Met and Unmet Expectations for Breast Reconstruction in Early Posttreatment Breast Cancer Survivors

The purpose of this study was to evaluate the prevalence of met and unmet expectations after breast reconstruction among breast cancer survivors following mastectomy. A secondary objective was to examine reasons women report their experiences of reconstructive surgery were better or worse than expected. As part of a larger study of breast cancer survivors, participants completed self-administered questionnaires within 8 months of diagnosis and at 6, 12, and 18 months later. At the 18-month follow-up, women who had breast reconstruction were asked whether their reconstruction was better, the same, or worse than expected. The sample consisted of 130 survivors (mean age = 48.5 years) who had breast reconstruction following mastectomy and completed the 18-month follow-up, 42% of whom reported their reconstruction was worse than expected and only 25% reported it was better. Most frequently reported reasons for reconstruction being worse than expected were related to appearance of the reconstructed breast and pain. A high percentage of patients with breast cancer undergoing breast reconstruction following mastectomy reported the results as worse than expected, with the primary reasons for dissatisfaction related to the feel and appearance of the reconstructed breast. Patients with breast cancer considering breast reconstruction need better preoperative education or understanding about what to expect from reconstruction.

Role of Age, Tumor Grade, and Radiation Therapy on Immediate Postmastectomy Breast Reconstruction

BACKGROUND

Despite the psychological benefits and oncologic safety of postmastectomy breast reconstruction, most breast cancer patients do not undergo reconstruction. To better understand the patterns of breast reconstruction usage, it is important to identify the clinicopathologic factors associated with immediate breast reconstruction (IBR), and whether modification of the reconstruction incidence when stratified by patient- or cancer-related factors exists in the breast cancer population. The primary objectives were to determine whether the incidence of immediate postmastectomy breast reconstruction varies across age, and whether the tumor grade or radiation therapy modify the effect of age on the incidence of immediate breast reconstruction.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results database, we identified women who had undergone mastectomy for breast cancer from 2000 to 2014. Inverse probability of treatment-weighted log-binomial regression was used to estimate the effect of age on IBR after accounting for potential confounding by patient demographic data and cancer characteristics. Potential effect measure modification by tumor grade and radiation therapy on the age-IBR relationship was also assessed.

RESULTS

Of 321,206 women, 77,798 (24.2%) had undergone IBR. Age was significantly associated with IBR prevalence (P < .0001), with younger women more likely to undergo IBR. Both tumor grade (P < .0001) and radiation therapy (P < .0001) modified the effect of age on IBR.

CONCLUSION

Compared with their older counterparts, younger breast cancer patients were more likely to undergo IBR, and both tumor grade and radiation therapy were differentially associated with the likelihood of IBR across patient age.

Barriers to Completing Delayed Breast Reconstruction Following Mastectomy: a Critical Need for Patient and Clinician Education

Rates of breast reconstruction following mastectomy vary widely, and little is known about why women who originally express an interest in breast reconstruction do not receive it. Improved documentation of clinical decision-making is one of the potential benefits of the electronic health record (EHR), and may serve as a tool to enhance patient-centered, clinical outcomes research. The goals of this study were to explore patterns in delayed reconstruction (DR), identify barriers to follow through, and to determine the adequacy of EHR documentation in providing information about decision-making for breast reconstruction. Retrospective EHR review of women undergoing mastectomy, 2008-2012, was conducted in an academic medical center in New England. Data included patient demographics, cancer stage, co-morbidity index, post-mastectomy reconstruction status, and documented decision-making regarding reconstruction. Of 367 women who had undergone a total mastectomy, 219 did not receive immediate reconstruction. Of these, 24.6 % expressed no interest in DR, 21.9 % expressed interest but were still pending the procedure, and 5.9 % had completed DR. Of decision-making regarding breast reconstruction, 47.5 % lacked documentation. Median follow-up was 34 months. Reasons for not following through with DR included poor timing (25 %), indecision (17 %), desired method of reconstruction not available at treating facility (10 %), persistent obesity (8.3 %), continued smoking (4 %), and reason not specified (35 %). Many women do not receive breast reconstruction despite expressing an initial interest in the procedure. Reasons were multi-factorial and the extent of documentation was inconsistent. Further exploration of potential barriers to breast reconstruction as well as opportunities to enhance shared decision-making may serve to improve patient experience and satisfaction following mastectomy.

Influence of race, insurance status, and geographic access to plastic surgeons on immediate breast reconstruction rates

BACKGROUND

This study evaluates the rates of immediate breast reconstruction (IBR) among racial and insurance status subgroups, in the setting of a changing plastic surgeon workforce.

METHODS

Using state level inpatient and ambulatory surgery data, we identified discharges for adult women who underwent mastectomy for breast cancer. This information was supplemented with plastic surgeon workforce data and aggregated to the health service area-level (HSA). Hierarchical linear models were used to risk standardized IBR rates for 8 race-payer subgroups.

RESULTS

The final cohort included 65,246 women treated across 67 HSAs. The plastic surgeon density per 100,000 population directly related to the IBR rate. While all subgroups saw a modest increase in IBR rates, Caucasian women with private insurance realized the largest absolute increase (46%) while African-American and Asian women with public insurance saw the smallest increase (6%).

CONCLUSION

Significant disparities persist in the provision of IBR according to the form of insurance a patient possesses. Of heightened concern is the novel finding that even within privately insured patients, women of color have significantly lower IBR rates compared to Caucasian women.

A Retrospective Cohort Study on Payor Type and the Effect on Revisions in Breast Reconstruction

BACKGROUND

Patients who are insured by Medicare and Medicaid are less likely to undergo breast reconstruction than their privately insured counterparts. Whether insurance type also affects subsequent revisions remains unknown. This study explores the relationship among payor type, revision procedures, and the completion of breast reconstruction.

METHODS

A retrospective cohort study was created including patients who underwent breast reconstruction at the authors' institution from 1996 to 2016. Data collected included age, cancer stage, race, laterality, initial breast reconstruction type, total number of procedures, number of trips to the operating room, and subsequent revisions. Analysis of covariance and logistic regression were used to estimate the controlled mean number of revisions and probability of completion of reconstruction as a function of insurance type.

RESULTS

A total of 3113 patients were included: 2271 (72.9 percent) with private insurance, 450 (14.5 percent) with Medicare, and 392 (12.6 percent) with Medicaid. On controlled analysis, there was no difference in total number of procedures, number of revisions, or number of trips to the operating room among the three insurance types. There was no difference in the proportion of patients undergoing symmetry procedures or nipple-areola reconstruction.

