Socioeconomic and geographic differences in immediate reconstruction after mastectomy in the United States

Unplanned 180-day Readmissions and Health Care Utilization after Immediate Breast Reconstruction for Breast Cancer

BACKGROUND

 To assess the burden of postdischarge health care utilization given by readmissions beyond 30 days following immediate breast reconstruction (IBR) nationwide.

METHODS

 Women with breast cancer who underwent mastectomy and concurrent IBR (autologous and implant-based) were identified within the 2010 to 2019 Nationwide Readmission Database. Cox proportional hazards and generalized linear regression controlling for patient- and hospital-level confounders were used to determine factors associated with 180-day unplanned readmissions and incremental hospital costs, respectively.

RESULTS

 Within 180 days, 10.7% of 100,942 women were readmitted following IBR. Readmissions tended to be publicly insured (30.8 vs. 21.7%, p < 0.001) and multimorbid (Elixhauser Comorbidity Index > 2 31.6 vs. 19.6%, p < 0.001) compared with nonreadmitted patients. There were no differences in readmission rates among types of IBR (tissue expander 11.2%, implant 10.7%, autologous 10.8%; p > 0.69). Of all readmissions, 40% occurred within 30 days and 21.7% in a different hospital and 40% required a major procedure in the operating room. Infection was the leading cause of readmissions (29.8%). In risk-adjusted analyses, patients with carcinoma in situ, publicly insured, low socioeconomic status, and higher comorbidity burden were associated with increased readmissions (all p < 0.05). Readmissions resulted in additional $8,971.78 (95% confidence interval: $8,537.72-9,405.84, p < 0.001) in hospital costs, which accounted for 15% of the total cost of IBR nationwide.

CONCLUSION

 The majority of inpatient health care utilization given by readmissions following mastectomy and IBR occurs beyond the 30-day benchmark. There is evidence of fragmentation of care as a quarter of readmissions occur in a different hospital and over one-third require major procedures. Mitigating postoperative infectious complications could result in the highest reduction of readmissions.

Post-Mastectomy Breast Reconstruction Disparities: A Systematic Review of Sociodemographic and Economic Barriers

Background: Breast reconstruction (BR) following mastectomy is a well-established beneficial medical intervention for patient physical and psychological well-being. Previous studies have emphasized BR as the gold standard of care for breast cancer patients requiring surgery. Multiple policies have improved BR access, but there remain social, economic, and geographical barriers to receiving reconstruction. Threats to equitable healthcare for all breast cancer patients in America persist despite growing awareness and efforts to negate these disparities. While race/ethnicity has been correlated with differences in BR rates and outcomes, ongoing research outlines a multitude of issues underlying this variance. Understanding the current and continuous barriers will help to address and overcome gaps in access. Methods: A systematic review assessing three reference databases (PubMed, Web of Science, and Ovid Medline) was carried out in accordance with PRISMA 2020 guidelines. A keyword search was conducted on 3 February 2024, specifying results between 2004 and 2024. Studies were included based on content, peer-reviewed status, and publication type. Two independent reviewers screened results based on title/abstract appropriateness and relevance. Data were extracted, cached in an online reference collection, and input into a cloud-based database for analysis. Results: In total, 1756 references were populated from all databases (PubMed = 829, Ovid Medline = 594, and Web of Science = 333), and 461 duplicate records were removed, along with 1147 results deemed ineligible by study criteria. Then, 45 international or non-English results were excluded. The screening sample consisted of 103 publications. After screening, the systematic review produced 70 studies with satisfactory relevance to our study focus. Conclusions: Federal mandates have improved access to women undergoing postmastectomy BR, particularly for younger, White, privately insured, urban-located patients. Recently published studies had a stronger focus on disparities, particularly among races, and show continued disadvantages for minorities, lower-income, rural-community, and public insurance payers. The research remains limited beyond commonly reported metrics of disparity and lacks examination of additional contributing factors. Future investigations should elucidate the effect of these factors and propose measures to eliminate barriers to access to BR for all patients.

We are moving the needle: Improving racial disparities in immediate breast reconstruction

BACKGROUND

Although racial disparities in receipt of immediate breast reconstruction (IBR) have been previously reported, prior studies may not have fully assessed the impact of recent advocacy efforts as healthcare disparities gain increased national attention. The aim of this study is to assess more recent racial differences and annual trends in receiving IBR.

METHODS

Using the National Surgery Quality Improvement Program database, black or white women over 18 years who underwent mastectomy from 2012 to 2021 were included. IBR was defined by undergoing mastectomy with breast reconstruction during the same anesthetic event. Propensity score analysis was utilized to balance variables between black and white patients. A multivariate logistic regression was performed to determine the effect of race on the odds of receiving IBR.

RESULTS

The annual percentage of white patients receiving IBR remained stable at around 50% throughout the study period. The annual percentage of black patients receiving IBR increased from 34% in 2012 to 49% in 2021. Compared with white patients, black patients had lower odds of receiving IBR during the entire study period (odds ratio 0.57, 95% confidence interval 0.49-0.67). When assessing annual trends, black patients were less likely to receive IBR each year from 2012 to 2017. By 2021, both races had similar odds of IBR.

