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Chia Z, Lee RXN, Cardoso MJ, Cheung KL, Parks RM. Oncoplastic breast surgery in older women with primary breast cancer: systematic review. Br J Surg 2023; 110:1309-1315. [PMID: 37310128 PMCID: PMC10480033 DOI: 10.1093/bjs/znad161] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/02/2023] [Accepted: 05/06/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Oncoplastic procedures allow excision of larger breast tumours, or unfavourable tumour/breast ratio lesions while achieving a good cosmetic outcome. This increases the pool of patients eligible for breast conservation over mastectomy, reducing the need for more extensive surgery in older women and potentially improving their quality of life. Nonetheless, studies to date suggest a poor uptake of oncoplastic breast surgery in the older group. This review aimed to establish whether a disparity in uptake of oncoplastic breast surgery exists between older and younger women, and to explore the underlying reasons for this. METHODS A literature search was conducted on 17 January 2022 using MEDLINE and Embase. Eligible studies comprised full-text articles of patients who underwent oncoplastic breast surgery for primary invasive breast cancer, and included those aged at least 65 years. RESULTS Ten published studies were identified. One study was ranked as providing level 2 evidence, and the remainder were level 3. A total of 567 women underwent oncoplastic breast surgery for primary breast cancer, of whom only 61 (10.8 per cent) were aged 65 years or older. None of the studies directly compared younger with older women, or explored the underlying factors contributing to this discrepancy in uptake. CONCLUSION This review has demonstrated a lower uptake of oncoplastic breast surgery in older compared with younger women. Given the increasing number of older women living with breast cancer who may be eligible for breast-conserving surgery, further research into this area is required.
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Affiliation(s)
- Zoe Chia
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- King’s Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust, UK
| | - Rachel X N Lee
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- Queen’s Medical Centre Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Maria J Cardoso
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- Breast Unit, Champalimaud Foundation and Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Kwok Leung Cheung
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Ruth M Parks
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
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Ryan JF, Lesniak DM, Cordeiro E, Campbell SM, Rajaee AN. Surgeon Factors Influencing Breast Surgery Outcomes: A Scoping Review to Define the Modern Breast Surgical Oncologist. Ann Surg Oncol 2023; 30:4695-4713. [PMID: 37036590 DOI: 10.1245/s10434-023-13472-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/26/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Modern breast surgical oncology incorporates many aspects of care including preoperative workup, surgical management, and multidisciplinary collaboration to achieve favorable oncologic outcomes and high patient satisfaction. However, there is variability in surgical practice and outcomes. This review aims to identify modifiable surgeon factors influencing breast surgery outcomes and provide a definition of the modern breast surgical oncologist. METHODS A systematic literature search with additional backward citation searching was conducted. Studies describing modifiable surgeon factors with associated breast surgery outcomes such as rates of breast conservation, sentinel node biopsy, re-excision, complications, acceptable esthetic outcome, and disease-free and overall survival were included. Surgeon factors were categorized for qualitative analysis. RESULTS A total of 91 studies met inclusion criteria describing both modifiable surgeon factor and outcome data. Four key surgeon factors associated with improved breast surgery outcomes were identified: surgical volume (45 studies), use of oncoplastic techniques (41 studies), sub-specialization in breast surgery or surgical oncology (9 studies), and participation in professional development activities (5 studies). CONCLUSIONS On the basis of the literature review, the modern breast surgical oncologist has a moderate- to high-volume breast surgery practice, understands the use and application of oncoplastic breast surgery, engages in additional training opportunities, maintains memberships in relevant societies, and remains up to date on key literature. Surgeons practicing in breast surgical oncology can target these modifiable factors for professional development and quality improvement.
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Affiliation(s)
- Joanna F Ryan
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - David M Lesniak
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Erin Cordeiro
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Sandra M Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
| | - A Nikoo Rajaee
- Department of Surgery, University of Alberta, Edmonton, Canada.
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Stankowski TJ, Alagoz E, Jacobson N, Neuman HB. Factors Associated With Socioeconomic Disparities in Breast Reconstruction: Perspectives of Wisconsin Surgeons. Clin Breast Cancer 2023; 23:461-467. [PMID: 37069035 PMCID: PMC10664705 DOI: 10.1016/j.clbc.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/20/2023] [Accepted: 03/23/2023] [Indexed: 03/30/2023]
Abstract
INTRODUCTION The objective is to expand our understanding of the factors associated with receipt of breast reconstruction for socioeconomically disadvantaged women within Wisconsin. METHODS A purposeful sample of general/breast and plastic surgeons were identified. One-on-one interviews were conducted, audio-recorded, and transcribed in full (n = 15). Conventional content analysis was performed to identify themes. RESULTS Both general/breast and plastic surgeons perceived that general/breast surgeons served as gatekeepers to which patients are offered a referral for reconstruction. Given the additional recovery time, frequent clinic visits, and potential for complications associated with reconstruction, general/breast surgeons perceived that not all women prioritize it. Surgeons perceived this to be especially true for socioeconomically disadvantaged women. Surgeons identified time off work, travel for visits, and out-of-pocket costs as specific challenges to reconstruction experienced by socioeconomically disadvantaged women. Surgeons perceived that early education, incorporating financial considerations into discussions, and reducing travel burden may help to improve access to reconstruction. CONCLUSION Wisconsin surgeons described factors they perceived contributed to lower rates of reconstruction for socioeconomically disadvantaged women and described ways to increase reconstruction access.
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Affiliation(s)
- Trista J Stankowski
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Esra Alagoz
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Nora Jacobson
- Institute for Clinical and Translational Research and School of Nursing, University of Wisconsin-Madison, Madison, WI
| | - Heather B Neuman
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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Racial Disparities in Breast Reconstruction at a Comprehensive Cancer Center. J Racial Ethn Health Disparities 2022; 9:2323-2333. [PMID: 34647274 DOI: 10.1007/s40615-021-01169-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Breast reconstruction after a mastectomy is an important component of breast cancer care that improves the quality of life in breast cancer survivors. African American women are less likely to receive breast reconstruction than Caucasian women. The purpose of this study was to further investigate the reconstruction disparities we previously reported at a comprehensive cancer center by assessing breast reconstruction rates, patterns, and predictors by race. METHODS Data were obtained from women treated with definitive mastectomy between 2000 and 2012. Sociodemographic, tumor, and treatment characteristics were compared between African American and Caucasian women, and logistic regression was used to identify significant predictors of reconstruction by race. RESULTS African American women had significantly larger proportions of public insurance, aggressive tumors, unilateral mastectomies, and modified radical mastectomies. African American women had a significantly lower reconstruction rate (35% vs. 49%, p < 0.01) and received a larger proportion of autologous reconstruction (13% vs. 7%, p < 0.01) compared to Caucasian women. The receipt of adjuvant radiation therapy was a significant predictor of breast reconstruction in Caucasian but not African American women. CONCLUSIONS We identified breast reconstruction disparities in rate and type of reconstruction. These disparities may be due to racial differences in sociodemographic, tumor, and treatment characteristics. The predictors of breast reconstruction varied by race, suggesting that the mechanisms underlying breast reconstruction may vary in African American women. Future research should take a target approach to examine the relative contributions of sociodemographic, tumor, and treatment determinants of the breast reconstruction disparities in African American women.
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Dudley CM, Stankowski TJ, Tucholka JL, Schumacher JR, Poore SO, Neuman HB. Perspectives of Wisconsin Providers on Factors Influencing Receipt of Post-Mastectomy Breast Reconstruction. Clin Breast Cancer 2022; 22:840-846. [PMID: 36008204 PMCID: PMC10684062 DOI: 10.1016/j.clbc.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The objective is to determine perspectives of general surgeons, plastic surgeons, and cancer navigators on factors contributing to breast cancer patients' decision for post-mastectomy reconstruction, especially for women facing financial hardship. METHODS We mailed Wisconsin general and plastic surgeons who performed >5 breast cancer procedures annually a survey, including a postcard inviting cancer navigators to participate. Descriptive statistics summarize item responses. McNemar's chi-squared tests evaluated surgeons' perspectives of factors influencing reconstruction for all women compared to women facing financial hardship. RESULTS Respondents include 70 general surgeons, 18 plastic surgeons, and 9 navigators. Respondents perceived preference-related factors as important, including "does not want more surgery" (85% reported it important overall and 77% for financial hardship women) and "reconstructed breast is not important to her" (77% vs. 61%). Surgeons perceived logistical factors were more important for women facing financial hardship, including "capacity to be away from work or home responsibilities for recovery" (30% reported important overall and 60% for financial hardship women), "concerned about out-of-pocket costs" (26% vs. 57%), and "frequent visits to complete reconstruction too burdensome" (27% vs. 49%). CONCLUSION Our findings demonstrate Wisconsin surgeons and cancer navigators perceive logistical concerns influence reconstruction decisions for women facing financial hardship.
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Affiliation(s)
- Christina M Dudley
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Jessica R Schumacher
- University of Wisconsin School of Medicine and Public Health, Madison, WI; University of Wisconsin Carbone Cancer Center, Madison, WI
| | - Samuel O Poore
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Heather B Neuman
- University of Wisconsin School of Medicine and Public Health, Madison, WI; University of Wisconsin Carbone Cancer Center, Madison, WI.