CONCLUSIONS

To the authors' knowledge, this is the first study to evaluate discrepancies in number of procedures, revisions, and the proportion of patients completing breast reconstruction among insurance types. When controlling for other factors, the authors report no differences in care based solely on payor type. Instead, patient and surgeon variables may be responsible for the differences observed, and should be targeted in future research to improve equity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Two-Stage Prosthetic Breast Reconstruction after Mastectomy with or without Prior Postmastectomy Radiotherapy

BACKGROUND

Two-stage prosthetic breast reconstruction with initial insertion of a tissue expander followed by an implant after a period of inflation is a well-established breast reconstruction option. Most of the current literature concentrates on the immediate setting, and there are only a few reports into delayed cases, especially after postmastectomy radiotherapy (RT). We performed a retrospective review of our experience over a 12.5-year period.

METHODS

Between June 1998 and December 2010, a total of 671 patients received prosthetic-only breast reconstruction. Of these, 170 (25.3%) underwent delayed 2-stage prosthetic breast reconstruction after mastectomy for cancer. Patients were divided into group A, no postmastectomy RT (n = 150), and group B, postmastectomy RT (n = 20). The primary factor examined was the failure of the reconstruction from loss of prosthesis with or without smoking. Other complications, as well as rates of revisional surgery were also recorded.

RESULTS

Expander or implant loss occurred in 3 of 150 patients in group A (2.0%) and 3 of 20 patients in group B (15%; P = 0.02). For nonsmokers, implant loss was 1.6% and 5.6%, respectively (P = NS). Smoking was associated with 1 of the 3 losses in group A and 2 of the 3 in group B (smokers, n = 2; P < 0.01). There was no significant difference in other complications such as seromas or minor wound infections.

CONCLUSIONS

Delayed 2-stage prosthetic breast reconstruction has a low failure rate. It can also be successfully completed in selected patients after postmastectomy RT, but care must be taken with patients who smoke.

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.

A Call for Fertility Preservation Coverage for Breast Cancer Patients: The Cost of Consistency

In 1998, the passage of the Women's Health and Cancer Rights Act required insurance health plans nationwide covering breast cancer treatments to also reimburse for subsequent breast reconstructive surgery and prostheses. In response to low utilization of breast reconstructive services, particularly among racial minorities, plastic surgery interest groups successfully advocated for the passage of the Breast Cancer Patient Education Act, which provides a timely opportunity to reconsider patient accessibility to other equally important quality of life issues for cancer survivors. Currently, the potential threat of infertility as a consequence of cancer therapy does not meet preexisting definitions of infertility, making preemptive fertility preservation elective. Ultimately, cost remains the largest barrier to the pursuit of fertility preservation. In this Commentary, we estimate the potential additive cost of providing fertility preservation coverage for approximately 19 000 eligible women of reproductive age diagnosed with breast cancer based on previously published prevalence and cost data. We determine an upper limit of yearly cost of $126.6 million US dollars assuming 100% participation. Legislation providing mandatory insurance coverage of breast reconstruction surgeries in all 50 states following cancer treatment represents a powerful policy commitment to address existing health disparities in reproductive health services and ensures comprehensive cancer survivorship care. Extending coverage for fertility preservation in the setting of fertility-threatening treatment offers a consistent stance for insurance coverage of iatrogenic sequelae of cancer therapy at a fraction of the cost of breast reconstruction.

Breast reconstruction rate and profile in a Singapore patient population: a National University Hospital experience

INTRODUCTION

Breast reconstruction is an integral part of breast cancer management with the aim of restoring a breast to its natural form. There is increasing awareness among women that it is a safe procedure and its benefits extend beyond aesthetics. Our aim was to establish the rate of breast reconstruction and provide an overview of the patients who underwent breast reconstruction at National University Hospital (NUH), Singapore.

METHODS

We evaluated factors that impact a patient's decision to proceed with breast reconstruction, such as ethnicity, age, time and type of implant. We retrospectively reviewed the medical records of women who had breast cancer and underwent breast surgery at NUH between 2001 and 2010.

RESULTS

The breast reconstruction rate in this study was 24.3%. There were 241 patients who underwent breast reconstruction surgeries (including delayed and immediate procedures) among 993 patients for whom mastectomies were done for breast cancer. Chinese patients were the largest ethnic group who underwent breast reconstruction after mastectomy (74.3%). Within a single ethnic patient group, Malay women had the largest proportion of women undergoing breast reconstruction (60.0%). The youngest woman in whom cancer was detected in our study was aged 20 years. Malay women showed the greatest preference for autologous tissue breast reconstruction (92.3%). The median age at cancer diagnosis of our cohort was 46 years.

CONCLUSION

We noted increases in the age of patients undergoing breast reconstruction and the proportion of breast reconstruction cases over the ten-year study period.

Impact of Safety Net Hospitals in the Care of the Hand-Injured Patient: A National Perspective

A clear disparity in the pattern and provision of surgical care exists, particularly for patients with vulnerable socioeconomic backgrounds. For hand-injured patients in particular, this discrepancy has been frequently shown in their receiving appropriate care. With the advent of the Affordable Care Act and with Medicaid expansion on the horizon, more patients will be requiring access to care. Safety net programs have been shown to provide equivalent levels of care for patients compared with non-safety net providers, and the survival of these hospitals for the disadvantaged is essential to providing quality care for this growing patient population. In this article, the authors review the factors that affect the barriers to care, the importance of safety net hospitals, the epidemiology of the hand-injured patient, and how the Affordable Care Act will impact these safety net programs.

Survival Differences in Women with and without Autologous Breast Reconstruction after Mastectomy for Breast Cancer

Background:

Breast reconstruction (BR) is an option for women who are treated with mastectomy; however, there has been concern regarding the oncologic safety of BR. In this study, we evaluated recurrences and mortality in women treated with mastectomy and compared outcomes in those treated with mastectomy alone to those with mastectomy plus transverse rectus adbominis (TRAM) flap BR.

Methods:

The prospective cohort study included women treated with mastectomy at Women’s College Hospital from 1987 to 1997. Women with TRAM flap BR were matched to controls based on age and year of diagnosis, stage, and nodal status. Patients were followed from the date of diagnosis until death or date of last follow-up. Hazard ratios were generated to compare cases and controls for outcome variables using Cox’s proportional hazards models.