CONCLUSIONS

Although racial disparities in IBR have been longstanding, this study demonstrates that the racial gap appears to be closing. This may be because of increased awareness of racial disparities and their impact on patient outcomes.

Impact of Race, Ethnicity, Primary Language, and Insurance on Reconstruction after Mastectomy for Patients with Breast Cancer at an Urban, Academic Safety-Net Hospital

BACKGROUND

Disparities in breast reconstruction have been observed in national cohorts and single-institution studies based on race, ethnicity, insurance, and language. However, little is known regarding whether safety-net hospitals deliver more or less equitable breast reconstruction care in comparison with national cohorts.

STUDY DESIGN

We performed a retrospective study of patients with either invasive breast cancer or ductal carcinoma in situ diagnosed and treated at our institution (January 1, 2009, to December 31, 2014). The rate of, timing of, and approach to breast reconstruction were assessed by race, ethnicity, insurance status, and primary language among women who underwent mastectomy. Reasons for not performing reconstruction were also analyzed.

RESULTS

A total of 756 women with ductal carcinoma in situ or nonmetastatic invasive cancer were identified. The median age was 58.5 years, 56.2% were non-White, 33.1% were non-English-speaking, and 48.9% were Medicaid/uninsured patients. A total of 142 (18.8%) underwent mastectomy during their index operation. A total of 47.9% (n = 68) did not complete reconstruction. Reasons for not performing reconstruction included patient preference (n = 22), contraindication to immediate reconstruction (ie, locoregionally advanced disease prohibiting immediate reconstruction) without follow-up for consideration of delayed reconstruction (n = 12), prohibitive medical risk or contraindication (ie, morbid obesity; n = 8), and progression of disease, prohibiting reconstruction (n = 7). Immediate and delayed reconstruction were completed in 43.7% and 8.5% of patients. The rate of reconstruction was inversely associated with tumor stage (odds ratio 0.52, 95% CI 0.31 to 0.88), but not race, ethnicity, insurance, or language, on multivariate regression.

CONCLUSIONS

At a safety-net hospital, we observed rates of reconstruction at or greater than national estimates. After adjustment for clinical attributes, rates did not vary by race, ethnicity, insurance or language. Future research is needed to understand the role of reconstruction in breast cancer care and how to advance shared decision-making among diverse patients.

Factors Associated With Socioeconomic Disparities in Breast Reconstruction: Perspectives of Wisconsin Surgeons

INTRODUCTION

The objective is to expand our understanding of the factors associated with receipt of breast reconstruction for socioeconomically disadvantaged women within Wisconsin.

METHODS

A purposeful sample of general/breast and plastic surgeons were identified. One-on-one interviews were conducted, audio-recorded, and transcribed in full (n = 15). Conventional content analysis was performed to identify themes.

RESULTS

Both general/breast and plastic surgeons perceived that general/breast surgeons served as gatekeepers to which patients are offered a referral for reconstruction. Given the additional recovery time, frequent clinic visits, and potential for complications associated with reconstruction, general/breast surgeons perceived that not all women prioritize it. Surgeons perceived this to be especially true for socioeconomically disadvantaged women. Surgeons identified time off work, travel for visits, and out-of-pocket costs as specific challenges to reconstruction experienced by socioeconomically disadvantaged women. Surgeons perceived that early education, incorporating financial considerations into discussions, and reducing travel burden may help to improve access to reconstruction.

CONCLUSION

Wisconsin surgeons described factors they perceived contributed to lower rates of reconstruction for socioeconomically disadvantaged women and described ways to increase reconstruction access.

Impact of Health Insurance Contract Timing on Breast Reconstruction Completion

BACKGROUND

Cost of breast reconstruction can create a substantial burden for patients. As patients hope to maximize insurance plan benefits, it is crucial to receive efficient, cost-reducing care. This study analyzes the impact of insurance cycle [calendar-based insurance (CBI) versus non-calendar-based insurance (NCBI)] on breast reconstruction.

METHODS

Between January of 2014 and 2018, patients undergoing postmastectomy breast reconstruction performed by two senior surgeons (N.T.H. and S.S.T.) at a single academic institution were retrospectively evaluated. Data were collected on insurance contract timing (CBI versus NCBI) and insurance payor.

RESULTS

A total of 514 patients were included: 136 patients on NCBI and 378 patients on CBI. Individuals enrolled in CBI were more likely than NCBI patients to have their last operation toward the end of the calendar year ( P < 0.0005). In addition, individuals on private CBIs are more likely to have their last operation closer to the end of the year than those on public CBIs ( P < 0.0001). Individuals enrolled in CBI were less likely to receive autologous reconstruction than individuals on NCBI ( P = 0.011). Among patients on private CBIs, patients with all major revisions were more likely to start their reconstructive journey earlier in the year than patients who did not finish major revisions ( P = 0.011). Lastly, individuals on private insurance also undergo more revision procedures than those on public insurance ( P < 0.0001).