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Access to Breast Reconstruction in Kuwait: Assessing Surgeon-related Factors as a Barrier to Referral. Plast Reconstr Surg Glob Open 2022; 10:e4633. [PMID: 36381485 PMCID: PMC9646627 DOI: 10.1097/gox.0000000000004633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/08/2022] [Indexed: 01/25/2023]
Abstract
UNLABELLED It is not uncommon for breast cancer patients to undergo a mastectomy without receiving or being presented with the option of having a breast reconstruction. With a low rate of breast reconstruction in Kuwait, we aim to assess physician-related factors as a barrier to referral. METHODS This is an online questionnaire-based study to investigate the variation in the referring general surgeons' knowledge and perception towards breast reconstructive surgery. RESULTS A total of 141 general surgeons responded to the questionnaire, and only 63 (44.7%) always discuss the available options for reconstruction with their breast cancer patients. When asked about referral to a plastic surgeon, only 49 (34.8%) responded with always, and the majority (N = 61; 43.3%) responded with sometimes. More than half (N = 73; 51.8%) believe that the general surgeon should determine patient suitability for referral to a plastic surgeon, while only 53 (37.6%) agree that breast cancer patients should always be referred to a plastic surgeon for consideration of reconstruction. The mean knowledge score was 6.6 of 8, while the mean perception score was 8.9 of 12. Responders with a higher total knowledge score were more likely to discuss with patients the availability of reconstruction. CONCLUSIONS Despite the acceptable knowledge scores in our general surgeons, there is a low rate of referral for breast reconstruction in Kuwait. There is a pressing need to generate legislations and a streamlined protocol for referral that facilitate access to breast reconstructive services.
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Lee RXN, Cardoso MJ, Cheung KL, Parks RM. Immediate breast reconstruction uptake in older women with primary breast cancer: systematic review. Br J Surg 2022; 109:1063-1072. [PMID: 35909248 PMCID: PMC10364779 DOI: 10.1093/bjs/znac251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/22/2022] [Accepted: 07/04/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Postmastectomy immediate breast reconstruction (PMIBR) may improve the quality of life of patients with breast cancer, of whom older women (aged 65 years or more) are a growing proportion. This study aimed to assess PMIBR in older women with regard to underlying impediments (if any). METHODS MEDLINE, Embase, and PubMed were searched by two independent researchers up to June 2022. Eligible studies compared PMIBR rates between younger and older women with invasive primary breast cancer. RESULTS A total of 10 studies (2012-2020) including 466 134 women were appraised, of whom two-thirds (313 298) were younger and one-third (152 836) older. Only 10.0 per cent of older women underwent PMIBR in contrast to 45.0 per cent of younger women. Two studies explored factors affecting uptake of PMIBR in older women; surgeon-associated (usual practice), patient-associated (socioeconomic status, ethnicity, and co-morbidities), and system-associated (insurance status and hospital location) factors were identified. CONCLUSION Uptake of PMIBR in older women is low with definable (and some correctable) barriers.
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Affiliation(s)
- Rachel Xue Ning Lee
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- Queen’s Medical Centre Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Maria Joao Cardoso
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- Breast Unit, Champalimaud Foundation and Nova Medical School Lisbon, Lisbon, Portugal
| | - Kwok Leung Cheung
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Ruth M Parks
- Correspondence to: Ruth M. Parks, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Uttoxeter Road, Derby DE22 3DT, UK (e-mail: )
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Stankowski TJ, Schumacher JR, Hanlon BM, Tucholka JL, Venkatesh M, Yang DY, Poore SO, Neuman HB. Barriers to breast reconstruction for socioeconomically disadvantaged women. Breast Cancer Res Treat 2022; 195:413-419. [PMID: 35969284 PMCID: PMC9639139 DOI: 10.1007/s10549-022-06697-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/27/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Socioeconomic disparities in post-mastectomy breast reconstruction exist. Key informants have suggested that finding providers who accept Medicaid insurance and longer travel time to a plastic surgeon are important barriers. Our objective was to assess the relationship between these factors and reconstruction for socioeconomically disadvantaged women in Wisconsin. METHODS We identified women < 75 years of age with stage 0-III breast cancer who underwent mastectomy using the Wisconsin Cancer Reporting System. Women in the most disadvantaged state-based tertile of the Area Deprivation Index were included (n = 1809). Geocoding determined turn-by-turn drive time from women's address to the nearest accredited Commission on Cancer or National Accreditation Program for Breast Centers. Multivariable logistic regression determined the relationship between reconstruction, Medicaid, and travel time, controlling for patient factors known to impact reconstruction. Average adjusted predicted probabilities of receiving reconstruction were calculated. RESULTS Most patients had early-stage breast cancer (51% stage 0/I) and 15.2% had Medicaid. 37% of women underwent reconstruction. Socioeconomically disadvantaged women with Medicaid (OR = 0.62, 95% CI 0.46-0.84) and longer travel times (OR = 0.99, 95% CI 0.99-1.0) were less likely to receive reconstruction. Patients with the lowest predicted probability of reconstruction were those with Medicaid who lived furthest from a plastic surgeon. CONCLUSION Among socioeconomically disadvantaged women, Medicaid and travel remained associated with lower rates of reconstruction. Further work will explore opportunities to improve access to reconstruction for women with Medicaid. This is particularly challenging as it may require socioeconomically disadvantaged women to travel further to receive care.
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Affiliation(s)
- Trista J Stankowski
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA
| | - Jessica R Schumacher
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA
- University of Wisconsin Carbone Cancer Center, Madison, USA
| | - Bret M Hanlon
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA
| | - Jennifer L Tucholka
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA
| | - Manasa Venkatesh
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA
| | - Dou-Yan Yang
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA
| | - Samuel O Poore
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA
| | - Heather B Neuman
- School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave, Madison, W 53792, USA.
- University of Wisconsin Carbone Cancer Center, Madison, USA.
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9
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Stalled at the intersection: insurance status and disparities in post-mastectomy breast reconstruction. Breast Cancer Res Treat 2022; 194:327-335. [PMID: 35699853 DOI: 10.1007/s10549-022-06639-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 05/24/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Post-mastectomy breast reconstruction (PMBR) is an important component of breast cancer treatment, but disparities relative to insurance status persist despite legislation targeting the issue. We aimed to study this relationship in a large health system combining a safety-net hospital and a private academic center. METHODS Data were collected on all patients who underwent mastectomy for breast cancer from 2011 to 2019 in a private academic center and an adjacent public safety-net hospital served by the same surgical teams. Multivariable logistic regression was used to assess the effect of insurance status on PMBR, controlling for covariates that included socioeconomic, demographic, and clinical factors. RESULTS Of 1554 patients undergoing mastectomy for breast cancer, 753 (48.5%) underwent PMBR, of which 592 (79.9%) were privately insured, 50 (6.7%) Medicare, 68 (9.2%) Medicaid, and 31 (4.2%) uninsured. Multivariable logistic regression showed a significantly higher likelihood of not undergoing PMBR for uninsured (OR 6.0, 95% CI 3.7-9.8; p < 0.0001), Medicare (OR 1.9, (95% CI 1.2-3.0; p = 0.006), and Medicaid (OR 1.5, 95% CI 1.0-2.3; p = 0.04) patients compared with privately insured patients. Age, stage, race and ethnicity, and hospital type confounded this relationship. CONCLUSION Patients without health insurance have dramatically reduced access to PMBR compared to those with private insurance. Expanding access to this important procedure is essential to achieve greater health equity for breast cancer patients.
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Fasano G, Bayard S, Tamimi R, An A, Zenilman ME, Davis M, Newman L, Bea VJ. Postmastectomy Breast Reconstruction Patterns at an Urban Academic Hospital and the Impact of Surgeon Gender. Ann Surg Oncol 2022; 29:5437-5444. [PMID: 35583690 PMCID: PMC9116063 DOI: 10.1245/s10434-022-11807-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/08/2022] [Indexed: 11/18/2022]
Abstract
Background Postmastectomy breast reconstruction is an essential element of multidisciplinary breast cancer care but may be underutilized. Methods This retrospective study analyzed mastectomy patients (2018–2021) at an urban hospital. Multivariable logistic regression was performed, and a mixed-effects logistic regression model was constructed to determine patient-level factors (age, race, body mass index, comorbidities, smoking status, insurance, type of surgery) and provider-level factors (breast surgeon gender, participation in multidisciplinary breast clinic) that influence reconstruction. Results Overall, 167 patients underwent mastectomy. The reconstruction rate was 35%. In multivariable analysis, increasing age (odds ratio [OR] 0.95; 95% confidence interval [CI] 0.91–0.99) and Medicaid insurance (OR 0.18; 95% CI 0.06–0.53) relative to private insurance were negative predictors, whereas bilateral mastectomy was a positive predictor (OR 7.07; 95% CI 2.95–17.9) of reconstruction. After adjustment for patent age, race, insurance, and type of surgery, female breast surgeons had 3.7 times greater odds of operating on patients who had reconstruction than males (95% CI 1.20–11.42). Conclusion Both patient- and provider-level factors have an impact on postmastectomy reconstruction. Female breast surgeons had nearly four times the odds of caring for patients who underwent reconstruction, suggesting that a more standardized process for plastic surgery referral is needed.
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Affiliation(s)
- Genevieve Fasano
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Solange Bayard
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Rulla Tamimi
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Anjile An
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Michael E Zenilman
- Department of Surgery, New York-Presbyterian, Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Melissa Davis
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Lisa Newman
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Vivian J Bea
- Department of Surgery, New York-Presbyterian, Brooklyn Methodist Hospital, Brooklyn, NY, USA.