Results:

Of 443 women with invasive breast cancer, 85 subjects had TRAM flap BR. Sixty-five of these women were matched to 115 controls. The mean follow-up was 11.2 (0.4–26.3) years. There were no significant differences between those with and without BR with weight, height, or smoking status. Women with TRAM flap were less likely to experience a distant recurrence compared to women without a TRAM flap (relative risk, 0.42; P = 0.0009) and were more likely to be alive (relative risk, 0.54; P = 0.03).

Conclusions:

Women who elect for TRAM flap BR after an invasive breast cancer diagnosis do have lower rates of recurrences and mortality than women treated with mastectomy alone. This cannot be explained by differences in various clinical or lifestyle factors.

Technique to Promote Symmetry in 2-Staged Bilateral Breast Reconstruction in the Setting of Unilateral Postmastectomy Radiation

BACKGROUND

Bilateral breast reconstruction in the setting of unilateral postmastectomy radiation therapy (PMRT) remains one of the most difficult reconstructive challenges due to significant radiation-induced asymmetry from capsular contracture and superior migration of the irradiated reconstructed breast. We describe a novel and straightforward intraoperative technique for creating compensatory asymmetry to maximize postradiation symmetry in immediate bilateral tissue expander (TE) and acellular dermal matrix (ADM) reconstruction requiring unilateral PMRT.

METHODS

A cohort of 25 bilateral TE/ADM breast reconstructions with planned unilateral PMRT was performed using this approach, and outcomes were reviewed. On the PMRT side, the ADM edge was inset to a lower inframammary fold (IMF) position resulting in a near "bottoming-out" effect. On the non-PMRT side, the ADM was inset using a triple point stitch onto the IMF in a higher chest wall location. The planned PMRT side TE was overexpanded and second-stage exchanges were performed 6+ months post-PMRT.

RESULTS

Post-PMRT results showed improved symmetry as the PMRT side migrated superiorly to match the contralateral non-irradiated side. Minimal pocket or IMF adjustments were required during second-stage procedures, with just 6 patients (24%) requiring minor lowering and 1 patient (4%) requiring elevation of the PMRT side IMF. Thus, most (72%) patients undergoing bilateral mastectomy and unilateral PMRT did not require any IMF modifications during the second-stage procedure.

CONCLUSIONS

A differential ADM inset and TE pocket creation for bilateral TE/ADM breast reconstructions with planned unilateral PMRT can minimize the typical adverse aesthetic effects of PMRT on reconstruction results and maximize symmetry.

Predictors of satisfaction and quality of life following post-mastectomy breast reconstruction

OBJECTIVE

Breast reconstruction is associated with multiple psychological benefits. However, few studies have identified clinical and psychological factors associated with improved satisfaction and quality of life. This study examined factors, which predict satisfaction with breast appearance, outcome satisfaction and quality of life following post-mastectomy breast reconstruction.

METHODS

Women who underwent post-mastectomy breast reconstruction between 2010 and 2016 received a postal questionnaire consisting of The BREAST-Q Patient Reported Outcomes Instrument, The European Organisation for Research and Treatment of Cancer QLQ-30 Questionnaire, The Patient and Observer Scar Assessment Scale, and a series of Visual-Analogue Scales. One hundredforty-eight women completed the questionnaire, a 56% response rate.

RESULTS

Hierarchical multiple regression analyses revealed psychosocial factors accounted for 75% of the variance in breast satisfaction, 68% for outcome satisfaction, and 46% forquality of life. Psychosocial well-being emerged as a significant predictor of satisfaction with breast appearance (β = .322) and outcome satisfaction (β = .406). Deep inferior epigastric perforator flap patients reported greater satisfaction with breast appearance (β = .120) and outcome satisfaction (β = .167).

CONCLUSIONS

This study extends beyond the limited research by distinguishing between satisfaction with breast appearance and outcome satisfaction. The study provides evidence for the role of psychosocial factors predicting key patient reported outcomes and demonstrates the importance of psychosocial well-being and reconstruction type. The findings also highlight the need for healthcare providers to consider the psychosocial well-being of patients both preoperatively and post operatively and provide preliminary evidence for the use of deep inferior epigastric perforator reconstructions over other types of reconstructive procedures.

Trends in Breast Reconstruction by Ethnicity: An Institutional Review Centered on the Treatment of an Urban Population

Previous studies have investigated reconstructive decisions after mastectomy and such studies document a preference among African American women for autologous tissue-based procedures and among Latin American women for implant-based reconstructions, however, there is a paucity of studies evaluating the current relationship between ethnicity and reconstructive preferences. This institutional review provides a unique, up-to-date evaluation of an understudied urban population composed of majority ethnic minority patients and explores reconstructive trends. Consecutive breast reconstruction patients were entered into a prospectively maintained database at the University of Illinois at Chicago and affiliate hospitals between July 2010 and October 2013. Demographics and oncologic characteristics including tumor stage, pathology, BRCA status, and adjuvant treatment were reviewed, and reconstructive trends were assessed by racial group with a focus on reconstructive procedure, mastectomy volume, and implant characteristics. Statistical analysis was performed using SAS (version 9.2). One-hundred and sixty breast reconstructions were performed in 105 women; of which 50 per cent were African American, 26 per cent Hispanic, 22 per cent Caucasian, and 2 per cent Asian. Age, tumor stage, prevalence of triple negative disease, chemotherapy, and radiation treatment was comparable between groups. Rates of obesity, hypertension, and diabetes mellitus were slightly higher in African American and Hispanic cohorts, with more African American patients having one or more of these comorbidities as compared with the Caucasian and Hispanic cohorts (P = 0.047). Despite comparable positive BRCA testing rates, significant differences were seen in the percentage of bilateral mastectomy; 68 per cent African American, 48 per cent Caucasian, and 30 per cent Hispanic (P = 0.004). Hispanics predominantly underwent flap-based reconstruction (56%), while African American (74%) and Caucasian (60%) patients had a preference toward tissue expander reconstruction (P = 0.04 across all groups). African American and Hispanic presented with increased mastectomy weights and thus required higher implant volumes as compared with Caucasians that approached significance (P = 0.06 and P = 0.06). Implant size utilization followed a unimodal distribution for Caucasians, peaking at 500 cc; while African American and Hispanic demonstrated a bimodal distribution, peaking once at 550 cc and again at the max implant volume of 800 cc. This study of a large proportion of minority patients in an urban geographic setting offers an evolving understanding of breast reconstruction patterns. The data demonstrated unique findings of increased rates of bilateral implant-based reconstruction in African American women and unilateral flap-based reconstructions in Hispanic patients. Reconstructive decision-making seems to be greatly influenced by cultural and geographically driven preferences.