CONCLUSIONS

Insurance contract cycle and payor impact the timing of breast reconstruction. This study emphasizes the importance of both patient and provider working toward maximizing health insurance plan benefits.

Racial Disparities in Breast Reconstruction at a Comprehensive Cancer Center

INTRODUCTION

Breast reconstruction after a mastectomy is an important component of breast cancer care that improves the quality of life in breast cancer survivors. African American women are less likely to receive breast reconstruction than Caucasian women. The purpose of this study was to further investigate the reconstruction disparities we previously reported at a comprehensive cancer center by assessing breast reconstruction rates, patterns, and predictors by race.

METHODS

Data were obtained from women treated with definitive mastectomy between 2000 and 2012. Sociodemographic, tumor, and treatment characteristics were compared between African American and Caucasian women, and logistic regression was used to identify significant predictors of reconstruction by race.

RESULTS

African American women had significantly larger proportions of public insurance, aggressive tumors, unilateral mastectomies, and modified radical mastectomies. African American women had a significantly lower reconstruction rate (35% vs. 49%, p < 0.01) and received a larger proportion of autologous reconstruction (13% vs. 7%, p < 0.01) compared to Caucasian women. The receipt of adjuvant radiation therapy was a significant predictor of breast reconstruction in Caucasian but not African American women.

CONCLUSIONS

We identified breast reconstruction disparities in rate and type of reconstruction. These disparities may be due to racial differences in sociodemographic, tumor, and treatment characteristics. The predictors of breast reconstruction varied by race, suggesting that the mechanisms underlying breast reconstruction may vary in African American women. Future research should take a target approach to examine the relative contributions of sociodemographic, tumor, and treatment determinants of the breast reconstruction disparities in African American women.

Perspectives of Wisconsin Providers on Factors Influencing Receipt of Post-Mastectomy Breast Reconstruction

BACKGROUND

The objective is to determine perspectives of general surgeons, plastic surgeons, and cancer navigators on factors contributing to breast cancer patients' decision for post-mastectomy reconstruction, especially for women facing financial hardship.

METHODS

We mailed Wisconsin general and plastic surgeons who performed >5 breast cancer procedures annually a survey, including a postcard inviting cancer navigators to participate. Descriptive statistics summarize item responses. McNemar's chi-squared tests evaluated surgeons' perspectives of factors influencing reconstruction for all women compared to women facing financial hardship.

RESULTS

Respondents include 70 general surgeons, 18 plastic surgeons, and 9 navigators. Respondents perceived preference-related factors as important, including "does not want more surgery" (85% reported it important overall and 77% for financial hardship women) and "reconstructed breast is not important to her" (77% vs. 61%). Surgeons perceived logistical factors were more important for women facing financial hardship, including "capacity to be away from work or home responsibilities for recovery" (30% reported important overall and 60% for financial hardship women), "concerned about out-of-pocket costs" (26% vs. 57%), and "frequent visits to complete reconstruction too burdensome" (27% vs. 49%).

CONCLUSION

Our findings demonstrate Wisconsin surgeons and cancer navigators perceive logistical concerns influence reconstruction decisions for women facing financial hardship.

Barriers to breast reconstruction for socioeconomically disadvantaged women

PURPOSE

Socioeconomic disparities in post-mastectomy breast reconstruction exist. Key informants have suggested that finding providers who accept Medicaid insurance and longer travel time to a plastic surgeon are important barriers. Our objective was to assess the relationship between these factors and reconstruction for socioeconomically disadvantaged women in Wisconsin.

METHODS

We identified women < 75 years of age with stage 0-III breast cancer who underwent mastectomy using the Wisconsin Cancer Reporting System. Women in the most disadvantaged state-based tertile of the Area Deprivation Index were included (n = 1809). Geocoding determined turn-by-turn drive time from women's address to the nearest accredited Commission on Cancer or National Accreditation Program for Breast Centers. Multivariable logistic regression determined the relationship between reconstruction, Medicaid, and travel time, controlling for patient factors known to impact reconstruction. Average adjusted predicted probabilities of receiving reconstruction were calculated.

RESULTS

Most patients had early-stage breast cancer (51% stage 0/I) and 15.2% had Medicaid. 37% of women underwent reconstruction. Socioeconomically disadvantaged women with Medicaid (OR = 0.62, 95% CI 0.46-0.84) and longer travel times (OR = 0.99, 95% CI 0.99-1.0) were less likely to receive reconstruction. Patients with the lowest predicted probability of reconstruction were those with Medicaid who lived furthest from a plastic surgeon.

CONCLUSION

Among socioeconomically disadvantaged women, Medicaid and travel remained associated with lower rates of reconstruction. Further work will explore opportunities to improve access to reconstruction for women with Medicaid. This is particularly challenging as it may require socioeconomically disadvantaged women to travel further to receive care.

Survival in breast cancer patients with a delayed DIEP flap breast reconstruction after adjustment for socioeconomic status and comorbidity

Purpose

Overall survival in breast cancer patients receiving a delayed deep inferior epigastric perforator (DIEP) flap breast reconstruction is better than in those without delayed breast reconstruction. This study aimed at determining the impact of socioeconomic status (SES) and comorbidity on these observations.

