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.

Disparities associated with breast reconstruction in Japan

BACKGROUND

With increasing rates of postmastectomy breast reconstruction, it has been suggested that there is an insufficient supply of services that meet patient demands. This study aimed to identify potential disparities in, and variables associated with, postmastectomy reconstruction in Japan.

METHODS

Using 20,257 Japanese breast cancer discharge data from 2010, the authors identified 1616 breast cancer patients, with tumor-node-metastasis classification of malignant tumors T1~4 and N0M0, between 20 and 59 years of age. Factors influencing the use of immediate breast reconstruction of either autogenous tissue or tissue expander placement were analyzed using multinomial logistic regression comparing no reconstruction to either autogenous tissue or tissue expander placement.

RESULTS

The immediate breast reconstruction rate was 11.2 percent among the study patients. The rate of autogenous method use was 49 percent and the rate of tissue expander use was 51 percent. Tissue expander placement was performed primarily in patients who resided in cities (OR, 2.4; 95 percent confidence interval, 1.5 to 4.1) and was performed at city hospitals. Patients who lived in rural areas primarily underwent autogenous tissue reconstruction, traveled to city hospitals to undergo surgery (OR, 2.0; 95 percent confidence interval, 1.0 to 4.0), and had normal body mass index (OR, 1.9; 95 percent confidence interval, 1.1 to 3.1).

CONCLUSIONS

The authors identified potential disparities associated with breast reconstruction. These disparities might be due to limited surgery methods and might have excluded some patients because of their age, physical, and economic status. Uneven distribution of plastic surgeons might have required patients to travel for breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Patient motivations for choosing postmastectomy breast reconstruction

INTRODUCTION

The number of women who undergo postmastectomy breast reconstruction is reported to be around 40% and, although increased from previous decades, seems lower than expected. The purpose of this report is to investigate and improve our understanding of women's motivations for choosing reconstruction.

METHODS

We prospectively surveyed consecutive patients referred for possible reconstructive surgery at Emory University Hospital between December 2008 and September 2010. A Likert-scale (1-5) questionnaire was used evaluating body image, femininity and sexuality, and influences regarding reconstruction. Demographic information was collected and analyzed. A PubMed search was also performed evaluating national rates of reconstruction, the demographic disparities, and the decision-making process behind undergoing reconstruction.

RESULTS

Among the 155 women surveyed, most (63%, n = 99) were 40 to 60 years old, 54.8% (n = 85) were African American, and 41.3% (n = 64) were white. Overall, patients agreed more strongly with questions related to body image as a motivating factor for breast reconstruction than they did with questions related to sexuality or femininity (mean score, 2.85 vs 3.26). When asked about their primary motivation for breast reconstruction, 76% of women agreed it was to maintain a balanced appearance, 34% agreed it was to continue to feel feminine, and 7.7% agreed it was to maintain sexual functioning. When asked about outside influences in pursuing breast reconstruction, the 51.6% of patients reported that they were urged by their referring physician to consider it, and most of the patients (58%) discussed the surgery with other breast cancer patients considering breast reconstruction.

CONCLUSIONS

Women pursuing breast reconstruction are motivated more by concerns of body image than issues of sexuality or femininity, which is independent of any demographic characteristics. It is important for referring physicians to recognize their role in initiating the discussion on reconstruction, and women would benefit from being referred to support groups to discuss their treatment and reconstruction with other breast cancer patients.

Reasons of not having breast reconstruction: a historical cohort of 1937 breast cancer patients undergoing mastectomy

Background

The aims of the study were to investigate the factors associated with not having breast reconstruction following mastectomy and to assess patient satisfaction with information on reconstruction.

Patients and methods

We analysed a historical cohort of 1937 consecutive patients who underwent mastectomy at Institut Curie between January 2004 and February 2007. Their sociodemographic and clinicobiological characteristics were recorded in a prospective database. A questionnaire was sent to 10% of nonreconstructed patients.