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Coudé Adam H, Docherty Skogh AC, Edsander Nord Å, Schultz I, Gahm J, Hall P, Frisell J, Halle M, de Boniface J. Survival in breast cancer patients with a delayed DIEP flap breast reconstruction after adjustment for socioeconomic status and comorbidity. Breast 2021; 59:383-392. [PMID: 34438278 PMCID: PMC8390766 DOI: 10.1016/j.breast.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 06/15/2021] [Accepted: 07/03/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose Overall survival in breast cancer patients receiving a delayed deep inferior epigastric perforator (DIEP) flap breast reconstruction is better than in those without delayed breast reconstruction. This study aimed at determining the impact of socioeconomic status (SES) and comorbidity on these observations. Materials and methods This matched cohort study included all consecutive women undergoing a delayed DIEP flap reconstruction at Karolinska University Hospital, Sweden, between 1999 and 2013. Controls had not received any delayed breast reconstruction and were relapse-free after a corresponding follow-up interval. Matching was by year of and age at mastectomy, tumour stage and lymph node status. Charlson Comorbidity Index (CCI) and socioeconomic data were obtained from national registers. Associations with breast cancer-specific (BCSS) and overall survival (OS) were investigated by Kaplan-Meier survival estimates and Cox proportional hazard regression analysis. Results Women in the DIEP group (N = 254) more often continued education after primary school (88.6% versus 82.6%, P = 0.026), belonged to the high-income group (76.0% versus 63.1%, P < 0.001), were in a partnership (57.1% versus 55.7%, P = 0.024) and healthier (median CCI 1.00 (range 0–13) versus 2.00 (range 0–16), P = 0.021) than the control group (N = 729). After adjustment for tumour and treatment factors, SES and comorbidity, OS remained significantly better for the DIEP group than the control group (HR 2.27, 95% CI 1.44–3.55). Conclusion Women with a delayed DIEP flap reconstruction are a subgroup of higher socioeconomic status and better health. Higher survival estimates for the DIEP group persisted after adjusting for those differences, suggesting the presence of further unmeasured covariates. Women with a delayed DIEP flap reconstruction have a higher socioeconomic status. They also have less comorbidity than women with no delayed reconstruction. Superior survival in DIEP patients is not eliminated by adjustments for such differences. Unmeasured selection to the reconstructive process may explain observed survival differences.
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Affiliation(s)
- H Coudé Adam
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| | - A C Docherty Skogh
- Department of Surgery, Breast Cancer Center, South General Hospital, Stockholm, Sweden; Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Å Edsander Nord
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - I Schultz
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - J Gahm
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - P Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Oncology, South General Hospital, Stockholm, Sweden
| | - J Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - M Halle
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - J de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Breast Unit, Capio St. Göran's Hospital, Stockholm, Sweden
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Rayzah M, Ryu JM, Lee JH, Nam SJ, Kim SW, Lee SK, Yu J, Lee KT, Bang SI, Mun GH, Pyon JK, Jeon BJ, Lee JE. Changes in Korean National Healthcare Insurance Policy and Breast Cancer Surgery Trend in Korea. J Korean Med Sci 2021; 36:e194. [PMID: 34313035 PMCID: PMC8313396 DOI: 10.3346/jkms.2021.36.e194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/20/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Since April 2015, the Korean National Health Insurance (NHI) has reimbursed breast cancer patients, approximately 50% of the cost of the breast reconstruction (BR) procedure. We aimed to investigate NHI reimbursement policy influence on the rate of immediate BR (IBR) following total mastectomy (TM). METHODS We retrospectively analyzed breast cancer data between April 2011 and June 2016. We divided patients who underwent IBR following TM for primary breast cancer into "uninsured" and "insured" groups using their NHI statuses at the time of surgery. Univariate analyses determined the insurance influence on the decision to undergo IBR. RESULTS Of 2,897 breast cancer patients, fewer uninsured patients (n = 625) underwent IBR compared with those insured (n = 325) (30.0% vs. 39.8%, P < 0.001). Uninsured patients were younger than those insured (median age [range], 43 [38-48] vs. 45 [40-50] years; P < 0.001). Pathologic breast cancer stage did not differ between the groups (P = 0.383). More insured patients underwent neoadjuvant chemotherapy (P = 0.011), adjuvant radiotherapy (P < 0.001), and IBR with tissue expander insertion (P = 0.005) compared with those uninsured. CONCLUSION IBR rate in patients undergoing TM increased after NHI reimbursement.
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Affiliation(s)
- Musaed Rayzah
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Surgery, College of Medicine, Majmaah University, Ministry of Education, Riyadh, Saudi Arabia
| | - Jai Min Ryu
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Hee Lee
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Jin Nam
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Won Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se Kyung Lee
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jonghan Yu
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyeong Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sa Ik Bang
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Goo Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jai Kyong Pyon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung Joon Jeon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Eon Lee
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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13
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Connors SK, Leal IM, Nitturi V, Iwundu CN, Maza V, Reyes S, Acquati C, Reitzel LR. Empowered Choices: African-American Women's Breast Reconstruction Decisions. Am J Health Behav 2021; 45:352-370. [PMID: 33888195 PMCID: PMC8383809 DOI: 10.5993/ajhb.45.2.14] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objectives: Breast reconstruction (BR) potentially can improve quality of life in postmastectomy breast cancer survivors (BCS); however, African-American women are less likely to undergo BR than Caucasian women. This qualitative study was undertaken to explore individual, sociocultural, and contextual factors influencing African-American women's BR decision-making processes and preferences. Methods: Postmastectomy African-American BCS with and without BR participated in semi-structured interviews. We adopted a grounded theory approach using the constant comparison method to understand the contexts and processes informing participants' BR decision-making. Results: Twenty-three women participated, of whom 17 elected BR and 6 did not. Whereas women's primary reasons for deciding for or against BR differed, our core category, "empowered choices ," describes both groups' decision-making as a process focused on empowering themselves physically and/or psychologically, through self-advocacy, informed and shared decision-making, and giving back/receiving communal and spiritual support from church and African-American survivor groups. Socioeconomic factors influenced women's access to BR. Women preferred autologous BR and expressed the need for greater culturally-matched resources and support to inform treatment and shared BR decision-making. Conclusions: Understanding and supporting African-American women's BR preferences and empowerment is essential to ensuring equal access, and culturally-relevant, high-quality, and informed patient-centered care.
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Affiliation(s)
- Shahnjayla K Connors
- Shahnjayla K. Connors, Assistant Professor, Department of Social Sciences, University of Houston-Downtown, Houston, TX, United States
| | - Isabel Martinez Leal
- Isabel Martinez Leal, Research Associate II, Social and Behavioral Science, Department of Psychological, Health, and Learning Sciences, University of Houston, Houston, TX, United States;,
| | - Vijay Nitturi
- Vijay Nitturi, Research Assistant, Department of Psychological, Health, and Learning Sciences, University of Houston, Houston, TX, United States
| | - Chisom N Iwundu
- Chisom N. Iwundu, Postdoctoral Fellow, Department of Psychological Health and Learning Sciences, University of Houston, Houston, TX, United States
| | - Valentina Maza
- Valentina Maza, Research Assistant, Department of Psychological, Health, and Learning Sciences, University, Houston, Houston, TX, United States
| | - Stacey Reyes
- Stacey Reyes, Research Assistant, Department of Social Sciences, University of Houston-Downtown, Houston, TX, United States
| | - Chiara Acquati
- Chiara Acquati, Assistant Professor, Graduate College of Social Work, University of Houston, Houston, TX, United States
| | - Lorraine R Reitzel
- Lorraine R. Reitzel, Professor, Department of Psychological, Health, and Learning Sciences, University of Houston, Houston, TX, United States
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14
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Laterality and Patient-Reported Outcomes following Autologous Breast Reconstruction with Free Abdominal Tissue: An 8-Year Examination of BREAST-Q Data. Plast Reconstr Surg 2020; 146:964-975. [PMID: 33141527 DOI: 10.1097/prs.0000000000007239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite the rise in rates of contralateral prophylactic mastectomy, few studies have used patient-reported outcomes to assess satisfaction between unilateral and bilateral breast reconstruction with autologous tissue. The purpose of this study was to investigate patient satisfaction and quality of life following autologous reconstruction to determine whether differences exist between unilateral and bilateral reconstructions to better guide clinical decision-making. METHODS The current study examined prospectively collected BREAST-Q results following abdominal free flap breast reconstruction procedures performed at a tertiary academic medical center from 2009 to 2017. The reconstruction module of the BREAST-Q was used to assess outcomes between laterality groups (unilateral versus bilateral) at 1 year, 2 years, 3 years, and more than 3 years. RESULTS Overall, 405 patients who underwent autologous breast reconstruction completed the BREAST-Q. Cross-sectional analysis at 1 year, 2 years, and 3 years revealed similar satisfaction scores between groups; however, bilateral reconstruction patients demonstrated higher satisfaction scores at more than 3 years (p = 0.04). Bilateral reconstruction patients reported lower scores of abdominal well-being at 1 year, 2 years, and more than 3 years (p = 0.01, p = 0.03, and p = 0.01, respectively). CONCLUSIONS These results suggest that satisfaction with breasts does not differ with the laterality of the autologous reconstruction up to 3 years postoperatively but may diverge thereafter. Bilateral reconstruction patients, however, have lower satisfaction with the abdominal donor site. These data can be used in preoperative counseling, informed consent, and expectations management in patients considering contralateral prophylactic mastectomy.