Materials and methods

This matched cohort study included all consecutive women undergoing a delayed DIEP flap reconstruction at Karolinska University Hospital, Sweden, between 1999 and 2013. Controls had not received any delayed breast reconstruction and were relapse-free after a corresponding follow-up interval. Matching was by year of and age at mastectomy, tumour stage and lymph node status. Charlson Comorbidity Index (CCI) and socioeconomic data were obtained from national registers. Associations with breast cancer-specific (BCSS) and overall survival (OS) were investigated by Kaplan-Meier survival estimates and Cox proportional hazard regression analysis.

Results

Women in the DIEP group (N = 254) more often continued education after primary school (88.6% versus 82.6%, P = 0.026), belonged to the high-income group (76.0% versus 63.1%, P < 0.001), were in a partnership (57.1% versus 55.7%, P = 0.024) and healthier (median CCI 1.00 (range 0–13) versus 2.00 (range 0–16), P = 0.021) than the control group (N = 729). After adjustment for tumour and treatment factors, SES and comorbidity, OS remained significantly better for the DIEP group than the control group (HR 2.27, 95% CI 1.44–3.55).

Conclusion

Women with a delayed DIEP flap reconstruction are a subgroup of higher socioeconomic status and better health. Higher survival estimates for the DIEP group persisted after adjusting for those differences, suggesting the presence of further unmeasured covariates.

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Women with a delayed DIEP flap reconstruction have a higher socioeconomic status.

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They also have less comorbidity than women with no delayed reconstruction.

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Superior survival in DIEP patients is not eliminated by adjustments for such differences.

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Unmeasured selection to the reconstructive process may explain observed survival differences.

Persistent Disparities in Postmastectomy Breast Reconstruction and Strategies for Mitigation

For many women, breast reconstruction is an essential component of the breast cancer care continuum after mastectomy. Despite postmastectomy breast reconstruction now being a standard of care, numerous studies over the past decade have documented persistent racial disparities in breast reconstruction rates, physician referral patterns, and patient knowledge of their reconstructive options. These disparities have disproportionately impacted women of color-most specifically, African American women. Recent data have revealed racial differences in patient comorbidities, informed decision-making satisfaction, and clinical outcomes after breast reconstruction. Explicitly, African American women have significantly more risk factors for complications and less baseline knowledge regarding reconstructive options than white women. With a recent heightened attention focused on social determinants of health, studies designed to improve these racial differences have demonstrated promising results through educational outreach to underserved communities, implementation of tailored legislation promoting inclusion, diversity, and equity, and encouragement of additional recruitment of ethnically underrepresented-in-medicine surgeons. This study uses a targeted review of the literature to provide a summary of racial disparities in breast reconstruction for African American women, with our perspective on opportunities for improvement.

National trends and predictors of mastectomy with immediate breast reconstruction

PURPOSE

This study aimed to evaluate national trends in utilization, resource use, and predictors of immediate breast reconstruction (IR) after mastectomy.

METHODS

The 2005-2014 National Inpatient Sample database was used to identify adult women undergoing mastectomy. IR was defined as any reconstruction during the same inpatient stay. Multivariable regression models were utilized to identify factors associated with IR.

RESULTS

Of 729,340 patients undergoing mastectomy, 41.3% received IR. Rates of IR increased from 28.2% in 2005 to 58.2% in 2014 (NP-trend<0.001). Compared to mastectomy alone, IR was associated with increased length of stay (2.5 vs. 2.1 days, P < 0.001) and hospitalization costs ($17,628 vs. $8,643, P < 0.001), which increased over time (P < 0.001). Predictors of IR included younger age, fewer comorbidities, White race, private insurance, top income quartile, teaching hospital designation, high mastectomy volume, and performance of bilateral mastectomy.

CONCLUSION

Mastectomy with IR is increasingly performed with resource utilization rising at a steady pace. Our study points to persistent sociodemographic and hospital level disparities associated with the under-utilization of IR. Efforts are needed to alleviate disparities in IR.

National Trends in Immediate Breast Reconstruction: An Analysis of Implant-Based Versus Autologous Reconstruction After Mastectomy

BACKGROUND

Many factors affect access to immediate breast reconstruction (IR) after mastectomy. The present study was performed to assess trends, outcomes, and predictors of IR techniques using a nationally representative cohort.

METHODS

The 2009-2014 National Inpatient Sample (NIS) was used to identify adult women who underwent inpatient mastectomy with IR. Patients were compared by type of reconstruction: implant-based IR versus autologous reconstruction (AR). AR was classified as a microsurgical or pedicled flap procedure. Incidence, outcomes, and predictors were assessed using Chi squared univariate tests and multivariable logistic regression analyses.