Results

The proportion of patients with invasive cancer was 82.7%. The rate of nonreconstruction in patients with in situ and invasive cancer was 34.6% and 74.9%, respectively. On multivariate analysis, only employment outside the home was associated with reconstruction in patients with in situ cancer (p < 0.001). In patients with invasive cancer, employment status (p < 0.001) and smoking (p = 0.045) were associated with reconstruction, while age > 50, ASA score >1, radiotherapy (p < 0.0001) and metastatic status (p = 0.018) were associated with nonreconstruction. For 80% of questionnaire responders, nonreconstruction was a personal choice, mainly for the following reasons: refusal of further surgery, acceptance of body asymmetry, risk of complications and advanced age. Information on reconstruction was entirely unsatisfactory or inadequate for 62% of patients.

Conclusion

Better understanding the factors that influence decision of nonreconstruction can help us adapt the information to serve the patient’s personal needs.

International rates of breast reconstruction after prophylactic mastectomy in BRCA1 and BRCA2 mutation carriers

BACKGROUND

Breast reconstruction is an option for women with BRCA1 or BRCA2 mutations who elect to undergo prophylactic mastectomy to prevent breast cancer. We report on the uptake of breast reconstruction after prophylactic mastectomy in women with BRCA mutations from eight countries.

METHODS

Women with a BRCA1 or BRCA2 mutation were questioned regarding their cancer preventive practices. Information was recorded on prophylactic mastectomy and breast reconstruction.

RESULTS

A total of 1,635 women with a BRCA1 or BRCA2 mutation who elected to undergo prophylactic mastectomy from eight countries were included. A total of 1,137 women (69.5%) had breast reconstruction after prophylactic mastectomy. A total of 58.7% of women over the age of 45 years at the time of prophylactic mastectomy had breast reconstruction compared to 77.6% of women 35 years of age or younger [odds ratio (OR) 0.36, 95% confidence interval (CI) 0.26-0.50, p < 0.001]. In addition, 62.9% of women with a breast cancer diagnosis (contralateral prophylactic mastectomy) had breast reconstruction after prophylactic mastectomy compared to 79.7% of women without a previous breast cancer diagnosis (OR 0.48, 95% CI 0.38-0.61, p < 0.001). A total of 66.9% of women from Canada had breast reconstruction after mastectomy compared to 71.9% of American women (OR 0.75, 95% CI 0.59-0.96, p = 0.02).

CONCLUSIONS

The majority of women elect for breast reconstruction after prophylactic mastectomy. However, younger women and those without a previous diagnosis of breast cancer are more likely to have breast reconstruction than older women or those with a previous diagnosis of cancer.

Trends in immediate breast reconstruction across insurance groups after enactment of breast cancer legislation

BACKGROUND

To improve access to breast reconstruction for mastectomy patients, the United States enacted the Women's Health and Cancer Rights Act in January of 1999. The objective of the current study was to evaluate the impact of this legislation on patients with different insurance plans.

METHODS

Women aged ≥18 years who underwent mastectomy for cancer were identified in the Nationwide Inpatient Sample database (2000-2009) and were classified according to their immediate breast reconstruction (IBR) status. Trends in rates of IBR were described for each insurance category. Multivariable logistic regression analysis with adjustment for age, race, estimated household income, and Elixhauser comorbidity index was performed to evaluate the relation between insurance status and IBR.

RESULTS

In total, 168,236 patients were identified who underwent a mastectomy during the study interval. Across the 10-year study period, rates of IBR increased 4.2-fold in Medicaid patients, 2.9-fold in Medicare patients, 2.6-fold in privately insured patients, and 2.1-fold in self-pay patients (P < .01). However, after adjustment for confounders, women without private insurance were less likely to undergo IBR compared with women who had private insurance (Medicaid: odds ratio [OR], 0.34; 95% confidence interval [CI], 0.32-0.37; Medicare: OR, 0.53; 95% CI, 0.49-0.58; self-pay: OR, 0.43; 95% CI, 0.37-0.50; other types of nonprivate insurance: OR, 0.64, 95% CI, 0.56-0.73).