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15
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Hart SE, Momoh AO. Breast Reconstruction Disparities in the United States and Internationally. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00366-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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16
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Disparities in Postmastectomy Breast Reconstruction: A Systematic Review of the Literature and Modified Framework for Advancing Research Toward Intervention. Ann Plast Surg 2019; 81:495-502. [PMID: 29851727 DOI: 10.1097/sap.0000000000001503] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND As the United States' population diversifies, eliminating disparities in health and healthcare has become increasingly important across all disciplines of medicine, including plastic and reconstructive surgery. This is evidenced by the growing body of literature in recent years focusing on disparities in postmastectomy breast reconstruction. No study to date has evaluated whether this research is progressing appropriately to promote tangible evidence-based interventions to reduce these disparities. METHODS A systematic literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was performed to identify studies focusing on disparities in postmastectomy breast reconstruction. A previously established public health framework for advancing health disparities research was used to inform analysis of the quality and progression of the included studies. This triphasic framework categorizes disparities research as follows: detecting (identifies and measures disparities in vulnerable populations), understanding (establishes determinants of disparities), or reducing (proposes and evaluates interventions for eliminating disparities). RESULTS Ninety-five studies were identified between 1979 and 2016, with 61 (64.2%) published after 2010. The majority of studies (51.6%) were retrospective cohort or case-control studies (American Society of Plastic Surgery level III evidence). Fifty-eight (63.7%), 31 (34.1%), and 2 (2.2%) studies provided detecting-, understanding- and reducing-phase disparities research, respectively. Non-plastic and reconstructive surgery journals accounted for 70.5% of all articles and for most higher phase research articles, publishing 83.9% and 100% of second and third phase studies, respectively. Disparity categories investigated included race/ethnicity, age, income, insurance status/type, geography, and education level, with race/ethnicity being the most common (73.7%). The most commonly measured outcome was percent of subpopulation receiving reconstruction (63, 66.3%), followed by reconstruction type (14, 16.7%). Patient-, provider-, system-, and research-level factors were all identified as potential targets for interventions to reduce disparities. CONCLUSIONS Despite a recent increase in literature focusing on postmastectomy breast reconstruction disparities, the majority focuses on identifying vulnerable populations with inadequate progression to second (understanding) and third (reducing) phases. Increasing research funding, availability of language-concordant and culturally concordant educational materials, and advocacy and sociopolitical awareness within the plastic surgery community is necessary to advance research on postmastectomy breast reconstruction and, ultimately, eliminate it.
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17
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Krigel A, Chen L, Wright JD, Lebwohl B. Substantial Increase in Anesthesia Assistance for Outpatient Colonoscopy and Associated Cost Nationwide. Clin Gastroenterol Hepatol 2019; 17:2489-2496. [PMID: 30625407 DOI: 10.1016/j.cgh.2018.12.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/20/2018] [Accepted: 12/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The use of anesthesia assistance (AA) for outpatient colonoscopy has been increasing over the past decade, raising concern over its effects on procedure safety, quality, and cost. We performed a nationwide claims-based study to determine regional, patient-related, and facility-related patterns of anesthesia use as well as cost implications of AA for payers. METHODS We analyzed the Premier Perspective database to identify patients undergoing outpatient colonoscopy at over 600 acute-care hospitals throughout the United States from 2006 through 2015, with or without AA. We used multivariable analysis to identify factors associated with AA and cost. RESULTS We identified 4,623,218 patients who underwent outpatient colonoscopy. Of these, 1,671,755 (36.2%) had AA; the proportion increased from 16.7% in 2006 to 58.1% in 2015 (P < .001). Factors associated with AA included younger age (odds ratios [ORs], compared to patients 18-39 years old: 0.94, 0.82, 0.77, 0.72, and 0.77 for age groups 40-49 years, 50-59 years, 60-69 years, 70-79 years, and ≥80 years, respectively); and female sex (OR, 0.96 for male patients compared to female patients; 95% CI, 0.95-0.96). Black patients were less likely to receive AA than white patients (OR, 0.81; 95% CI, 0.81-0.82), although this difference decreased with time. The median cost of outpatient colonoscopy with AA was higher among all payers, ranging from $182.43 (95% CI, $180.80-$184.06) higher for patients with commercial insurance to $232.62 (95% CI, $222.58-$242.67) higher for uninsured patients. CONCLUSIONS In an analysis of a database of patients undergoing outpatient colonoscopy throughout the United States, we found that the use of AA during outpatient colonoscopy increased significantly from 2006 through 2015, associated with increased cost for all payers. The increase in anesthesia use mandates evaluation of its safety and effectiveness in colorectal cancer screening programs.
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Affiliation(s)
- Anna Krigel
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Ling Chen
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University, New York, New York; Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Benjamin Lebwohl
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York; Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.
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18
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Richards CA, Rundle AG, Wright JD, Hershman DL. Association Between Hospital Financial Distress and Immediate Breast Reconstruction Surgery After Mastectomy Among Women With Ductal Carcinoma In Situ. JAMA Surg 2019; 153:344-351. [PMID: 29214316 DOI: 10.1001/jamasurg.2017.5018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Hospital financial distress (HFD) is a state in which a hospital is at risk of closure because of its financial condition. Hospital financial distress may reduce the services a hospital can offer, particularly unprofitable ones. Few studies have assessed the association of HFD with quality of care. Objective To examine the association between HFD and receipt of immediate breast reconstruction surgery after mastectomy among women diagnosed with ductal carcinoma in situ (DCIS). Design, Setting, and Participants This retrospective cohort study assessed data from the Nationwide Inpatient Sample of 5760 women older than 18 years (mean [SD] age: 57.5 [13.2]) with DCIS who underwent mastectomy in 2008-2012 at hospitals categorized by financial distress. Women treated at 1156 hospitals located in 538 different counties across Arkansas, Arizona, California, Colorado, Connecticut, Florida, Iowa, Kentucky, Massachusetts, Maryland, Missouri, North Carolina, New Hampshire, New Jersey, Nevada, New York, Oregon, Pennsylvania, Rhode Island, Utah, Virginia, Vermont, Washington, Wisconsin, West Virginia, and Wyoming were included. Of these, 2385 women (41.4%) underwent immediate breast reconstruction surgery. Women with invasive cancer were excluded. The database included unique hospital identification variables, and participants were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Data were analyzed from January 1, 2012, to February 28, 2014. Main Outcomes and Measures The primary outcome was the adjusted association between HFD and receipt of immediate breast reconstruction surgery after mastectomy. Results In this analysis of database information, 2385 of 5760 women (41.4%) received immediate breast reconstruction surgery. Of these, 693 (36.7%) were treated at a hospital under high HFD and received immediate breast reconstruction surgery compared with 863 (44.0%) treated at a hospital under low HFD (P < .001). Reconstruction surgery was associated with younger age, white race, private insurance, treatment at a teaching and cancer hospital, private hospital ownership, and the percentage of individuals in the county with insurance. After adjustment, women treated at hospitals under high HFD (OR, 0.79; 95% CI, 0.62-0.99) and medium HFD (OR, 0.76; 95% CI, 0.61-0.94) were significantly less likely to receive reconstruction than women treated at hospitals with low to no HFD. Conclusions and Relevance The financial strength of the hospital where a patient receives treatment is associated with receipt of immediate breast reconstruction surgery. In addition to focusing on patient-related factors, efforts to improve quality should also focus on hospital-related factors.
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Affiliation(s)
| | - Andrew G Rundle
- Department of Epidemiology, Columbia University, New York, New York
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York
| | - Dawn L Hershman
- Department of Epidemiology, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York.,Department of Medicine, Columbia University Medical Center, New York, New York
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19
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Feng Y, Flitcroft K, van Leeuwen MT, Elshaug AG, Spillane A, Pearson SA. Patterns of immediate breast reconstruction in New South Wales, Australia: a population-based study. ANZ J Surg 2019; 89:1230-1235. [PMID: 31418524 PMCID: PMC6852512 DOI: 10.1111/ans.15381] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 06/21/2019] [Accepted: 06/24/2019] [Indexed: 11/28/2022]
Abstract
Background The rate of immediate breast reconstruction (IBR) following mastectomy for breast cancer in Australia is low and varies between regions. To date, no previous Australian studies have examined IBR rates between all hospitals within a particular jurisdiction, despite hospitals being an important known contributor to variation in IBR rates in other countries. Methods We used cross‐classified random‐effects logistic regression models to examine the inter‐hospital variation in IBR rates by using data on 7961 women who underwent therapeutic mastectomy procedures in New South Wales (NSW) between January 2012 and June 2015. We derived IBR rates by patient‐, residential neighbourhood‐ and hospital‐related factors and investigated the underlying drivers for the variation in IBR. Results We estimated the mean IBR rate across all hospitals performing mastectomy to be 17.1% (95% Bayesian credible interval (CrI) 12.1–23.1%) and observed wide inter‐hospital variation in IBR (variance 4.337, CrI 2.634–6.889). Older women, those born in Asian countries (odds ratio (OR) 0.5, CrI 0.4–0.6), residing in neighbourhoods with lower socioeconomic status (OR 0.7, CrI 0.5–0.8 for the most disadvantaged), and who underwent surgery in public hospitals (OR 0.4, CrI 0.1–1.0) were significantly less likely to have IBR. Women residing in non‐metropolitan areas and attending non‐metropolitan hospitals were significantly less likely to undergo IBR than their metropolitan counterparts attending metropolitan hospitals. Conclusion Wide inter‐hospital variation raises concerns about potential inequities in access to IBR services and unmet demand in certain areas of NSW. Explaining the underlying drivers for IBR variation is the first step in identifying policy solutions to redress the issue.