The decision-making process for breast reconstruction after cancer surgery: Representations of heterosexual couples in long-standing relationships

OBJECTIVES

Most people deal with intrusive life events such as cancer and the care trajectory together with their intimate partners. To our knowledge, no research has studied the involvement of the partner in the decision-making process regarding breast reconstruction (BR) after cancer. This study aimed to gain a better understanding of the couples' decision-making process for BR in the cancer context and particularly to investigate the partners' involvement in this process.

METHOD

Eighteen participants (nine women who underwent a mastectomy following a first breast cancer and their intimate partners) took part in this study. We conducted semidirective interviews, and a general inductive approach was chosen to capture the representations of the couples.

RESULTS

The women in the sample were aged between 33 and 66 years (M = 54, SD = 7.5) and their partner between 40 and 76 years (M = 59, SD = 11.6). The duration of their intimate relationship was on average 18 years (SD = 10.4; minimum = 4; maximum = 33). The analysis revealed 11 major themes. The two most salient ones were 'external influence' and 'implication of the partner'. The exploration of the subthemes revealed that the decision-making process is often reported as an interrelated experience by the couples and as a dyadic stressor. The partner's role is depicted as consultative and mostly supportive.

CONCLUSION

These results provide new insights on the involvement of the partner in decision-making. Thus, it now seems crucial to develop a prospective study, which will help understand the progression of the decision-making process over time. Statement of contribution What is already known on this subject? Most people deal with intrusive life events such as cancer and the care trajectory together with their intimate partners. Shared decision-making between patients and physicians is now the 'gold standard' in Western Europe and the United States. However, in the context of breast reconstruction (BR) after cancer, factors guiding the decision-making process for BR, especially the potential involvement of the partner, are not very well understood. What does this study add? Provides a qualitative insight on the specific nature of heterosexual couples' representations regarding the decision-making process for breast reconstruction after cancer. Reveals that the decision-making process is often reported as an interrelated experience by the couples and as a dyadic stressor. Underlines the consultative function of partners with women engaged in breast reconstruction.

Acceptability and pilot efficacy trial of a web-based breast reconstruction decision support aid for women considering mastectomy

OBJECTIVE

The study aim was to test the acceptability and preliminary efficacy of a novel interactive web-based breast reconstruction decision support aid (BRAID) for newly diagnosed breast cancer patients considering mastectomy.

METHODS

Fifty-five women considering mastectomy were randomly assigned to receive the BRAID versus the Cancer Support Community's Frankly Speaking About Cancer: Breast Reconstruction pamphlet. Participants completed measures of breast reconstruction (BR) knowledge, preparation to make a decision, decisional conflict, anxiety, and BR intentions before randomization and 2 weeks later.

RESULTS

In terms of acceptability, enrollment into the study was satisfactory, but the rate of return for follow-up surveys was lower among BRAID participants than pamphlet participants. Both interventions were evaluated favorably in terms of their value in facilitating the BR decision, and the majority of participants completing the follow-up reported viewing the materials. In terms of preliminary efficacy, both interventions resulted in significant increases in BR knowledge and completeness and satisfaction with preparation to make a BR decision, and both interventions resulted in a significant reduction in decision conflict. However, there were no differences between interventions.

CONCLUSION

A widely available free pamphlet and a web-based customized decision aid were highly utilized. The pamphlet was as effective in educating women about BR and prepared women equally as well to make the BR decision as compared with a more costly, customized web-based decision support aid. Copyright © 2015 John Wiley & Sons, Ltd.

Matching Procedures at the Time of Immediate Breast Reconstruction: An American College of Surgeons National Surgical Quality Improvement Program Study of 24,191 Patients

BACKGROUND

The purpose of this study was to assess for compounded risk of postoperative morbidity with the addition of a simultaneous contralateral breast matching procedure at the time of mastectomy and immediate breast reconstruction.

METHODS

2005 to 2012 American College of Surgeons National Surgical Quality Improvement Program databases were used to identify cases of mastectomy and immediate breast reconstruction with and without simultaneous contralateral breast matching procedures. Matching procedures included mastopexy, reduction mammaplasty, and augmentation mammaplasty. Thirty-day postoperative morbidity was assessed using univariable and multivariable logistic regression.

RESULTS

Of 59,766 mastectomy patients, 24,191 (40 percent) underwent immediate breast reconstruction: 903 (3.7 percent) underwent matching procedures and 23,288 (96.3 percent) did not. Univariable logistic regression demonstrated that the matching procedure group had statistically significantly higher overall morbidity (OR, 1.288; 95 percent CI, 1.022 to 1.623; p = 0.032). Although surgical and systemic morbidity did not differ significantly, the matching procedure group demonstrated higher risk for superficial surgical-site infection (OR, 1.57; 95 percent CI, 1.066 to 2.31; p = 0.022), reconstruction failure (OR, 1.69; 95 percent CI, 1.014 to 2.814; p = 0.044), and pulmonary embolism (OR, 2.54; 95 percent CI, 1.01 to 6.37; p = 0.048). Controlling for possible confounders, multivariable logistic regression rendered the relationship between matching procedure and complications insignificant (OR, 1.17; 95 percent CI, 0.92 to 1.48; p = 0.2).

CONCLUSION

These data suggest that preoperative comorbidities and other patient-related factors may have a larger influence on postoperative morbidity than the addition of a contralateral matching procedure alone.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Examination of Racial Disparities in the Receipt of Minimally Invasive Surgery Among a National Cohort of Adult Patients Undergoing Colorectal Surgery

BACKGROUND

Racial disparities in outcomes are well described among surgical patients.

OBJECTIVE

The purpose of this work was to identify any racial disparities in the receipt of a minimally invasive approach for colorectal surgery.

DESIGN

Adults undergoing colorectal surgery were studied using the University HealthSystem Consortium. Univariate and multivariable analyses were used to identify predictors for the receipt of a minimally invasive approach.

SETTINGS

The study was conducted at academic hospitals and their affiliates.

PATIENTS

Adults ≥18 years of age who underwent surgery for colorectal cancer, diverticular disease, IBD, or benign colorectal tumor between 2008 and 2011 were included.