CONCLUSIONS

After the enactment of policy designed to improve access to IBR, Medicaid and Medicare patients experienced the greatest relative increase in rates of IBR. Although policy changes had the most impact on traditionally underserved populations, disparities still exist. Future studies should endeavor to understand why such disparities have persisted.

Comparing thirty-day outcomes in prosthetic and autologous breast reconstruction: a multivariate analysis of 13,082 patients?

BACKGROUND

There is a paucity of multi-institutional data that directly compares short term outcomes of autologous and prosthetic breast reconstruction. The National Surgical Quality Improvement Program provides a unique data platform for evaluating peri-operative outcomes of these two main categories of breast reconstruction. It has detailed data from nearly 250 hospitals and over 13,000 patients. We performed risk-adjusted analysis of prosthetic and autologous breast reconstruction to compare 30-day morbidity outcomes.

METHODS

Patients who underwent prosthetic breast reconstruction or autologous tissue reconstruction from 2006 to 2010 were identified using operation descriptions. Over 240 tracked variables were extracted for patients undergoing breast reconstruction. Thirty-day postoperative outcomes were compared, and subgroup analysis was performed on the autologous population to describe outcomes of specific flap procedures. Reconstruction was analyzed as an independent risk factor for specific complications, with propensity scores used to help standardize compared patient populations. Regression analyses were performed using SPSS (version 20.0, Chicago, IL).

RESULTS

A total of 13,082 patients underwent breast reconstruction; 9786 patients received prosthetic reconstruction and 3296 received autologous reconstruction. Within the autologous cohort, 1608 (48.8%) patients underwent a pedicle TRAM flap, 1079 (32.7%) had a LD flap, and 609 (18.5%) received a free flap. Autologous reconstruction patients had higher rates of overall complications (12.47% vs 5.38%, p<.001), wound infection (5.46% vs 3.45%, p<.001), prosthesis/flap failure (3.13% vs 0.85%, p<.001), and reoperation (9.59% vs 6.76%, p<.001). Risk-adjusted multivariate analysis also showed autologous reconstruction to be a significant independent predictor of specific short term outcomes.

CONCLUSIONS

Using risk-adjusted models of a large multi-institutional database, we found that--relative to prosthetic reconstruction--autologous reconstruction had higher rates of 30-day overall complications, wound infection, prosthesis/flap failure, and reoperation. This may be due, in part, to a concomitant increase in operative time and higher case complexity. Taken with other reports such as NMBRA, this study helps to educate patients and surgeons alike on potential, comparative complications during the perioperative period.

Patients opting for breast reconstruction following mastectomy: an analysis of uptake rates and benefit

For women with breast cancer who undergo a mastectomy, breast reconstruction offers improved psychological and cosmetic outcomes. We analyzed the rates of breast reconstruction and potential benefits to these women. The review was based on a PubMed search using the terms "reconstruction," "mastectomy," "rates," "benefits," and "breast cancer." Breast-reconstruction rates have continued to rise in recent years; however, there are definite barriers to widespread use of this procedure. These barriers include age, ethnicity, income, tumor characteristics, and the need for adjuvant radiation therapy. There are notable psychological advantages to women who receive breast reconstruction. These women also express an improved quality of life. Breast reconstruction is an acceptable technique for women undergoing mastectomy. It should be offered to all women in an immediate or delayed fashion, with guidance from their physician about the benefits and risks.

Mediation of the effects of living in extremely poor neighborhoods by health insurance: breast cancer care and survival in California, 1996 to 2011

BACKGROUND

We examined the mediating effect of health insurance on poverty-breast cancer care and survival relationships and the moderating effect of poverty on health insurance-breast cancer care and survival relationships in California.