RESULTS

Of 194,073 women who underwent IR, 136,668 (70.4%) received implant-based IR and 57,405 (29.6%) received AR. Of those who underwent AR procedures, 31,336 (54.6%) received microsurgical flaps and 26,680 (46.5%) received pedicled flaps. Utilization of deep inferior epigastric perforator (DIEP) flaps increased significantly (28.6-42.5% of AR, P < 0.001). Predictors of AR were Black race [adjusted odds ratio (AOR) = 1.46, P < 0.001], lower Elixhauser Comorbidity Index (AOR = 1.25, P < 0.001), private insurance (AOR = 1.07, P = 0.030), body mass index (BMI) ≥ 30 kg/m² (AOR = 1.38, P < 0.001), urban teaching hospital designation (AOR = 1.77, P < 0.001), and high hospital volume (AOR = 3.11, P < 0.001). Similar factors were associated with the use of microsurgical flaps. AR and microsurgical flaps were associated with higher rates of acute inpatient complications, resource utilization and length of stay (LOS) compared with implant-based IR and pedicled flaps, respectively.

CONCLUSION

Implant-based IR remains the most common type of IR, although rates of microsurgical AR are on the rise. Follow-up of complications, costs, and quality-of-life measures may show that AR provides long-term high-value care despite upfront morbidity, cost, and use of hospital resources.

Medicaid for the Plastic and Reconstructive Surgeon

Medicaid is a complex federally and state funded health insurance program in the United States that insures an estimated 76 million individuals, approximately 20 percent of the U.S. population. Many physicians may not receive formal training or education to help understand the complexities of Medicaid. Plastic surgeons, residents, and advanced practice practitioners benefit from a basic understanding of Medicaid, eligibility requirements, reimbursement methods, and upcoming healthcare trends. Medicaid is implemented by states with certain federal guidelines. Eligibility varies from state to state (in many states it's linked to the federal poverty level), and is based on financial and nonfinancial criteria. The passage of the Affordable Care Act in 2010 permitted states to increase the federal poverty level eligibility cutoff to expand coverage for low-income adults. The aim of this review is to provide a brief history of Medicaid, explain the basics of eligibility and changes invoked by the Affordable Care Act, and describe how federal insurance programs relate to plastic surgery, both at academic institutions and in community practice environments.

Closing the Breast Cancer Loop: Barriers and Perceptions of Breast Reconstruction among Rural Women

Background:

Despite policies such as the Women's Health and Cancer Rights Act (WHCRA) and Breast Cancer Patient Education Act, rates for breast reconstruction vary and are especially low for some subpopulations of patients, especially rural women. In order to better understand patient perceptions, qualitative analysis using focus groups is an underutilized tool for obtaining patient perspectives regarding health-related issues and access to care. Our aim was to better understand patient perceptions using qualitative analysis.

Methods:

Three focus groups were held in rural counties within West Virginia in order to better understand patient perceptions, knowledge, and beliefs regarding breast health, breast cancer, access to breast reconstruction, and how to disseminate and educate this patient population regarding their right to accessing breast reconstruction.

Results:

Major themes analyses revealed perceived barriers to care related to lacking care coordination, lack of insurance coverage and other resources, as well as issues related to transportation. Participants consistently discussed avoiding breast screening care due fear and denial in addition to pain. Few patients were aware of their right to accessing breast reconstruction per the WHCRA, and many were concerned about follow-up burden, complications, and general fear related to breast reconstruction. Themes related to dissemination of information to promote the option of breast reconstruction included social media, patient counseling by their referring physician, and other means of intervention in clinics and other points in the care coordination chain.

Conclusions:

Rural women have important, unique viewpoints regarding access to and perceived barriers from obtaining breast reconstruction. Plastic surgeons must work diligently to educate, disseminate, and improve care coordination among this population in order to improve access to breast reconstruction among rural breast cancer patients.

Barriers of Access to Breast Reconstruction: A Systematic Review

BACKGROUND

The purpose of this systematic review was to comprehensively summarize barriers of access to breast reconstruction and evaluate access using the Penchansky and Thomas conceptual framework based on the six dimensions of access to care.

METHODS

The authors performed a systematic review that focused on (1) breast reconstruction, (2) barriers, and (3) breast cancer. Eight databases (i.e., EMBASE, MEDLINE, PsycINFO, CINHAL, ePub MEDLINE, ProQuest, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials) were searched. English peer-reviewed articles published between 1996 and 2016 were included.

RESULTS

The authors' search retrieved 4282 unique articles. Two independent reviewers screened texts, selecting 99 articles for inclusion. All studies were observational and qualitative in nature. The availability of breast reconstruction was highest in teaching hospitals, private hospitals, and national cancer institutions. Accessibility affected access, with lower likelihood of breast reconstruction in rural geographic locations. Affordability also impacted access; high costs of the procedure or poor reimbursement by insurance companies negatively influenced access to breast reconstruction. Acceptability of the procedure was not universal, with unfavorable physician attitudes toward breast reconstruction and specific patient and tumor characteristics correlating with lower rates of breast reconstruction. Lastly, lack of patient awareness of breast reconstruction reduced the receipt of breast reconstruction.

CONCLUSIONS

Using the access-to-care framework by Penchansky and Thomas, the authors found that barriers to breast reconstruction existed in all six domains and interplayed at many levels. The authors' systematic review analyzed this complex relationship and suggested multiprong interventions aimed at targeting breast reconstruction barriers, with the goal of promoting equitable access to breast reconstruction for all breast cancer patients.