MAIN OUTCOME MEASURES

The receipt of a minimally invasive surgical approach was the main measured outcome.

RESULTS

A total of 82,474 adult patients met the study inclusion criteria. Of these, 69,664 (84%) were white, 10,874 (13%) were black, and 1936 (2%) were Asian. Blacks were younger, with higher rates of public insurance and higher comorbidity burden and baseline severity of illness compared with white and Asian patients. Black patients were less likely (adjusted OR = 0.83 (95% CI, 0.79-0.87)) and Asian patients more likely (adjusted OR = 1.34 (95% CI, 1.21-1.49)) than whites to receive minimally invasive surgery. This association did not change with stratification by insurance type (public or private). Black patients had higher rates of intensive care unit admission and nonhome discharge, as well as an increased length of stay compared with white and Asian patients. No differences in complications, readmission, or mortality rates were observed with minimally invasive surgery, but black patients were more likely to be readmitted or to die with open surgery.

LIMITATIONS

The study was limited by the retrospective nature of its data.

CONCLUSIONS

We identified racial differences in the receipt of a minimally invasive approach for colorectal surgery, regardless of insurance status, as well as improved outcomes for minority races who underwent a minimally invasive technique compared with open surgery. The improved outcomes associated with minimally invasive surgery should prompt efforts to increase rates of its use among black patients.

What Would Women Choose When Given a Choice in Breast Reconstruction?

Reconstruction after mastectomy is an important milestone for many women treated for breast cancer. However, because many surgeons only offer their preferred method of reconstruction, it is not clear which approach women would choose if offered a genuine choice.

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.

The Impact of Travel Distance on Breast Reconstruction in the United States

BACKGROUND

Inadequate access to breast reconstruction was a motivating factor underlying passage of the Women's Health and Cancer Rights Act. It remains unclear whether all patients interested in breast reconstruction undergo this procedure. The aim of this study was to determine whether geographic disparities are present that limit the rate and method of postmastectomy reconstruction.

METHODS

Travel distance in miles between the patient's residence and the hospital reporting the case was used as a quantitative measure of geographic disparities. The American College of Surgeons National Cancer Database was queried for mastectomy with or without reconstruction performed from 1998 to 2011. Reconstructive procedures were categorized as implant or autologous techniques. Standard statistical tests including linear regression were performed.

RESULTS

Patients who underwent breast reconstruction had to travel farther than those who had mastectomy alone (p < 0.01). A linear correlation was demonstrated between travel distance and reconstruction rates (p < 0.01). The mean distances traveled by patients who underwent reconstruction at community, comprehensive community, or academic programs were 10.3, 19.9, and 26.2 miles, respectively (p < 0.01). Reconstruction rates were significantly greater at academic programs. Patients traveled farther to undergo autologous compared with prosthetic reconstruction.

CONCLUSIONS

Although greater patient awareness and insurance coverage have contributed to increased breast reconstruction rates in the United States, the presence of geographic barriers suggests an unmet need. Academic programs have the greatest reconstruction rates, but are located farther from patients' residences. Increasing the number of plastics surgeons, especially in community centers, would be one method of addressing this inequality.

Tissue Expander Overfilling: Achieving New Dimensions of Customization in Breast Reconstruction

Overfill of tissue expanders is a commonly used modality to achieve customized dimensions in breast reconstruction. Little formal study of the dynamics of hyperexpansion of these devices has been performed to date, however.

Paying on the margin for medical care: Evidence from breast cancer treatments

We present a simple graphical framework to illustrate the potential welfare gains from a "top-up" health insurance policy requiring patients to pay the incremental price for more expensive treatment options. We apply this framework to breast cancer treatments, where lumpectomy with radiation therapy is more expensive than mastectomy but generates similar average health benefits. We estimate the relative demand for lumpectomy using variation in distance to the nearest radiation facility, and estimate that the "top-up" policy increases social welfare by $700-2,500 per patient relative to two common alternatives. We briefly discuss additional tradeoffs that arise from an ex-ante perspective.

The desire to utilize postmastectomy breast reconstruction in Saudi Arabian women. Predictors and barriers

Objectives:

To study factors that influence the desire to utilize breast reconstruction after mastectomy, and to investigate the barriers to reconstruction among women in Saudi Arabia.

Methods:

We conducted a cross-sectional study at 2 surgical centers in Jeddah, Saudi Arabia. A self-administered questionnaire was distributed to all breast cancer patients attending the surgery clinics for follow-up after mastectomy between January and March 2013. Ninety-one patients met the study inclusion criteria. The first part of the questionnaire covered the demographic and socioeconomic information regarding factors that might influence the desire to utilize breast reconstruction including possible barriers. Multivariate logistic regression was used to determine the significant predictors of the desire to undergo reconstruction.

Results:

Overall, 16.5% of patients underwent breast reconstruction after mastectomy. Young age and high educational attainment were significantly associated with an increased desire to undergo reconstruction. The main barriers to reconstruction were the lack of adequate information on the procedure (63%), concerns on the complications of the procedure (68%), and concerns on the reconstruction interfering with the detection of recurrence (54%).

Conclusion:

Age and educational level were significant predictors of the desire to utilize breast reconstruction. Furthermore, modifiable barriers included the lack of knowledge and misconceptions on the procedure. Addressing these issues may increase the rate of breast reconstruction in Saudi Arabia.

Sociodemographic Predictors of Breast Reconstruction Procedure Choice: Analysis of the Mastectomy Reconstruction Outcomes Consortium Study Cohort

Background. To promote patient-centered care, it is important to understand the impact of sociodemographic factors on procedure choice for women undergoing postmastectomy breast reconstruction. In this context, we analyzed the effects of these variables on the reconstructive method chosen. Methods. Women undergoing postmastectomy breast reconstruction were recruited for the prospective Mastectomy Reconstruction Outcomes Consortium Study. Procedure types were divided into tissue expander-implant/direct-to-implant and abdominally based flap reconstructions. Adjusted odds ratios were calculated from logistic regression. Results. The analysis included 2,203 women with current or previous breast cancer and 202 women undergoing prophylactic mastectomy. Compared with women <40 years old with current or previous breast cancer, those 40 to 59 were significantly more likely to undergo an abdominally based flap. Women working or attending school full-time were more likely to receive an autologous procedure than those working part-time or volunteering. Women undergoing prophylactic mastectomy who were ≥50 years were more likely to undergo an abdominal flap compared to those <40. Conclusions. Our results indicate that sociodemographic factors affect the reconstructive procedure received. As we move forward into a new era of patient-centered care, providing tailored treatment options to reconstruction patients will likely lead to higher satisfaction and better outcomes for those we serve.

