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Black breast cancer survivors more likely to undergo autologous breast reconstruction after mastectomy
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Black women with breast cancer were significantly more likely to undergo autologous breast reconstruction than implant-based reconstruction after mastectomy, according to the results of a retrospective analysis.
They remained twice as likely to receive autologous reconstruction after controlling for several potential confounding factors, including age, pathologic stage and type of health insurance.
Racial and ethnic disparities remain a frequent problem in health care. Data are limited as to whether women of different races and ethnicities have equal access to breast reconstruction services after cancer treatment.
“If the difference is related to system-based rather than patient-based factors, interventions may be needed to alleviate racial disparities in breast reconstruction,” Terence Myckatyn, MD, professor of plastic and reconstructive surgery and director of cosmetic and breast plastic surgery at Washington University in St. Louis, said in a press release.
Myckatyn and colleagues reviewed data from 2,533 women (median age, 50 years; interquartile range, 42-57) who underwent first-time breast reconstruction after mastectomy between 2000 and 2013.
Black women accounted for 14% of the cohort. The majority were non-Hispanic white (82%), and the remaining 4% belonged to other racial groups or were of unknown race.
The researchers had access to relevant clinical data, including pathologic stage, surgeon charge, insurance status, smoking history, diabetes history, obesity and median household income by zip code.
Sixty-seven percent of women (n = 1,687) underwent implant-based reconstructive surgery and 18% (n = 455) underwent autologous reconstruction. Reconstruction type was unknown for the remaining 15% (n = 391).
A higher proportion of black women than white women had Medicaid as their primary insurance (38% vs. 9%; P < .01) and received less of an overall charge to their insurance company (median, $3,990 vs. $5,580; P < .01).
Black women also had higher rates of active smoking (20% vs. 12%; P < .01), obesity (23% vs. 18%; P < .01) and diabetes (10% vs. 3%; P < .01), and they tended to live in zip codes with a lower median household income ($35,071 vs. $51,512; P < .01).
Twenty-three percent of black women (n = 79 of 349) and 17% (n = 356 of 2,086) of non-Hispanic white women underwent autologous breast reconstruction (P < .01).
A multivariate analysis that accounted for age, obesity, pathologic stage, health insurance type, socioeconomic status, smoking and diabetes showed black race (OR = 2.23; P < .01) was the most clinically significant predictor of autologous breast reconstruction.
“Our findings build on previous valuable work,” Myckatyn and colleagues wrote. “Notable studies have found that African Americans are less likely to undergo immediate breast reconstruction, that this disparity persists despite Medicaid expansion, and that they are also less likely to undergo any type of breast reconstruction and less likely to consult with a plastic surgeon before oncologic resection.”
The researchers identified the study’s retrospective design as a potential limitation, but they acknowledged that a prospective study based on race would be unethical.
Other study limitations included the use of median income by zip code as a proxy for socioeconomic status, and the sole inclusion of data from a single academic institution.
“The findings of this study should spur future research efforts that validate these results and identify potential causes,” Myckatyn and colleagues wrote. “Ideally, large national registries can be augmented with specific patient surveys that confirm these findings and then posit which provider-based, patient-based, or systems-based variables are contributing to this particular health care disparity.” – by Cameron Kelsall
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Anees B. Chagpar
We often talk about disparities in health care and worry about implicit bias. Could we be treating one group of patients differently than another, perhaps not offering them the same level of care or options that others may enjoy? This paper by Myckatyn and colleagues provides an interesting spin on racial disparities in breast reconstruction. They found that a disproportionately higher percentage of black women opt for autologous reconstruction, independent of age, insurance status, BMI or comorbidities.
Rather than lament the fact that more black women are receiving what would often be considered the “Cadillac” of breast reconstruction, I wonder why white women are less likely to do so. It may well be due to patient-derived preferences — black women may not want implant-based reconstruction, often seen as a foreign object being placed in their bodies, whereas white women may not want an extensive surgery. Implant-based reconstruction is often much shorter and simpler in duration than autologous reconstruction, particularly with free flaps.
It was gratifying to see that insurance status, often the primary mediator of health care disparities, was not seen in this study as a predictor of type of reconstruction. Although charges to insurance were associated with type of reconstruction, this is an aftereffect of the type of reconstruction, rather than a predictor of it. Of course, providers may also have contributed to a difference in terms of type of reconstruction, but this may well be related to the fact that not all plastic surgeons have the microvascular skills for autologous reconstruction.
Hence, although at first blush on reading the title of this study one’s heart sinks at the potential of yet more evidence of a system that favors the rich and the white over poor and minority patients, I take solace in the fact that, in this case, the effects seem to be more related to patient preference than discriminatory practices.
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