Persistent disparities in breast cancer surgical outcomes among hispanic and African American patients

BACKGROUND

Racial disparities among patients who receive breast mastectomy and reconstruction have not been well characterized.

METHODS

Records of patients undergoing breast extirpative and reconstructive surgery at a high-volume university-affiliated hospital over 5 consecutive years were reviewed. Patient demographics, breast cancer profiles, reconstructive modality, and outcomes were compared by race.

RESULTS

A total of 1045 patients underwent 1678 breast reconstructions during the five-year period. Mean age and standard deviation was 49.8 ± 10.6 years with a BMI of 27.9 ± 6.5. Hispanic and African American patients had significantly higher BMIs (p < 0.001), higher rates of ASA class III or IV (p = 0.025), obesity, diabetes, hypertension (p < 0.001 for these three comparisons), and smoking (p = 0.003), and had more prior abdominal surgeries (p = 0.007). Comparing oncologic characteristics, this population subset had higher rates of neoadjuvant chemotherapy (p = 0.036), history of radiation (p = 0.016), and were more likely to undergo modified radical mastectomy (p = 0.002) over nipple-sparing mastectomy (p = 0.035). Reconstructive complications revealed a higher overall complication rate (p = 0.023), higher rates of partial mastectomy flap necrosis (p = 0.043), as well as arterial (p = 0.009) and venous insufficiency (p = 0.026) during microvascular reconstruction among Hispanic and African American patients.

CONCLUSIONS

Compared to other patients, the present study identifies higher comorbidity burdens, higher rates of prior radiation and neoadjuvant chemotherapy, and higher post-surgical complication rates among Hispanic and African American patients with breast cancer.

Geographic variations in racial disparities in postmastectomy breast reconstruction: A SEER database analysis

The purpose of this study was to determine whether racial disparities in reconstruction in the United States vary by geographic region. The SEER database years 2000-2013 was queried for all mastectomies in women ages 20-85+. Logistic regression was used to examine the main effects and interaction of race and geographic region on reconstruction. Hot spot Analysis was used to examine clustering of reconstruction across counties by race. We found large regional variation in racial differences in the rate of immediate postmastectomy reconstruction. Understanding how racial disparities vary by region can identify important factors for intervention to reduce disparities in practice.

Sexual and gender minority breast cancer patients choosing bilateral mastectomy without reconstruction: "I now have a body that fits me"

Sexual and gender minority (SGM) breast cancer patients have begun embracing the choice to "go flat" or opt out of reconstruction after bilateral mastectomy, though little is known about this population. SGM breast cancer survivors were identified through purposive and referral sampling and invited to participate in a web-based survey containing both closed- and open-ended items. Of the sixty-eight SGM breast cancer survivors aged 18-75 years who completed the survey between May 2015 and January 2016, 25 percent reported "going flat" (flattoppers®). Bivariate analyses revealed that flattoppers® were significantly more likely to have been diagnosed in the past five years, to identify as genderqueer, to have disclosed their sexual orientation or gender identity (SOGI) to providers, and to report participating in lesbian, gay, bisexual, or transgender cancer support groups, compared to other participants. More flattoppers® believed that SOGI mattered in terms of getting the support they needed regarding their cancer; this difference was not statistically significant. Thematic analysis of qualitative comments from flattoppers® revealed themes related to reasons for making this treatment choice, interactions with health-care providers around treatment choice, and physical and emotional outcomes of treatment choice. Providers would benefit from training about SOGI as they relate to treatment choices.

The National Surgical Quality Improvement Program 30-Day Challenge: Microsurgical Breast Reconstruction Outcomes Reporting Reliability

Supplemental Digital Content is available in the text.

Background:

The aim was to assess reliability of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) 30-day perioperative outcomes and complications for immediate, free-tissue transfer breast reconstruction by direct comparisons with our 30-day and overall institutional data, and assessing those that occur after 30 days.

Methods:

Data were retrieved for consecutive immediate, free-tissue transfer breast reconstruction patients from a single-institution database (2010–2015) and the ACS-NSQIP (2011–2014). Multiple logistic regressions were performed to compare adjusted outcomes between the 2 datasets.

Results:

For institutional versus ACS-NSQIP outcomes, there were no significant differences in surgical-site infection (SSI; 30-day, 3.6% versus 4.1%, P = 0.818; overall, 5.3% versus 4.1%, P = 0.198), wound disruption (WD; 30-day, 1.3% versus 1.5%, P = 0.526; overall, 2.3% versus 1.5%, P = 0.560), or unplanned readmission (URA; 30-day, 2.3% versus 3.3%, P = 0.714; overall, 4.6% versus 3.3%, P = 0.061). However, the ACS-NSQIP reported a significantly higher unplanned reoperation (URO) rate (30-day, 3.6% versus 9.5%, P < 0.001; overall, 5.3% versus 9.5%, P = 0.025). Institutional complications consisted of 5.3% SSI, 2.3% WD, 5.3% URO, and 4.6% URA, of which 25.0% SSI, 28.6% WD, 12.5% URO, and 7.1% URA occurred at 30–60 days, and 6.3% SSI, 14.3% WD, 18.8% URO, and 42.9% URA occurred after 60 days.