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Affiliation(s)
- Yingyu Feng
- Menzies Centre for Health Policy, Sydney School of Public Health, Charles Perkins Centre D17, The University of Sydney, Sydney, New South Wales, Australia.,Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kathy Flitcroft
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Breast and Surgical Oncology, The Poche Centre, Sydney, New South Wales, Australia
| | - Marina T van Leeuwen
- Centre for Big Data Research in Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Adam G Elshaug
- Menzies Centre for Health Policy, Sydney School of Public Health, Charles Perkins Centre D17, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Spillane
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Breast and Surgical Oncology, The Poche Centre, Sydney, New South Wales, Australia.,Breast and Melanoma Surgery Units, The Mater Hospital, Sydney, New South Wales, Australia.,Breast and Melanoma Surgery Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Sallie-Anne Pearson
- Menzies Centre for Health Policy, Sydney School of Public Health, Charles Perkins Centre D17, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Big Data Research in Health, The University of New South Wales, Sydney, New South Wales, Australia
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20
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Abstract
BACKGROUND The purpose of this systematic review was to comprehensively summarize barriers of access to breast reconstruction and evaluate access using the Penchansky and Thomas conceptual framework based on the six dimensions of access to care. METHODS The authors performed a systematic review that focused on (1) breast reconstruction, (2) barriers, and (3) breast cancer. Eight databases (i.e., EMBASE, MEDLINE, PsycINFO, CINHAL, ePub MEDLINE, ProQuest, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials) were searched. English peer-reviewed articles published between 1996 and 2016 were included. RESULTS The authors' search retrieved 4282 unique articles. Two independent reviewers screened texts, selecting 99 articles for inclusion. All studies were observational and qualitative in nature. The availability of breast reconstruction was highest in teaching hospitals, private hospitals, and national cancer institutions. Accessibility affected access, with lower likelihood of breast reconstruction in rural geographic locations. Affordability also impacted access; high costs of the procedure or poor reimbursement by insurance companies negatively influenced access to breast reconstruction. Acceptability of the procedure was not universal, with unfavorable physician attitudes toward breast reconstruction and specific patient and tumor characteristics correlating with lower rates of breast reconstruction. Lastly, lack of patient awareness of breast reconstruction reduced the receipt of breast reconstruction. CONCLUSIONS Using the access-to-care framework by Penchansky and Thomas, the authors found that barriers to breast reconstruction existed in all six domains and interplayed at many levels. The authors' systematic review analyzed this complex relationship and suggested multiprong interventions aimed at targeting breast reconstruction barriers, with the goal of promoting equitable access to breast reconstruction for all breast cancer patients.
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21
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Angarita FA, Dossa F, Zuckerman J, McCready DR, Cil TD. Is immediate breast reconstruction safe in women over 70? An analysis of the National Surgical Quality Improvement Program (NSQIP) database. Breast Cancer Res Treat 2019; 177:215-224. [PMID: 31154580 DOI: 10.1007/s10549-019-05273-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE The safety of immediate breast reconstruction (IBR) in older women is largely unknown. This study aimed to determine the 30-day postoperative complication rates following IBR (implant-based or autologous) in older women (≥ 70 years) with breast cancer and to compare them to younger women (18-69 years). METHODS The National Surgical Quality Improvement Program (NSQIP) database was used to identify women with in situ or invasive breast cancer who underwent IBR (2005-2016). Outcomes included 30-day postoperative morbidity and mortality, which were compared across age groups stratified by type of reconstruction. RESULTS Of 28,850 women who underwent implant-based and 9123 who underwent autologous reconstruction, older women comprised 6.5% and 5.7% of the sample, respectively. Compared to younger women, older women had more comorbidities, shorter operative times, and longer length of hospital stay. In the implant-based reconstruction group, the 30-day morbidity rate was significantly higher in older women (7.5% vs 5.3%, p < 0.0001) due to higher rates of infectious, pulmonary, and venous thromboembolic events. Wound morbidity and prosthesis failure occurred equally among age groups. In the autologous reconstruction group, there was no statistically significant difference in the 30-day morbidity rates (older 9.5% vs younger 11.6%, p = 0.15). Both wound morbidity and flap failure rates were similar between the two age groups. For both reconstruction techniques, mortality within 30 days of breast surgery was rare. CONCLUSION Immediate breast reconstruction is safe in older women. These data support the notion that surgeons should discuss IBR as a safe and integral part of cancer treatment in well-selected older women.
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Affiliation(s)
- Fernando A Angarita
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Fahima Dossa
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jesse Zuckerman
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - David R McCready
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Tulin D Cil
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada. .,Department of Surgery, Women's College Hospital, Toronto, ON, Canada. .,Division of General Surgery, University Health Network, 610 University Ave, OPG- 6th Floor, Toronto, ON, M5G 2M9, Canada.
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22
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Sergesketter AR, Thomas SM, Lane WO, Orr JP, Shammas RL, Fayanju OM, Greenup RA, Hollenbeck ST. Decline in Racial Disparities in Postmastectomy Breast Reconstruction: A Surveillance, Epidemiology, and End Results Analysis from 1998 to 2014. Plast Reconstr Surg 2019; 143:1560-1570. [PMID: 31136468 PMCID: PMC6708552 DOI: 10.1097/prs.0000000000005611] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite increasing emphasis on reducing racial disparities in breast cancer care in the United States, it remains unknown whether access to breast reconstruction has improved over time. The authors characterized contemporary patterns of breast reconstruction by race and ethnicity. METHODS The Surveillance, Epidemiology, and End Results database was used to identify women undergoing mastectomy for stage 0 to III breast cancer from 1998 to 2014. Multivariable logistic regression was used to estimate the association of demographic factors with likelihood of postmastectomy reconstruction. Multivariable logistic regression was used to predict reconstruction subtype. Patients undergoing reconstruction were grouped by diagnosis year to assess change in the population over time by race and ethnicity. RESULTS Of 346,418 patients, 21.8 percent underwent immediate reconstruction. Non-Hispanic black race (OR, 0.71) and Hispanic ethnicity (OR, 0.63) were associated with a decreased likelihood of reconstruction (all p < 0.001). Race was predictive of reconstruction type, with non-Hispanic black (OR, 1.52) and Hispanic women (OR, 1.22) more likely to undergo autologous versus implant-based reconstruction (p < 0.001). Although rates of reconstruction increased over time across all races, non-Hispanic black and Hispanic patients had a higher adjusted per-year increase in rate of reconstruction compared with non-Hispanic white patients (interaction p < 0.001). CONCLUSIONS Rates of postmastectomy reconstruction have increased more quickly over time for minority women compared with white women, suggesting that racial disparities in breast reconstruction may be improving. However, race continues to be associated with differences in types and rates of reconstruction. Further research is necessary to continue to improve access to breast reconstruction in the United States. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Amanda R Sergesketter
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
| | - Samantha M Thomas
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
| | - Whitney O Lane
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
| | - Jonah P Orr
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
| | - Ronnie L Shammas
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
| | - Oluwadamilola M Fayanju
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
| | - Rachel A Greenup
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
| | - Scott T Hollenbeck
- From the Division of Plastic, Maxillofacial, and Oral Surgery and the Department of Surgery, Duke University Medical Center; and the Department of Biostatistics and Bioinformatics, Duke Cancer Institute
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23
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Riggio E, Toffoli E, Tartaglione C, Marano G, Biganzoli E. Local safety of immediate reconstruction during primary treatment of breast cancer. Direct-to-implant versus expander-based surgery. J Plast Reconstr Aesthet Surg 2018; 72:232-242. [PMID: 30497914 DOI: 10.1016/j.bjps.2018.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 10/14/2018] [Accepted: 10/28/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION After mastectomy, immediate breast reconstruction is paramount. With the growing number of nipple-sparing mastectomies, the chances of successful one-stage reconstruction with implants are also increasing. Local safety is one of the main issues. This study investigated the factors that could lead to major or minor complications after expander-based versus direct-to-implant (DTI) reconstruction. METHODS The studied factors were age, body mass index (BMI), hypertension, smoking, diabetes, type of mastectomy (nipple-sparing/total), implant size, neoadjuvant/adjuvant chemotherapy, and radiotherapy. The study sample included 294 immediate reconstructions over 3 years. The primary outcome was the incidence of complications, major or minor depending on the necessity of revision surgery. For the DTI pocket, we applied a variant of the conventional submuscular technique. RESULTS In DTI reconstructions (median follow-up 26 months), the complication rate was 17.2% (4.3% major and 12.8% minor) with no significant association with clinical variables. In expander-based reconstructions (median follow-up 19 months), the complication rate was 18.3% (12.5% major and 5.8% minor). Univariate analysis showed a significant association between overall complications and radiotherapy (P = 0.01) as well as between major complications and expander size (P < 0.005), BMI (P < 0.005), and radiotherapy (P < 0.01); radiotherapy and BMI retained significance in multivariate analysis. Neoadjuvant/adjuvant chemotherapy did not affect the complication rate. CONCLUSIONS There was evidence of an association between major complications and clinical variables in the expander-based cohort. Larger expander size was a predictor of failure, especially combined with radiation. Direct-to-implant reconstruction proved to be safe. We describe a reliable method of reconstruction and a safe range of implant sizes even beyond 500 g.
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Affiliation(s)
- Egidio Riggio
- Unit of Plastic and Reconstructive Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy.
| | - Elisa Toffoli
- Unit of Plastic and Reconstructive Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy
| | - Caterina Tartaglione
- Unit of Plastic and Reconstructive Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy
| | - Giuseppe Marano
- Laboratory of Medical Statistics, Biometry and Bioinformatics G.A. Maccacaro, Department of Clinical Science and Community Health, University of Milan, 20133 Milan, Italy
| | - Elia Biganzoli
- Laboratory of Medical Statistics, Biometry and Bioinformatics G.A. Maccacaro, Department of Clinical Science and Community Health, University of Milan, 20133 Milan, Italy; Unit of Medical Statistics, Biometry and Bioinformatics, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
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Wright JD, Chen L, Accordino M, Taback B, Ananth CV, Neugut AI, Hershman DL. Regional Market Competition and the Use of Immediate Breast Reconstruction After Mastectomy. Ann Surg Oncol 2018; 26:62-70. [PMID: 30327971 DOI: 10.1245/s10434-018-6825-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prior work has shown that the competitiveness of the market in which hospitals operate is associated with use of surgical procedures. This study examined the association between regional market competition and use of breast reconstruction for women with breast cancer and ductal carcinoma in situ undergoing mastectomy. METHODS Women who underwent mastectomy from 2010 to 2011 recorded in the National Inpatient Sample were selected. The competitive market environment for each hospital in which patients were treated was estimated using the Herfindahl-Hirschman Index. Multivariable models were developed to examine the association between regional market competition and breast reconstruction, with adjustment for other clinical, demographic, and structural variables. RESULTS Immediate breast reconstruction was performed for 9902 (45%) of 22,011 women. The rate of immediate breast reconstruction was 34.5% at hospitals in non-competitive markets, 49% at hospitals in moderately competitive markets, and 56.4% at hospitals in highly competitive markets (P < 0.0001). In a multivariable model, women in moderately competitive markets were 24% (risk ratio [RR] 1.24; 95% confidence interval [CI] 1.10-1.41) more likely to undergo immediate breast reconstruction than women in noncompetitive markets, whereas those in competitive markets were 25% (RR 1.25; 95% CI 1.11-1.41) more likely to have reconstruction. Later year of treatment, higher census tract income level, and residence in an urban area were associated with an increased likelihood of reconstruction (P < 0.05 for all). In contrast, older age, non-white race, and non-commercial insurance were associated with a lower likelihood of reconstruction (P < 0.05 for all). CONCLUSION Patients who undergo mastectomy at hospitals in competitive markets are more likely to undergo immediate breast reconstruction.