METHODS

Registry data for 6,300 women with breast cancer diagnosed between 1996 and 2000 and followed until 2011 on stage at diagnosis, surgeries, adjuvant treatments and survival were analyzed. Socioeconomic data were obtained for residences from the 2000 census to categorize neighborhoods: high poverty (30% or more poor), middle poverty (5%-29% poor) and low poverty (less than 5% poor). Primary payers or health insurers were Medicaid, Medicare, private or uninsured.

RESULTS

Evidence of survival mediation was observed for women with node negative breast cancer. The apparent effect of poverty disappeared in the presence of Medicare or private health insurance. Women who were so insured were advantaged on 8-year survival compared to the uninsured or those insured by Medicaid (OR = 1.89). Evidence of payer moderation by poverty was also observed for women with node negative breast cancer. The survival advantaging effect of Medicare or private insurance was stronger in low poverty (OR = 1.81) than it was in middle poverty (OR = 1.57) or in high poverty neighborhoods (OR = 1.16). This same pattern of mediated and moderated effects was also observed for early stage at diagnosis, shorter waits for adjuvant radiation therapy and for the receipt of sentinel lymph node biopsies. These findings are consistent with the theory that more facilitative social and economic capital is available in low poverty neighborhoods, where women with breast cancer may be better able to absorb the indirect and direct, but uncovered, costs of care. As for treatments, main protective effects as well as moderator effects indicative of protection, particularly in high poverty neighborhoods were observed for women with private health insurance.

CONCLUSIONS

America's multi-tiered health insurance system mediates the quality of breast cancer care. The system is inequitable and unjust as it advantages the well insured and the well to do. Recent health care reforms ought to be enacted in ways that are consistent with their federal legislative intent, that high quality health care be truly available to all.

Variation in the utilization of reconstruction following mastectomy in elderly women

BACKGROUND

Regardless of their age, women who choose to undergo postmastectomy reconstruction report improved quality of life as a result. However, actual use of reconstruction decreases with increasing age. Whereas this may reflect patient preference and clinical factors, it may also represent age-based disparity.

METHODS

Women aged 65 years or older who underwent mastectomy for DCIS/stage I/II breast cancer (2000-2005) were identified in the SEER-Medicare database. Overall and institutional rates of reconstruction were calculated. Characteristics of hospitals with higher and lower rates of reconstruction were compared. Pseudo-R² statistics utilizing a patient-level logistic regression model estimated the relative contribution of institution and patient characteristics.

RESULTS

A total of 19,234 patients at 716 institutions were examined. Overall, 6 % of elderly patients received reconstruction after mastectomy. Institutional rates ranged from zero to >40 %. Whereas 53 % of institutions performed no reconstruction on elderly patients, 5.6 % performed reconstructions on more than 20 %. Although patient characteristics (%ΔR² = 70 %), and especially age (%ΔR² = 34 %), were the primary determinants of reconstruction, institutional characteristics also explained some of the variation (%ΔR² = 16 %). This suggests that in addition to appropriate factors, including clinical characteristics and patient preferences, the use of reconstruction among older women also is influenced by the institution at which they receive care.

CONCLUSIONS

Variation in the likelihood of reconstruction by institution and the association with structural characteristics suggests unequal access to this critical component of breast cancer care. Increased awareness of a potential age disparity is an important first step to improve access for elderly women who are candidates and desire reconstruction.

