstruction
SAN FRANCISCO — The likelihood that women underwent immediate breast reconstruction after mastectomy varied significantly based on age, race, insurance type and geographic location, according to findings in a national retrospective study.
Barbara Wexelman, MD, MBA, of the department of surgery at St Luke’s-Roosevelt Hospital Center, and colleagues used the Nationwide Inpatient Sample — a statistical sample of all US hospital discharges — to evaluate data on 14,986 women who underwent mastectomy in 2008.
The researchers performed statistical analysis to identify variations between three groups: patients who did not undergo reconstruction (NR), patients who underwent breast implant/tissue expander reconstruction (TE), and patients who underwent advanced reconstruction techniques, such as free or pedicled flaps (FLAP).
Study results showed that most women (63%) did not undergo reconstruction, whereas 25.3% underwent breast implant/tissue expander reconstruction, and another 12% underwent free or pedicled flaps reconstruction.
Compared with patients who did not undergo reconstruction, women who underwent tissue expander reconstruction or pedicled flaps reconstruction were younger (NR, 64.9 years; TE, 51.3 years; and FLAP, 51.1 years; P<.001), had fewer chronic conditions (NR, 3.85; TE, 2.6; and FLAP, 2.54; P<.001), and had higher mean hospital charges (NR, $22,300; TE, $42,850; and FLAP, $48,680, P<.001).
The length of stay was longest for patients who underwent pedicled flaps reconstruction (3.62 days) compared with patients who did not undergo reconstruction (2.02 days) and patients who underwent tissue expander reconstruction (1.9 days; P<.001).
White patients were disproportionately more likely to undergo both tissue expander reconstruction and pedicled flaps reconstruction compared with black and Hispanic patients, study results showed.
Patients who underwent pedicled flaps reconstruction also were more likely to have private insurance (81.1%) than those who underwent tissue expander reconstruction (80.1%) or those who did not undergo reconstruction (35.2%). Patients who did not undergo reconstruction were more likely to have Medicare and Medicaid insurance.
Women who underwent any type of reconstruction were more likely to live in ZIP codes with higher average incomes, study results showed. They also were more likely to live in or near a major city, defined as more than 1 million residents.
For more information:
Wexelman BA. Abstract #63. Presented at: 2012 Breast Cancer Symposium; Sept. 13-15, 2012; San Francisco.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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This large database review of patients undergoing mastectomy highlights a growing recognition of the issue of disparities in breast cancer screening, diagnosis and treatment based on socioeconomic and geographic factors. According to the study, 63% of patients who underwent mastectomy did not have reconstruction. It is not known whether these women presented with more advanced cancers, which may account for the lack of reconstruction. It is also not known if patients who underwent mastectomy without reconstruction were given the option of reconstruction and declined. However, it is clear that more research is needed to determine the root cause of disparities in access to care and to determine how to best educate women about their options.
Perspective
Back to TopIn this study, the researchers used the nationwide patient sample to compare the socioeconomic features of about 15,000 patients who underwent mastectomies. They found a difference between racial and economic groups in both the rate and type of breast reconstruction. They also found disparities by state. I attempted to look at the distribution of plastic surgeons across the country to see if that impacted the rate of reconstruction. My Internet search did not result in a pattern of distribution of plastic surgeons who perform breast reconstruction, but it did produce a map of surgeon density. There appears to be a relationship on the maps of breast reconstruction rates by state and surgeon density. Other data show that breast reconstruction rates correlate with insurance status and income. Why are there disparities in reconstruction rates in the United States? Patients may live in an area with few plastic surgeons, plastic surgeons might not take Medicare or Medicaid, and patients may not be appropriate for immediate reconstruction. Both economic level and race are associated with more advanced stage of disease. Immediate reconstruction may be contraindicated due to the need for postmastectomy irradiation, which increases the complication risk. I also want to point out that many plastic surgeons have decreased their volume of reconstruction. In an NCCN institution study, the likelihood of having reconstruction was higher if patients were white, educated and employed, if they had third-party insurance, and if they had a higher income.