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Affiliation(s)
- Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, 4th Floor, New York, USA. .,Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, USA. .,New York Presbyterian Hospital, New York, USA.
| | - Ling Chen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, 4th Floor, New York, USA
| | - Melissa Accordino
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, 4th Floor, New York, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, USA.,New York Presbyterian Hospital, New York, USA
| | - Bret Taback
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, 4th Floor, New York, USA
| | - Cande V Ananth
- Mailman School of Public Health, Columbia University, New York, USA
| | - Alfred I Neugut
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, 4th Floor, New York, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, USA.,New York Presbyterian Hospital, New York, USA.,Mailman School of Public Health, Columbia University, New York, USA
| | - Dawn L Hershman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, 4th Floor, New York, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, USA.,New York Presbyterian Hospital, New York, USA.,Mailman School of Public Health, Columbia University, New York, USA
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Breast Reconstruction Among Commercially Insured Women With Breast Cancer in the United States. Ann Plast Surg 2018; 81:220-227. [DOI: 10.1097/sap.0000000000001454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Dasgupta P, Baade PD, Youlden DR, Garvey G, Aitken JF, Wallington I, Chynoweth J, Zorbas H, Youl PH. Variations in outcomes by residential location for women with breast cancer: a systematic review. BMJ Open 2018; 8:e019050. [PMID: 29706597 PMCID: PMC5935167 DOI: 10.1136/bmjopen-2017-019050] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To systematically assess the evidence for variations in outcomes at each step along the breast cancer continuum of care for Australian women by residential location. DESIGN Systematic review. METHODS Systematic searches of peer-reviewed articles in English published from 1 January 1990 to 24 November 2017 using PubMed, EMBASE, CINAHL and Informit databases. Inclusion criteria were: population was adult female patients with breast cancer; Australian setting; outcome measure was survival, patient or tumour characteristics, screening rates or frequencies, clinical management, patterns of initial care or post-treatment follow-up with analysis by residential location or studies involving non-metropolitan women only. Included studies were critically appraised using a modified Newcastle-Ottawa Scale. RESULTS Seventy-four quantitative studies met the inclusion criteria. Around 59% were considered high quality, 34% moderate and 7% low. No eligible studies examining treatment choices or post-treatment follow-up were identified. Non-metropolitan women consistently had poorer survival, with most of this differential being attributed to more advanced disease at diagnosis, treatment-related factors and socioeconomic disadvantage. Compared with metropolitan women, non-metropolitan women were more likely to live in disadvantaged areas and had differing clinical management and patterns of care. However, findings regarding geographical variations in tumour characteristics or diagnostic outcomes were inconsistent. CONCLUSIONS A general pattern of poorer survival and variations in clinical management for Australian female patients with breast cancer from non-metropolitan areas was evident. However, the wide variability in data sources, measures, study quality, time periods and geographical classification made direct comparisons across studies challenging. The review highlighted the need to promote standardisation of geographical classifications and increased comparability of data systems. It also identified key gaps in the existing literature including a lack of studies on advanced breast cancer, geographical variations in treatment choices from the perspective of patients and post-treatment follow-up.
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Affiliation(s)
- Paramita Dasgupta
- Cancer Research Centre, Cancer Council Queensland, Brisbane, Queensland, Australia
| | - Peter D Baade
- Cancer Research Centre, Cancer Council Queensland, Brisbane, Queensland, Australia
- None, Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Danny R Youlden
- Cancer Research Centre, Cancer Council Queensland, Brisbane, Queensland, Australia
| | - Gail Garvey
- Menzies School of Health Research, Brisbane, Queensland, Australia
| | - Joanne F Aitken
- Cancer Research Centre, Cancer Council Queensland, Brisbane, Queensland, Australia
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Institute for Resilient Regions, University of Southern Queensland, Toowoomba, Queensland, Australia
| | | | | | - Helen Zorbas
- Cancer Australia, Sydney, New South Wales, Australia
| | - Philippa H Youl
- Cancer Research Centre, Cancer Council Queensland, Brisbane, Queensland, Australia
- None, Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
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Neugut AI, Zhong X, Lebwohl B, Hillyer GC, Accordino MK, Wright JD, Kiran RP, Hershman DL. Adherence to colonoscopy at 1 year following resection of localized colon cancer: a retrospective cohort study. Therap Adv Gastroenterol 2018; 11:1756284818765920. [PMID: 35154382 PMCID: PMC8832335 DOI: 10.1177/1756284818765920] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 02/01/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND For patients with stages I-III colon cancer who have undergone surgical resection, guidelines recommend surveillance colonoscopy at 1 year. However, limited data exist on adherence and associated factors. We aimed to determine the rate of adherence to surveillance colonoscopy at 1 year among nonmetastatic colon cancer patients who underwent resection and factors associated with adherence. METHODS In this population-based retrospective cohort study, the Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used. We identified patients with stages I-III colon cancer who underwent surgical resection and survived >3 years without recurrence (no chemotherapy after 8 months) from 2002-2011. Our primary outcome was a colonoscopy claim 10-15 months after resection. We used multivariable regression analysis to assess associations between sociodemographic and clinical factors and receipt of timely colonoscopy. RESULTS Among 28,732 patients who survived >3 years without recurrence, 7967 (28%) did not undergo colonoscopy; 12,033 (42%) had it at one year, with 3159 (11%) before 10 months and 5573 (19%) after 15 months. Decreased adherence was associated with older age; being male versus female; being black or Hispanic versus white; higher tumor stage; left-sided tumors versus right sided; and increased comorbidities. Chemotherapy receipt was associated with increased adherence (odds ratio 2.06; 95% confidence interval 1.88-2.24). CONCLUSIONS In a large population-based sample of individuals aged ⩾ 65 years, only 42% of colon cancer survivors underwent 1-year surveillance colonoscopy. Demographic and clinical factors were associated with adherence.
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Affiliation(s)
- Alfred I. Neugut
- Department of Medicine, Columbia University, New
York, USA,Department of Epidemiology, Columbia University,
New York, USA,Herbert Irving Comprehensive Cancer Center,
Columbia University, New York, USA
| | - Xiaobo Zhong
- Department of Biostatistics, Columbia
University, New York, USA
| | | | - Grace C. Hillyer
- Deparment of Epidemiology, Columbia University,
New York, USA,Herbert Irving Comprehensive Cancer Center,
Columbia University, New York, USA
| | - Melissa K. Accordino
- Department of Medicine, Columbia University, New
York, USA,Herbert Irving Comprehensive Cancer Center,
Columbia University, New York, USA
| | - Jason D. Wright
- Department of Epidemiology, Columbia
University, New York, USA,Herbert Irving Comprehensive Cancer Center,
Columbia University, New York, USA,Department of Obstetrics and Gynecology,
Columbia University, New York, USA
| | - Ravi P. Kiran
- Department of Epidemiology, Columbia
University, New York, USA,Herbert Irving Comprehensive Cancer Center,
Columbia University, New York, USA,Department of Surgery, Columbia University, New
York, USA
| | - Dawn L. Hershman
- Department of Medicine, Columbia University,
New York, USA,Department of Epidemiology, Columbia
University, New York, USA,Herbert Irving Comprehensive Cancer Center,
Columbia University, New York, USA
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Immediate Breast Reconstruction among Patients with Medicare and Private Insurance: A Matched Cohort Analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1552. [PMID: 29464148 PMCID: PMC5811278 DOI: 10.1097/gox.0000000000001552] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/08/2017] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background: By eliminating economic hurdles, the Women’s Health and Cancer Rights Act of 1998 represented a paradigm shift in the availability of breast reconstruction. Yet, studies report disparities among Medicare-insured women. These studies do not account for the inherent differences in age and comorbidities between a younger privately insured and an older Medicare population. We examined immediate breast reconstruction (IBR) utilization between a matched pre- and post-Medicare population. Methods: Using the Nationwide Inpatient Sample database (1992–2013), breast cancer patients undergoing IBR were identified. To minimize confounding medical variables, 64-year-old privately insured women were compared with 66-year-old Medicare-insured women. Demographic data, IBR rates, and complication rates were compared. Trend over time was plotted for both cohorts. Result: A total of 21,402 64-year-old women and 25,568 66-year-old women were included. Both groups were well matched in terms of demographic type of reconstruction and complication rates. 72.3% of 64-year-old and 71.2 of % 66-year-old women opted for mastectomy. Of these, 25.5% (n = 3,941) of 64-year-old privately insured and 17.7% (n = 3,213) of 66-year-old Medicare-insured women underwent IBR (P < 0.01). During the study period, IBR rates increased significantly in both cohorts in a similar cohort. Conclusion: This study demonstrates significant increasing IBR rates in both cohorts. Moreover, after an initial slower upward trend, after a decade, IBR in 66-year-old Medicare-insured women approached similar rates of breast reconstruction among those with private insurance. Trends in unilateral versus bilateral mastectomy are also seen.