Patterns and Trends in Immediate Postmastectomy Reconstruction in California: Complications and Unscheduled Readmissions

BACKGROUND

Immediate reconstruction rates after mastectomy are increasing but remain low. Little is known about hospital readmissions after these procedures. The authors studied unscheduled readmissions after immediate reconstruction.

METHODS

Using the Healthcare Cost and Utilization Project California State database, the authors identified patients undergoing mastectomy only or with immediate reconstruction for ductal carcinoma in situ and invasive breast cancer from 2005 to 2009. Immediate reconstruction included tissue expander/implant and autologous tissue reconstructions. The authors evaluated temporal trends in immediate reconstruction and factors associated with 30-day unscheduled readmissions after reconstruction.

RESULTS

The cohort contained 48,414 patients (mastectomy only, 35,648; immediate reconstruction, 12,766; tissue expander/implant, 10,437; autologous tissue, 2329). Readmission rates were not significantly different between mastectomy only and immediate reconstruction (3.55 percent versus 3.39 percent; p = 0.39); however, autologous tissue reconstruction was associated with a significantly higher readmission rate compared with tissue expander/implant reconstruction (4.08 percent versus 3.24 percent; p = 0.04).

CONCLUSIONS

Immediate reconstruction does not result in higher readmission rates compared with mastectomy only. All women undergoing mastectomy should be offered consultation for reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Effect of federal and state policy changes on racial/ethnic variation in immediate postmastectomy breast reconstruction

BACKGROUND

Breast reconstruction after mastectomy has been shown to provide substantial clinical and psychosocial benefits for many patients; however, disparities in the use of immediate postmastectomy breast reconstruction persist. Using the unique dataset from the New York State Inpatient Database, the following developments were studied: (1) trends in immediate postmastectomy breast reconstruction between 1998 and 2006 among white, African American, and Hispanic women; (2) factors associated with its use; and (3) changes in racial/ethnic variation in immediate postmastectomy breast reconstruction before and after implementation of the New York State Medicaid expansion in 2001.

METHODS

A step-in multivariable logistic regression model was used to assess the effect of race/ethnicity, age, mastectomy type, number of comorbidities, socioeconomic status, and insurance on the probability of undergoing immediate postmastectomy breast reconstruction. Then, adjusted immediate postmastectomy breast reconstruction rates for before and after Medicaid expansion were predicted, stratified by race/ethnicity.

RESULTS

The probability of undergoing immediate postmastectomy breast reconstruction increased (p < 0.001); however, even with Medicaid expansion occurring during the 8 years studied, gaps in use between white and African American women and between white and Hispanic women increased by 6 percent (95% CI, 0.07 to 0.05) and 5 percent (95% CI, 0.07 to 0.04), respectively. Being younger, having greater income and education, and having private health insurance are associated with a greater probability of immediate postmastectomy breast reconstruction.

CONCLUSION

These findings indicate that expanding safety-net policies such as Medicaid without providing support such as consultation or health literacy education might not be effective in reducing disparities in health care.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

National trends and complication rates after bilateral mastectomy and immediate breast reconstruction from 2005 to 2012

BACKGROUND

This study's purpose was to examine the national rate of breast cancer patients undergoing bilateral mastectomy (BM) and immediate breast reconstruction (IBR) and their associated complication rates.

METHODS

Using the National Surgical Quality Improvement Program database, breast cancer patients undergoing mastectomy between 2005 and 2012 were identified. Rates in BM and IBR as well as associated complication rates were evaluated. Logistic regression was used to identify predictors of BM, IBR, and complications.

RESULTS

A total of 56,905 breast cancer patients underwent mastectomy. The rate of BM tripled (9.14% vs 25.44%, P < .0001) and the rate of IBR increased by 50% (29.73% vs 44.68%, P < .0001). Complication rates were higher in patients undergoing BM compared with unilateral mastectomy (11.49% vs 9.52%, P < .0001) and in patients undergoing IBR compared with mastectomy alone (11.62% vs 8.91%, P < .0001). White race and age less than 40 years were predictors of patients undergoing BM and IBR.

CONCLUSIONS

The rates of BM and associated IBR have increased significantly since 2005 despite higher complication rates. Further research is needed to understand the reasons for these trends.

Breast cancer treatment among African American women in north St. Louis, Missouri

Similar to disparities seen at the national and state levels, African American women in St. Louis, Missouri have higher breast cancer mortality rates than their Caucasian counterparts. We examined breast cancer treatment (regimens and timing) in a sample of African American breast cancer patients diagnosed between 2000 and 2008 while residing in a North St. Louis cluster (eight zip codes) of late stage at diagnosis. Data were obtained from medical record extractions of women participating in a mixed-method study of breast cancer treatment experiences. The median time between diagnosis and initiation of treatment was 27 days; 12.2% of the women had treatment delay over 60 days. These findings suggest that treatment delay and regimens are unlikely contributors to excess mortality rates for African American women diagnosed in early stages. Conflicting research findings on treatment delay may result from the inconsistent definitions of treatment delay and variations among study populations. Breast cancer treatment delay may reduce breast cancer survival; additional research is needed to better understand the points at which delays are most likely to occur and develop policies, programs, and interventions to address disparities in treatment delay. There may also be differences in treatment-related survivorship quality of life; approximately 54% of the women in this sample treated with mastectomies received breast reconstruction surgery. Despite the high reconstruction rates, most women did not receive definitive completion. African American women have higher reconstruction complication rates than Caucasian women; these data provide additional evidence to suggest a disparity in breast reconstruction outcomes by race.

Access to breast reconstruction after mastectomy and patient perspectives on reconstruction decision making

IMPORTANCE

Most women undergoing mastectomy for breast cancer do not undergo breast reconstruction.

OBJECTIVE

To examine correlates of breast reconstruction after mastectomy and to determine if a significant unmet need for reconstruction exists.