Conclusion:

For immediate, free-tissue breast reconstruction, the ACS-NSQIP may be reliable for monitoring and comparing SSI, WD, URO, and URA rates. However, clinicians may find it useful to understand limitations of the ACS-NSQIP for complications and risk factors, as it may underreport complications occurring beyond 30 days.

Immediate Breast Reconstruction among Patients with Medicare and Private Insurance: A Matched Cohort Analysis

Supplemental Digital Content is available in the text.

Background:

By eliminating economic hurdles, the Women’s Health and Cancer Rights Act of 1998 represented a paradigm shift in the availability of breast reconstruction. Yet, studies report disparities among Medicare-insured women. These studies do not account for the inherent differences in age and comorbidities between a younger privately insured and an older Medicare population. We examined immediate breast reconstruction (IBR) utilization between a matched pre- and post-Medicare population.

Methods:

Using the Nationwide Inpatient Sample database (1992–2013), breast cancer patients undergoing IBR were identified. To minimize confounding medical variables, 64-year-old privately insured women were compared with 66-year-old Medicare-insured women. Demographic data, IBR rates, and complication rates were compared. Trend over time was plotted for both cohorts.

Result:

A total of 21,402 64-year-old women and 25,568 66-year-old women were included. Both groups were well matched in terms of demographic type of reconstruction and complication rates. 72.3% of 64-year-old and 71.2 of % 66-year-old women opted for mastectomy. Of these, 25.5% (n = 3,941) of 64-year-old privately insured and 17.7% (n = 3,213) of 66-year-old Medicare-insured women underwent IBR (P < 0.01). During the study period, IBR rates increased significantly in both cohorts in a similar cohort.

Conclusion:

This study demonstrates significant increasing IBR rates in both cohorts. Moreover, after an initial slower upward trend, after a decade, IBR in 66-year-old Medicare-insured women approached similar rates of breast reconstruction among those with private insurance. Trends in unilateral versus bilateral mastectomy are also seen.

Socioeconomic Factors Associated with Post-Mastectomy Immediate Reconstruction in a Contemporary Cohort of Breast Cancer Survivors

BACKGROUND

Post-mastectomy reconstruction is a critical component of high-quality breast cancer care. Prior studies demonstrate socioeconomic disparity in receipt of reconstruction. Our objective was to evaluate trends in receipt of immediate reconstruction and examine socioeconomic factors associated with reconstruction in a contemporary cohort.

METHODS

Using the National Cancer Database, we identified women <75 years of age with stage 0-1 breast cancer treated with mastectomy (n = 297,121). Trends in immediate reconstruction rates (2004-2013) for the overall cohort and stratified by socioeconomic factors were examined using Join-point regression analysis, and annual percentage change (APC) was calculated. We then restricted our sample to a contemporary cohort (2010-2013, n = 145,577). Multivariable logistic regression identified socioeconomic factors associated with immediate reconstruction. Average adjusted predicted probabilities of receiving reconstruction were calculated.

RESULTS

Immediate reconstruction rates increased from 27 to 48%. Although absolute rates of reconstruction for each stratification group increased, similar APCs across strata led to persistent gaps in receipt of reconstruction. On multivariable logistic regression using our contemporary cohort, race, income, education, and insurance type were all strongly associated with immediate reconstruction. Patients with the lowest predicted probability of receiving reconstruction were patients with Medicaid who lived in areas with the lowest rates of high-school graduation (Black 42.4% [95% CI 40.5-44.3], White 45.7% [95% CI 43.9-47.4]).

CONCLUSIONS

Although reconstruction rates have increased dramatically over the past decade, lower rates persist for disadvantaged patients. Understanding how socioeconomic factors influence receipt of reconstruction, and identifying modifiable factors, are critical next steps towards identifying interventions to reduce disparities in breast cancer surgical care.

Disparities in Rural Breast Cancer Care: Factors Affecting Choice of Breast Reconstruction in a West Virginia Tertiary Care Hospital

The decision to pursue immediate postmastectomy breast reconstruction (IBR) is not uniform across all groups of women in the United States. We sought to investigate if the challenges of caring for a socioeconomically and geographically challenged rural population affected the incidence of IBR and to identify predictive factors of IBR in this population. Using our institution's cancer registry, we conducted a 10-year review of women with early-stage, unilateral breast cancer who received mastectomy. Demographics, insurance status, comorbidities, and surgeon graduation year were compared for patients receiving IBR versus no reconstruction. Variables with P < 0.05 on univariate analysis were included into a multivariate logistic regression model to determine independent predictors of IBR. From 2006 to 2015, 53/423 (12.5%) patients underwent IBR. On multivariate analysis, three factors independently predicted the decision to undergo IBR: age (P = 0.004), insurance type (P = 0.034), and use of contralateral prophylactic mastectomy (CPM, P < 0.001). Our data indicate that age, insurance type, and utilization of CPM influence the decision to pursue reconstruction. Additionally, the rate of IBR was found to be much lower in our West Virginia population than reported nationally, suggesting disparities in the care of women with early-stage, unilateral breast cancer in a rural population, even in a tertiary care environment.