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Role of Age, Tumor Grade, and Radiation Therapy on Immediate Postmastectomy Breast Reconstruction. Clin Breast Cancer 2017; 18:313-319. [PMID: 29305307 DOI: 10.1016/j.clbc.2017.11.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 10/23/2017] [Accepted: 11/29/2017] [Indexed: 11/21/2022]
Abstract
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.
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30
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Offodile AC, Muldoon LD, Gani F, Canner JK, Jacobs LK. The site of care matters: An examination of the relationship between high Medicaid burden hospitals and the use, cost, and complications of immediate breast reconstruction after mastectomy. Cancer 2017; 124:346-355. [DOI: 10.1002/cncr.31046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 08/26/2017] [Accepted: 09/11/2017] [Indexed: 12/30/2022]
Affiliation(s)
- Anaeze C. Offodile
- Johns Hopkins Surgery Center for Outcomes Research; Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Plastic and Reconstructive Surgery; The University of Texas MD Anderson Cancer Center; Houston Texas
| | | | - Faiz Gani
- Johns Hopkins Surgery Center for Outcomes Research; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Joseph K. Canner
- Johns Hopkins Surgery Center for Outcomes Research; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Lisa K. Jacobs
- Johns Hopkins Surgery Center for Outcomes Research; Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
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Karunanayake M, Bortoluzzi P, Chollet A, Lin JC. Factors Influencing the Rate of Post-Mastectomy Breast Reconstruction in a Canadian Teaching Hospital. Plast Surg (Oakv) 2017; 25:242-248. [PMID: 29619346 DOI: 10.1177/2292550317728034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Post-mastectomy breast reconstruction (PMBR) improves psychosocial well-being, quality of life, and body image. Reconstruction rates vary widely (up to 42% in the United States), but the few Canadian studies available report rates of 3.8% to 7.9%. We sought to evaluate the current state of breast reconstruction in 1 Canadian teaching hospital and factors determining patients' access to reconstruction. Methods We performed a retrospective chart review of all patients with breast cancer undergoing mastectomy alone or mastectomy and reconstruction at a Canadian hospital between 2010 and 2013. We calculated rates of breast reconstruction and compared patient characteristics between the 2 groups, and then performed a multiple logistic regression to determine factors increasing the odds of receiving breast reconstruction. Results A total of 152 patients underwent 154 total or modified radical mastectomies. We obtained a rate of PMBR of 21%, 14% immediate reconstruction, and 8% delayed. Statistical analysis showed that compared to patients with mastectomy alone, patients who received PMBR were significantly younger, with a larger percentage having bilateral mastectomies, non-invasive breast cancer, and residing further from the hospital. Patients less than 50 years old and those with bilateral mastectomies had significantly greater odds of having a reconstruction. Conclusions Our Canadian tertiary care institution has a high volume of breast surgery and an active breast reconstruction team. However, the rate of immediate reconstruction remains low compared to similar centers in the United States. We recommend a united effort to increase awareness regarding PMBR and address common misconceptions hindering patients' access to breast reconstruction. Level of Evidence Epidemiologic study, Level III.
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Affiliation(s)
- Mihiran Karunanayake
- Division of Plastic and Reconstructive Surgery, Université de Montréal, Montreal, Québec, Canada
| | - Patricia Bortoluzzi
- Division of Plastic and Reconstructive Surgery, Université de Montréal, Montreal, Québec, Canada
| | - André Chollet
- Division of Plastic and Reconstructive Surgery, Université de Montréal, Montreal, Québec, Canada
| | - Jenny C Lin
- Division of Plastic and Reconstructive Surgery, Université de Montréal, Montreal, Québec, Canada
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Abstract
BACKGROUND Substantial federal resources have been directed toward ensuring the delivery of high-quality care at safety net hospitals. Although disparities in receipt of breast reconstruction persist at the patient level, the extent to which hospital factors contribute to these differences remains unclear. The rates of immediate breast reconstruction across safety net and non-safety net hospitals were investigated. METHODS Women 21 years and older with breast cancer or increased risk of breast cancer undergoing immediate post-mastectomy reconstruction were identified in the Nationwide Inpatient Sample database. Safety net hospitals were defined as hospitals with the highest tertile of Medicaid disproportionate share hospital payment adjustments. Adjusted odds ratios of undergoing reconstruction were calculated. RESULTS Thirty-one percent of patients (n = 10,910) at safety net hospitals underwent immediate reconstruction compared with 46 percent of patients (n = 14,619) at non-safety net hospitals (p < 0.001). Logistic regression revealed that women at non-safety net hospitals were significantly more likely to undergo reconstruction (OR, 1.89; 95 percent CI, 1.65 to 2.16). However, analysis by study year revealed that rates of reconstruction at safety net hospitals increased over time. CONCLUSIONS After accounting for sociodemographic factors, women undergoing mastectomies at safety net hospitals remain less likely to undergo immediate breast reconstruction. However, the differences in rates of reconstruction between safety net and non-safety net hospitals have narrowed over time. The availability of immediate reconstruction lessens the psychological trauma of mastectomy, and it is critical to continue redirecting federal efforts toward this valuable component of breast cancer care. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Schumacher JR, Taylor LJ, Tucholka JL, Poore S, Eggen A, Steiman J, Wilke LG, Greenberg CC, Neuman HB. Socioeconomic Factors Associated with Post-Mastectomy Immediate Reconstruction in a Contemporary Cohort of Breast Cancer Survivors. Ann Surg Oncol 2017; 24:3017-3023. [PMID: 28766209 DOI: 10.1245/s10434-017-5933-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Jessica R Schumacher
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Lauren J Taylor
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jennifer L Tucholka
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Samuel Poore
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Amanda Eggen
- Cancer Health Disparities Initiative, Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jennifer Steiman
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Lee G Wilke
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Caprice C Greenberg
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Heather B Neuman
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. .,University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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35
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Kamali P, Curiel D, van Veldhuisen CL, Bucknor AEM, Lee BT, Rakhorst HA, Lin SJ. Trends in immediate breast reconstruction and early complication rates among older women: A big data analysis. J Surg Oncol 2017; 115:870-877. [PMID: 28409847 DOI: 10.1002/jso.24595] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 02/08/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Although approximately 57% of breast cancer (BC) diagnoses are in older patients (>60 years), only 4.1-14% receives breast reconstruction (BR). This has been attributed to physician concerns about operative complications. This paper aims to: 1) analyze the 30-day complication rates in the older patient population undergoing immediate breast reconstruction (IBR); and 2) analyze links between complication type and category of reconstruction. METHODS Using the ACS-NSQIP database (2005-2014), all women older than 60 years of age diagnosed with BC and DCIS were identified. IBR and complication rates were plotted for all ages. Patients were divided into those with and those without complications. Patient demographics and co-morbidities were compared. Complications within each type of reconstruction were analyzed. RESULTS Of the 4450 BC and 1104 DCIS patients, 22.3% (BC) and 20.9% (DCIS) had complications. IBR decreased significantly with increased age (P < 0.00 in both cohorts), while complication rates remained stable across all ages (P = 0.32 in BC, P = 0.69 in DCIS patients). Patients were well matched in terms of demographics. CONCLUSIONS The rates of breast reconstruction decrease with increasing age. Despite increasing age, associated complication rates in IBR patients remained stable.
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Affiliation(s)
- Parisa Kamali
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Daniel Curiel
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Charlotte L van Veldhuisen
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alexandra E M Bucknor
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Hinne A Rakhorst
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Division of Plastic- Reconstructive and Hand Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Accordino MK, Wright JD, Vasan S, Neugut AI, Hillyer GC, Hershman DL. Factors and Costs Associated With Delay in Treatment Initiation and Prolonged Length of Stay With Inpatient EPOCH Chemotherapy in Patients With Hematologic Malignancies. Cancer Invest 2017; 35:202-214. [PMID: 28165774 DOI: 10.1080/07357907.2016.1276186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Reducing delays related to inpatient chemotherapy may reduce healthcare costs. Using a national database, we identified patients with lymphoma/leukemia with ≥1 etoposide, vincristine, doxorubicin, cyclophosphamide, and prednisone (EPOCH) chemotherapy claim and evaluated chemotherapy initiation delay (ID), >1 day from admission. Standard tests/procedures prior to initiation were evaluated. Among 4453 inpatient cycles, 19.7% had ID, odds ratio 2.28 (95% confidence interval: 1.83-2.85) with cycle 1 compared to cycle 2, and mean costs were higher in patients with ID than without ID (p < .0001). Prior to cycle 1, patients were more likely to undergo routine diagnostic procedures compared to subsequent cycles. Efforts to perform routine procedures prior to admission may reduce hospital length of stay and costs.