DESIGN, SETTING, AND PARTICIPANTS

We used Surveillance, Epidemiology, and End Results registries from Los Angeles, California, and Detroit, Michigan, for rapid case ascertainment to identify a sample of women aged 20 to 79 years diagnosed as having ductal carcinoma in situ or stages I to III invasive breast cancer. Black and Latina women were oversampled to ensure adequate representation of racial/ethnic minorities. Eligible participants were able to complete a survey in English or Spanish. Of 3252 women sent the initial survey a median of 9 months after diagnosis, 2290 completed it. Those who remained disease free were surveyed 4 years later to determine the frequency of immediate and delayed reconstruction and patient attitudes toward the procedure; 1536 completed the follow-up survey. The 485 who remained disease free at follow-up underwent analysis.

EXPOSURES

Disease-free survival of breast cancer.

MAIN OUTCOMES AND MEASURES

Breast reconstruction at any time after mastectomy and patient satisfaction with different aspects of the reconstruction decision-making process.

RESULTS

Response rates in the initial and follow-up surveys were 73.1% and 67.7%, respectively (overall, 49.4%). Of 485 patients reporting mastectomy at the initial survey and remaining disease free, 24.8% underwent immediate and 16.8% underwent delayed reconstruction (total, 41.6%). Factors significantly associated with not undergoing reconstruction were black race (adjusted odds ratio [AOR], 2.16 [95% CI, 1.11-4.20]; P = .004), lower educational level (AOR, 4.49 [95% CI, 2.31-8.72]; P < .001), increased age (AOR in 10-year increments, 2.53 [95% CI, 1.77-3.61]; P < .001), major comorbidity (AOR, 2.27 [95% CI, 1.01-5.11]; P = .048), and chemotherapy (AOR, 1.82 [95% CI, 0.99-3.31]; P = .05). Only 13.3% of women were dissatisfied with the reconstruction decision-making process, but dissatisfaction was higher among nonwhite patients in the sample (AOR, 2.87 [95% CI, 1.27-6.51]; P = .03). The most common patient-reported reasons for not having reconstruction were the desire to avoid additional surgery (48.5%) and the belief that it was not important (33.8%), but 36.3% expressed fear of implants. Reasons for avoiding reconstruction and systems barriers to care varied by race; barriers were more common among nonwhite participants. Residual demand for reconstruction at 4 years was low, with only 30 of 263 who did not undergo reconstruction still considering the procedure.

CONCLUSIONS AND RELEVANCE

Reconstruction rates largely reflect patient demand; most patients are satisfied with the decision-making process about reconstruction. Specific approaches are needed to address lingering patient-level and system factors with a negative effect on reconstruction among minority women.

Understanding the factors that influence breast reconstruction decision making in Australian women

BACKGROUND

Breast reconstruction is safe and improves quality of life. Despite this, many women do not undergo breast reconstruction and the reasons for this are poorly understood. This study aims to identify the factors that influence a woman's decision whether or not to have breast reconstruction and to better understand their attitudes toward reconstruction.

METHODOLOGY

An online survey was distributed to breast cancer patients from Breast Cancer Network Australia. Results were tabulated, described qualitatively and analyzed for significance using a multiple logistic regression model.

RESULTS

501 mastectomy patients completed surveys, of which 62% had undergone breast reconstruction. Factors that positively influenced likelihood of reconstruction included lower age, bilateral mastectomy, access to private hospitals, decreased home/work responsibilities, increased level of home support and early discussion of reconstructive options. Most common reasons for avoiding reconstruction included "I don't feel the need" and "I don't want more surgery". The most commonly sited sources of reconstruction information came from the breast surgeon followed by the plastic surgeon then the breast cancer nurse and the most influential of these was the plastic surgeon.

CONCLUSIONS

A model using factors easily obtained on clinical history can be used to understand likelihood of reconstruction. This knowledge may help identify barriers to reconstruction, ultimately improving the clinicians' ability to appropriately educate mastectomy patients and ensure effective decision making around breast reconstruction.

Influence of Patient and Hospital Characteristics on the Performance of Direct Reconstruction after Mastectomy

Aim: International studies have shown that the performance of a direct (or immediate) reconstruction (DR) after mastectomy is associated with patient (e.g., socio-economic status, insurance status, age) and hospital (number of cases, teaching status) characteristics. The present article addresses the question if such relationships also exist in Germany. Material and Methods: The results of a nationwide questionnaire to the patients of certified breast cancer centres were coupled with the clinical features of the patients and the characteristics of the hospital. Predictors for receiving a DR (vs. delayed or no reconstruction) were estimated by means of a logistic multilevel model for a sample of 1165 patients from 105 certified locations. Results: Substantial differences between the treating hospitals were found (intraclass correlation coefficient null model: 0.195) which can in part be explained by the total model (total model: 0.169). Patients with the following features are more likely to receive a DR: younger age, private health insurance, secondary school leaving certificate (vs. primary school leaving certificate), lower stage and acquisition of more information about reconstruction. ASA and partnership status are not statistically significantly related with DR. DR is more likely to be performed in hospitals with higher caseload of patients with primary breast cancer. Teaching status, operations per surgeon and urbanity of the location are not related to receiving a DR. Conclusions: Non-clinical features of the patients and the primary case number are associated with the performance of a DR, this poses questions concerning reasons and the equality of health care.

Post-mastectomy reconstruction: a risk-stratified comparative analysis of outcomes

INTRODUCTION

Although breast reconstruction following mastectomy plays a role in the psychological impact of breast cancer, only one in three women undergo reconstruction. Few multi-institutional studies have compared complication profiles of reconstructive patients to non-reconstructive.

METHODS

Using the National Surgical Quality Improvement database, all patients undergoing mastectomy from 2006 to 2010, with or without reconstruction, were identified and risk-stratified using propensity scored quintiles. The incidence of complications and comorbidities were compared.

RESULTS

Of 37,723 mastectomies identified, 30% received immediate breast reconstruction. After quintile matching for comorbidities, complications rates between reconstructive and non-reconstructives were similar. This trend was echoed across all quintiles, except in the sub-group with highest comorbidities. Here, the reconstructive patients had significantly more complications than the non-reconstructive (22.8% versus 7.0%, p < 0.001).

CONCLUSION

Immediate breast reconstruction is a well-tolerated surgical procedure. However, in patients with high comorbidities, surgeons must carefully counterbalance surgical risks with psychosocial benefits to maximize patient outcomes.

LEVEL OF EVIDENCE

Level 3.

The influence of race/ethnicity and place of service on breast reconstruction for Medicare beneficiaries with mastectomy

Racial disparities in breast reconstruction for breast cancer are documented. Place of service has contributed to disparities in cancer care; but the interaction of race/ethnicity and place of service has not been explicitly examined. We examined whether place of service modified the effect of race/ethnicity on receipt of reconstruction.