Breast reconstruction after mastectomy at a comprehensive cancer center

Background

Breast reconstruction after mastectomy is an integral part of breast cancer treatment that positively impacts quality of life in breast cancer survivors. Although breast reconstruction rates have increased over time, African American women remain less likely to receive breast reconstruction compared to Caucasian women. National Cancer Institute-designated Comprehensive Cancer Centers, specialized institutions with more standardized models of cancer treatment, report higher breast reconstruction rates than primary healthcare facilities. Whether breast reconstruction disparities are reduced for women treated at comprehensive cancer centers is unclear. The purpose of this study was to further investigate breast reconstruction rates and determinants at a comprehensive cancer center in St. Louis, Missouri.

Methods

Sociodemographic and clinical data were obtained for women who received mastectomy for definitive surgical treatment for breast cancer between 2000 and 2012. Logistic regression was used to identify factors associated with the receipt of breast reconstruction.

Results

We found a breast reconstruction rate of 54 % for the study sample. Women who were aged 55 and older, had public insurance, received unilateral mastectomy, and received adjuvant radiation therapy were significantly less likely to receive breast reconstruction. African American women were 30 % less likely to receive breast reconstruction than Caucasian women.

Conclusion

These findings suggest that racial disparities in breast reconstruction persist in comprehensive cancer centers. Future research should further delineate the determinants of breast reconstruction disparities across various types of healthcare institutions. Only then can we develop interventions to ensure all eligible women have access to breast reconstruction and the improved quality of life it affords breast cancer survivors.

Predictors for Reconstruction and Mood Disorder Associated With Reconstruction in Patients With Breast Cancer and Mastectomy: A Retrospective Cohort Study

This study used Taiwan's National Health Insurance medical claims to investigate the predictors for operative modes chosen by early-stage breast cancer patients; as well as to assess whether operative modes are associated with risk of mood disorder. We included 36,377 patients with breast cancer who received surgery between 2000 and 2008, and were followed to the end of 2010; they were further classified into 3 groups: mastectomy alone (n = 34,900), along with early reconstruction (n = 1080), and along with delayed reconstruction (n = 397). The results showed that age, insurance premium, urbanization level, and postsurgery chemotherapy and radiotherapy were all significant predictors for the selection of operative modes. Breast cancer patients with mastectomy alone, early reconstruction, and delayed reconstruction showed a cumulative incidence rate of mood disorder of 36.90%, 41.56%, and 33.89%, respectively. The multiple cox proportional model further revealed that early (hazard ratio [HR] = 1.06, 95% confidence interval (CI) = 0.93-1.21) and delayed (HR = 1.17, 95% CI = 0.96-1.42) reconstruction were associated with a slightly higher but insignificant risk of mood disorder, as compared to the patients received no reconstruction.

Current strategies with 2-staged prosthetic breast reconstruction

Over the last decade, prosthetic-based breast reconstruction has been revolutionized with technological advancements. Reconstructive surgeons now have a multitude of prosthetic devices and tissue expanders, tools for intraoperative perfusion analysis, implantable bioprosthetic materials and a technique for autoaugmentation within their armamentarium to reconstruct natural breasts today like never before.

Immediate Reconstruction of the Radiated Breast: Recent Trends Contrary to Traditional Standards

BACKGROUND

Immediate, implant-only breast reconstruction is traditionally discouraged in patients who receive radiation. It is not clear whether this widely recognized mantra of breast reconstruction is observed in practice. The purpose of this study was to evaluate immediate reconstruction trends and practices in patients who have undergone mastectomy and radiation therapy.

METHODS

Female patients with unilateral breast cancer who required radiation in addition to mastectomy were extracted from the Surveillance, Epidemiology, and End Results (SEER) database from 2000 through 2010. Patients who underwent immediate reconstruction were identified and analyzed. Univariate and logistic regression analyses were performed to study the relationship between reconstructive method and patient demographic and oncologic characteristics.

RESULTS

A total of 5,481 female patients who underwent radiation and breast reconstruction were included for analysis. Postmastectomy radiation therapy was performed in 98.3 % of the patients. The immediate breast reconstruction rate among patients requiring radiation increased from 13.6 to 25.1 %. The percentage of reconstructed patients who had implant-only reconstruction increased from 27 to 52 % (p < 0.001) with a decrease in tissue-only reconstruction from 56 to 32 % (p < 0.001). In regression analysis, the odds of implant reconstruction over autologous reconstruction increased each year by an odds ratio of 1.13 (95 % CI 1.10-1.15).

CONCLUSIONS

The frequency of immediate reconstruction continues to increase in the setting of postmastectomy radiation therapy, with immediate implant-based reconstruction representing the most commonly utilized method, contrary to traditional recommendations. These findings likely reflect changing attitudes towards implant reconstruction in the setting of planned postmastectomy radiation.