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Decision to undergo post-mastectomy breast reconstruction varied significantly by race, age
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Rates of post-mastectomy breast reconstruction have remained stable over time and largely appear to reflect patient demand, according to results of a SEER analysis.
However, researchers identified several factors — including black race — that were significantly associated with the decision not to undergo reconstruction.
The Women’s Health and Cancer Rights Act, enacted in 1998, mandated universal insurance coverage for breast reconstruction after mastectomy. Yet, previous population-based studies showed most women who undergo mastectomy for breast cancer do not undergo reconstruction, according to study background information.
Monica Morrow
Monica Morrow, MD, chief of the Breast Service in the department of surgery and Anne Burnett Windfohr chair of clinical oncology at Memorial Sloan Kettering Cancer Center, and colleagues sought to calculate post-mastectomy reconstruction rates, identify reasons why women forego reconstruction and assess patient satisfaction with the reconstruction decision-making process.
Morrow and colleagues used SEER registries from Detroit and Los Angeles to identify 3,252 women aged 20 to 79 years diagnosed with ductal carcinoma in situ or stage I to stage III invasive breast cancer between 2005 and 2007.
Of these women, 2,290 completed a baseline survey, and 1,536 who were disease-free completed an additional survey after 4 years.
The final analysis included 485 women who remained disease-free at follow-up. Results showed 41.6% of them underwent breast reconstruction after mastectomy: 146 (24.8%) underwent immediate reconstruction and 76 (16.8%) underwent delayed reconstruction. Thirty women (11.4%) who had not yet undergone reconstruction were still considering the procedure.
Researchers noted these rates were comparable to an analysis of the same SEER registries from 2001 to 2003. During that time period, 36% of women underwent immediate reconstruction and 12% underwent delayed reconstruction.
The current analysis showed women were less likely to undergo reconstruction if they were black (adjusted OR=2.16; 95% CI, 1.11-4.2), were older (adjusted OR in 10-year increments=2.53; 95% CI, 1.77-3.61) or if they had a major comorbidity (adjusted OR=2.27; 95% CI, 1.01-5.11). Women whose highest education level was high school (adjusted OR=4.49; 95% CI, 2.31-8.72) and those who received chemotherapy (adjusted OR=1.82; 95% CI, 0.99-3.31) also were less likely to undergo breast reconstruction.
Most women (86.7%) indicated they were satisfied with the reconstruction decision-making process. Women who were black and Latina were more likely to express dissatisfaction with the process (adjusted OR=2.87; 95% CI, 1.27-6.51). Researchers observed no association between dissatisfaction with the decision-making process and education level (
Women who underwent mastectomy but did not undergo reconstruction (n=263) cited several reasons for their decision. The most common were the desire to avoid additional surgery (48.5%), fear of implants (36.3%), the belief that reconstruction was not important (33.8%) and concerns that reconstruction might interfere with detection of subsequent cancer (23.9%).
Black (23.7%) and Latina (18.6%) women were more likely than those who were non-Hispanic white (2.2%;
A majority of women who delayed reconstruction did so to focus on treating their cancer (68.7%), or because they needed chemotherapy (50.7%) or radiation therapy (26.3%). Another 14.3% of women reported they did not know that reconstruction was an option.
“Our study suggests room exists for improved education regarding the safety of breast implants and the effect of reconstruction on follow-up surveillance, information about which could be readily addressed through decision tools,” Morrow and colleagues wrote. “Finally, development of specific approaches to address patient-level and systems factors with a negative effect on the use of reconstruction among minority women is needed.”
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Beverly Moy, MD, MPH
Reconstruction after mastectomy has the potential to improve psychological well-being and cosmetic results. Patients who undergo mastectomy for breast cancer experience more postoperative psychosocial distress compared with patients who undergo other surgical procedures (Margolis GJ. J Clin Oncol. 1989;7:1365-1366). Immediate breast reconstruction poses a minimal risk of delaying treatment and does not interfere with follow-up for recurrent cancer (Murphy RX. Ann Plast Surg. 2003;50:333-338; Osteen RT. Cancer. 1995;76:2070-2074). In a randomized clinical trial, patients who underwent immediate reconstruction experienced higher physical self-esteem compared with patients who were offered delayed reconstruction 12 months after mastectomy (Dean C. Lancet. 1983;1:459-462). Yet, studies observe lower rates of reconstruction among black, Asian, and Latina women (Kruper L. Ann Surg Oncol. 2011;18:2158-2165; Rosson GD. Arch Surg. 2008;143:1076-1081).This study by Morrow and colleagues — who used SEER registry data and surveyed patients from Los Angeles and Detroit — is no different in that it observed lower rates of reconstruction among minority women. This study also identified systems-level issues that may contribute to this disparity, including insurance-related barriers. Latina women also were more likely to believe that implants could interfere with future cancer detection.
The results of the study are not at all surprising because they are consistent with prior reports in the literature that showed racial disparities in the use of postmastectomy radiation. This report is particularly interesting, however, because the overall rate of postmastectomy reconstruction seems low, with only 41.6% of survey respondents reporting that they had reconstruction. This study suggests that system-wide efforts should be undertaken to better educate all of our patients about the potential benefits of reconstruction after mastectomy, and to remove insurance-related barriers that may be preventing our most vulnerable patients from receiving optimal care.
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