We included women with a mastectomy for incident breast cancer in SEER-Medicare from 2005–2009. Using Medicare claims, we determined breast reconstruction within 6 months. Facility characteristics included: rural/urban location, teaching status, NCI Cancer Center designation, cooperative oncology group membership, Disproportionate Share Hospital (DSH) status, and breast surgery volume. Using multivariable logistic regression, we analyzed reconstruction in relation to minority status and facility characteristics.

Of the 17,958 women, 14.2% were racial/ethnic women of color and a total of 9.3% had reconstruction. Caucasians disproportionately received care at non-teaching hospitals (53% v. 42%) and did not at Disproportionate Share Hospitals (77% v. 86%). Women of color had 55% lower odds of reconstruction than Caucasians (OR = 0.45; 95% CI 0.37-0.55). Those in lower median income areas had lower odds of receiving reconstruction, regardless of race/ethnicity. Odds of reconstruction reduced at rural, non-teaching and cooperative oncology group hospitals, and lower surgery volume facilities. Facility effects on odds of reconstruction were similar in analyses stratified by race/ethnicity status.

Race/ethnicity and facility characteristics have independent effects on utilization of breast reconstruction, with no significant interaction. This suggests that, regardless of a woman’s race/ethnicity, the place of service influences the likelihood of reconstruction.

Increasing mastectomy rates-the effect of environmental factors on the choice for mastectomy: a comparative analysis between Canada and the United States

PURPOSE

Unilateral mastectomy (UM) and contralateral prophylactic mastectomy (CPM) for early-stage breast cancer (ESBC) have been increasing. Numerous etiological factors for this rise have been suggested, including increasing use of magnetic resonance imaging (MRI) and reconstruction, surgeon's preference, and patient's choice. We conducted a qualitative study to explore what role the surgeon and their practice environment play in the increasing rates.

METHODS

Semi-structured interviews were conducted with general surgeons to explore their current approach to treating ESBC and their experience with women requesting mastectomy. Purposive sampling identified surgeons across Ontario, Canada, and the United States (US). Constant comparative analysis identified key concepts.

RESULTS

Data saturation was achieved after 45 interviews. 'The effect of external factors on rising mastectomy rates' was the dominant theme. All surgeons described increasing mastectomy rates over the last 5 years, and all surgeons discussed breast-conserving therapy (BCT) and UM as equivalent options. However, US surgeons discussed reconstruction early in the consultation process, reflecting legislative requirements. In contrast, Ontario surgeons discussed reconstruction only when a patient was considering mastectomy. Ontario surgeons often recommended BCT, whereas US surgeons rarely made a direct recommendation regarding the extent of surgery. Neither US nor Canadian surgeons recommended the use of UM + CPM in average-risk ESBC, and all surgeons described women initiating this request. MRI use and access to immediate breast reconstruction also impacted the choice for mastectomy.

CONCLUSIONS

Use of MRI, access to reconstruction, and legislative requirements regarding information disclosure, appeared to influence the surgical consultation process and the patient's request for CPM.

Barriers to immediate breast reconstruction in the Canadian universal health care system

PURPOSE

To describe the population-based rates of immediate breast reconstruction (IBR) for all women undergoing mastectomy for treatment or prophylaxis of breast cancer in the past decade, and to evaluate geographic, institutional, and patient factors that influence use in the publically funded Canadian health care system.

METHODS

This population-based retrospective cohort study used administrative data that included 28,176 women who underwent mastectomy (25,141 mastectomy alone and 3,035 IBR) between April 1, 2002, and March 31, 2012, in Ontario, Canada. We evaluated factors associated with IBR by using a multivariable logistic regression model with the generalized estimating equation approach.

RESULTS

The population-based, age-adjusted IBR rate increased from 5.1 procedures to 8.7 in 100,000 adult women (43.7%; P < .001), and the increase was greatest for prophylactic mastectomy or therapeutic mastectomy for in situ breast cancer (78.6%; P < .001). Women who lived in neighborhoods with higher median income had significantly increased odds of IBR compared with mastectomy alone (odds ratio [OR], 1.71; 95% CI, 1.47 to 2.00), and immigrant women had significantly lower odds (OR, 0.59; 95% CI, 0.44 to 0.78). A patient had nearly twice the odds of receiving IBR when she was treated at a teaching hospital (OR, 1.84; 95% CI, 1.1 to 3.06) or at a hospital with two or more available plastic surgeons (OR, 2.01; 95% CI, 1.53 to 2.65). Patients who received IBR traveled significantly farther compared with those who received mastectomy alone (OR, 1.04; 95% CI, 1.02 to 1.05 for every 10 km increase).

CONCLUSION

IBR is available to select patients with favorable clinical and demographic characteristics who travel farther to undergo surgery at teaching hospitals with two or more available plastic surgeons.

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

Disparities are evident in breast cancer diagnosis, treatment, and outcomes. This study examines multiple socioeconomic and geographic regions across the US to determine if disparities exist in the type of reconstruction obtained after mastectomy. This is a retrospective study evaluating socioeconomic and geographic variables of 14,764 women who underwent mastectomy in 2008 using the Nationwide Inpatient Sample (NIS). Statistical analysis was performed on three groups of women: patients without reconstruction (NR), patients who underwent breast implant/tissue expander reconstruction (TE), and patients with autologous reconstruction such as free or pedicled flaps (FLAP). The majority of patients (63.9%) had NR, while 23.9% had TE and 12.2% underwent FLAP. Compared to patients with NR, women with TE or FLAP were younger (64.9 years versus 51.3 and 51.1 years, p < 0.001), had fewer chronic conditions (2.60 and 2.54 chronic conditions for TE and FLAP respectively versus 3.85 for NR, p < 0.001) and higher mean hospital charges ($42,850 TE and $48,680 FLAP versus $22,300 NR, p < 0.001). Both Medicare and Medicaid insurance carriers had a higher proportion of women that did not get reconstructed compared to other insurance types (p < 0.001). Compared to NR, reconstructed women more often lived in urban areas and zip codes with higher average incomes (p < 0.001). This is the first national study analyzing insurance type and geographic variations to show statistically significant disparities in rate and type of immediate reconstruction after mastectomy. These inequalities need to be addressed to extend immediate reconstruction options to all women undergoing mastectomy.