Breast Reconstruction after Mastectomy at an Urban Community-Based Program

Reconstruction after mastectomy is an elective procedure. To date many factors have been associated with the choice of operation in these patients including socioeconomic status, insurance, age, comorbidities, and community factors. In an effort to understand the characteristics of patients who undergo reconstruction at our hospital, we performed a retrospective review of patients who received mastectomy at our institution. A total of 354 patients underwent mastectomy from 2006 to 2010 at our hospital. Data from 332 patients undergoing reconstruction within 1 year of mastectomy were then analyzed and x2 analysis was performed to identify factors significant in the choice of reconstruction. Age younger than 50 years (odds ratio [OR], 3.87), age older than 70 years (OR, 0.09), presence of insurance (OR, 2.89), diabetes (OR, 0.401), hypertension (OR, 0.379), and Medicare (0.182) were found to be significant factors associated with a choice of reconstruction among our patients. When age was corrected for, insurance status was no longer a significant factor in choice of reconstruction. Over 90 per cent of patients underwent implant or tissue expanders for reconstruction. This study reflects the reconstruction choices of patients in our community, city-based hospital.

Influence of health insurance, hospital factors and physician volume on receipt of immediate post-mastectomy reconstruction in women with invasive and non-invasive breast cancer

For women with breast cancer who undergo mastectomy, immediate breast reconstruction (IR) offers a cosmetic and psychological advantage. We evaluated the association between demographic, hospital, surgeon and insurance factors and receipt of IR. We conducted a retrospective hospital-based analysis with the Perspective database. Women who underwent a mastectomy for invasive breast cancer (IBC) and ductal carcinoma in situ (DCIS) from 2000 to 2010 were included. Logistic regression analysis was used to determine factors predictive of IR. Analyses were stratified by age (<50 vs. ≥ 50) and IBC versus DCIS. Of the 108,992 women with IBC who underwent mastectomy, 30,859 (28.3 %) underwent IR, as compared to 6,501 (44.2 %) of the 14,710 women with DCIS who underwent mastectomy underwent IR. In a multivariable model for IBC, increasing age, black race, being married, rural location, and increased comorbidities were associated with decreased IR. Odds ratios (OR) of IR increased with commercial insurance (OR 3.38) and Medicare (OR 1.66) insurance (vs. self-pay), high surgeon-volume (OR 1.19), high hospital-volume (OR 2.24), and large hospital size (OR 1.20). The results were identical for DCIS, and by age category. The absolute difference between the proportion of patients who received IR with commercial insurance compared to other insurance, increased over time. Immediate in-hospital complication rates were higher for flap reconstruction compared to implant or no reconstruction (15.2, 4.0, and 6.1 %, respectively, P < .0001). IR has increased significantly over time; however, modifiable factors such as insurance status, hospital size, hospital location, and physician volume strongly predict IR. Public policy should ensure that access to reconstructive surgery is universally available.

Utilization of mastectomy and reconstruction in the outpatient setting

BACKGROUND

Reconstruction rates after mastectomy have been reported to range from 25-40%; however, most studies have focused on patients treated in an inpatient setting. We sought to determine the utilization of outpatient mastectomy and use of breast reconstruction in Southern California.

METHODS

Postmastectomy reconstruction rates were determined from the California Office of Statewide Health Planning and Development database from 2006-2009 using CPT codes and similarly from an inpatient database using ICD-9 codes. Reconstruction rates were compared between the inpatient and outpatient setting. For the outpatient setting, univariate and multivariate odds ratios with 95% confidence intervals were estimated for relative odds of immediate reconstruction versus mastectomy alone.

RESULTS

The percentage of patients undergoing outpatient mastectomy ranged from 20.4 to 23.9% of the total number of all patients undergoing mastectomy. Whereas immediate inpatient reconstruction increased from 29.2 to 41.6% (overall rate 35.5%), the proportion of outpatients undergoing reconstruction only increased from 7.7 to 10.3% (overall rate 9.1%). Similar to the inpatient setting, in multivariate analysis, age, insurance status, race/ethnicity, and type of hospital were significantly associated with the use of reconstruction in the outpatient setting.

CONCLUSIONS

A substantial number of patients undergo outpatient mastectomy with low rates of reconstruction. Although the choice of an outpatient mastectomy may certainly represent a selection bias for those not choosing reconstruction, an increase in the use of outpatient mastectomy may result in decreases in the use of postmastectomy reconstruction.