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Affiliation(s)
- Melissa K Accordino
- a Department of Medicine College of Physicians and Surgeons , Columbia University , New York , NY , USA.,b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , NY , USA
| | - Jason D Wright
- b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , NY , USA.,c Department of Obstetrics and Gynecology, College of Physicians and Surgeons , Columbia University , New York , NY , USA
| | - Sowmya Vasan
- d Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , NY , USA
| | - Alfred I Neugut
- a Department of Medicine College of Physicians and Surgeons , Columbia University , New York , NY , USA.,b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , NY , USA.,d Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , NY , USA
| | - Grace C Hillyer
- b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , NY , USA.,d Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , NY , USA
| | - Dawn L Hershman
- a Department of Medicine College of Physicians and Surgeons , Columbia University , New York , NY , USA.,b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , NY , USA.,d Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , NY , USA
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Gerber B, Marx M, Untch M, Faridi A. Breast Reconstruction Following Cancer Treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:286. [PMID: 26377531 DOI: 10.3238/arztebl.2015.0593] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/10/2015] [Accepted: 06/10/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND About 8000 breast reconstructions after mastectomy are per - formed in Germany each year. It has become more difficult to advise patients because of the wide variety of heterologous and autologous techniques that are now available and because of changes in the recommendations about radiotherapy. METHODS This article is based on a review of pertinent articles (2005-2014) that were retrieved by a selective search employing the search terms "mastectomy" and "breast reconstruction." RESULTS The goal of reconstruction is to achieve an oncologically safe and aestically satisfactory result for the patient over the long term. Heterologous, i.e., implant-based, breast reconstruction (IBR) and autologous breast reconstruction (ABR) are complementary techniques. Immediate reconstruction preserves the skin of the breast and its natural form and prevents the psychological trauma associated with mastectomy. If post-mastectomy radiotherapy (PMRT) is not indicated, implant-based reconstruction with or without a net/acellular dermal matrix (ADM) is a common option. Complications such as seroma formation, infection, and explantation are significantly more common when an ADM is used (15.3% vs. 5.4% ). If PMRT is performed, then the complication rate of implant-based breast reconstruction is 1 to 48% ; in particular, Baker grade III/IV capsular fibrosis occurs in 7 to 22% of patients, and the prosthesis must be explanted in 9 to 41% . Primary or, preferably, secondary autologous reconstruction is an alternative. The results of ABR are more stable over the long term, but the operation is markedly more complex. Autologous breast reconstruction after PMRT does not increase the risk of serious complications (20.5% vs. 17.9% without radiotherapy). CONCLUSION No randomized controlled trials have yet been conducted to compare the reconstructive techniques with each other. If radiotherapy will not be performed, immediate reconstruction with an implant is recommended. On the other hand, if post-mastectomy radiotherapy is indicated, then secondary autologous breast reconstruction is the procedure of choice. Future studies should address patients' quality of life and the long-term aesthetic results after breast reconstruction.
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Affiliation(s)
- Bernd Gerber
- Department of Obstetrics and Gynecology, University of Rostock, Clinic for Plastic Surgery, Radebeul, Helios Klinikum Berlin Buch, Center for Breast Diseases, Vivantes Hospital am Urban, Berlin
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Dasgupta P, Youl PH, Pyke C, Aitken JF, Baade PD. Geographical disparity in breast reconstruction following mastectomy has reduced over time. ANZ J Surg 2016; 87:E183-E187. [DOI: 10.1111/ans.13710] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 06/23/2016] [Accepted: 07/03/2016] [Indexed: 11/29/2022]
Affiliation(s)
| | - Philippa H. Youl
- Cancer Council Queensland; Brisbane Queensland Australia
- School of Public Health and Social Work; Queensland University of Technology; Brisbane Queensland Australia
- Menzies Health Institute Queensland; Griffith University; Brisbane Queensland Australia
| | | | - Joanne F. Aitken
- Cancer Council Queensland; Brisbane Queensland Australia
- School of Public Health and Social Work; Queensland University of Technology; Brisbane Queensland Australia
- School of Population Health; The University of Queensland; Brisbane Queensland Australia
| | - Peter D. Baade
- Cancer Council Queensland; Brisbane Queensland Australia
- School of Public Health and Social Work; Queensland University of Technology; Brisbane Queensland Australia
- Menzies Health Institute Queensland; Griffith University; Brisbane Queensland Australia
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Connors SK, Goodman MS, Myckatyn T, Margenthaler J, Gehlert S. Breast reconstruction after mastectomy at a comprehensive cancer center. SPRINGERPLUS 2016; 5:955. [PMID: 27429869 PMCID: PMC4930439 DOI: 10.1186/s40064-016-2375-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 05/20/2016] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Shahnjayla K Connors
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA
| | - Melody S Goodman
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA
| | - Terence Myckatyn
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA
| | - Julie Margenthaler
- Division of Endocrine Oncologic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA
| | - Sarah Gehlert
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA ; George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, MO USA
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Oh D, Flitcroft K, Brennan M, Spillane A. Patterns and outcomes of breast reconstruction in older women – A systematic review of the literature. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2016; 42:604-15. [DOI: 10.1016/j.ejso.2016.02.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 01/30/2016] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
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Cui Z, Wright JD, Accordino MK, Buono D, Neugut AI, Hu JC, Hershman DL. Safety, Utilization, and Cost of Image-Guided Percutaneous Liver Biopsy Among Cancer Patients. Cancer Invest 2016; 34:189-96. [PMID: 27065211 PMCID: PMC5002313 DOI: 10.3109/07357907.2016.1166232] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Image-guided percutaneous liver biopsy (PLB) is a diagnostic tool for lesions in the liver. Hemorrhage is the most common complication. We selected patients with a diagnostic claim for cancer who had undergone PLB. There were a total of 26,941 patients who underwent PLB. Hemorrhage risk was 1.43% among patients undergoing PLB. When stratified by setting, odds of hemorrhage were 4.5 times higher when biopsy was performed in an inpatient setting (p < .001). Risk factors associated with hemorrhage included marital status, liver cancer and comorbidity score. The use of PLB has increased over time. Reassuringly, the hemorrhage risk associated with PLB is low.
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Affiliation(s)
- Zhu Cui
- a Department of Epidemiology , Mailman School of Public Health, Columbia University , New York , New York , USA
| | - Jason D Wright
- b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University , New York , New York , USA
- c Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , New York , USA
| | - Melissa K Accordino
- b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University , New York , New York , USA
- d Department of Medicine , College of Physicians and Surgeons, Columbia University , New York , New York , USA
| | - Donna Buono
- a Department of Epidemiology , Mailman School of Public Health, Columbia University , New York , New York , USA
| | - Alfred I Neugut
- a Department of Epidemiology , Mailman School of Public Health, Columbia University , New York , New York , USA
- b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University , New York , New York , USA
- d Department of Medicine , College of Physicians and Surgeons, Columbia University , New York , New York , USA
| | - Jim C Hu
- e Department of Urology , Weill Cornell Medical College , New York , New York , USA
| | - Dawn L Hershman
- a Department of Epidemiology , Mailman School of Public Health, Columbia University , New York , New York , USA
- b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University , New York , New York , USA
- d Department of Medicine , College of Physicians and Surgeons, Columbia University , New York , New York , USA
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Quinn TT, Miller GS, Rostek M, Cabalag MS, Rozen WM, Hunter-Smith DJ. Prosthetic breast reconstruction: indications and update. Gland Surg 2016; 5:174-86. [PMID: 27047785 DOI: 10.3978/j.issn.2227-684x.2015.07.01] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Despite 82% of patients reporting psychosocial improvement following breast reconstruction, only 33% patients choose to undergo surgery. Implant reconstruction outnumbers autologous reconstruction in many centres. METHODS A systematic review of the literature was undertaken. Inclusion required: (I) Meta-analyses or review articles; (II) adult patients aged 18 years or over undergoing alloplastic breast reconstruction; (III) studies including outcome measures; (IV) case series with more than 10 patients; (V) English language; and (VI) publication after 1(st) January, 2000. RESULTS After full text review, analysis and data extraction was conducted for a total of 63 articles. Definitive reconstruction with an implant can be immediate or delayed. Older patients have similar or even lower complication rates to younger patients. Complications include capsular contracture, hematoma and infection. Obesity, smoking, large breasts, diabetes and higher grade tumors are associated with increased risk of wound problems and reconstructive failure. Silicone implant patients have higher capsular contracture rates but have higher physical and psychosocial function. There were no associations made between silicone implants and cancer or systemic disease. There were no differences in outcomes or complications between round and shaped implants. Textured implants have a lower risk of capsular contracture than smooth implants. Smooth implants are more likely to be displaced as well as having higher rates of infection. Immediate breast reconstruction (IBR) gives the best aesthetic outcome if radiotherapy is not required but has a higher rate of capsular contracture and implant failure. Delayed-immediate reconstruction patients can achieve similar aesthetic results to IBR whilst preserving the breast skin if radiotherapy is required. Delayed breast reconstruction (DBR) patients have fewer complications than IBR patients. CONCLUSIONS Implant reconstruction is a safe and popular mode of post-mastectomy reconstruction. Evidence exists for the settings in which complications are more likely, and we can now more reliably predict outcomes of reconstruction on an individual basis and assess patient suitability.
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Affiliation(s)
- Tam T Quinn
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - George S Miller
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - Marie Rostek
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - Miguel S Cabalag
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - Warren M Rozen
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - David J Hunter-Smith
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
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Factors associated with surgical management in an underinsured, safety net population. Surgery 2016; 159:580-90. [DOI: 10.1016/j.surg.2015.08.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 08/11/2015] [Accepted: 08/15/2015] [Indexed: 01/11/2023]
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Bodilsen A, Christensen S, Christiansen P, Damsgaard TE, Zachariae R, Jensen AB. Socio-demographic, clinical, and health-related factors associated with breast reconstruction – A nationwide cohort study. Breast 2015; 24:560-7. [DOI: 10.1016/j.breast.2015.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 02/27/2015] [Accepted: 05/03/2015] [Indexed: 11/26/2022] Open
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Effect of federal and state policy changes on racial/ethnic variation in immediate postmastectomy breast reconstruction. Plast Reconstr Surg 2015; 135:1285-1294. [PMID: 25919243 DOI: 10.1097/prs.0000000000001149] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Changes in use of autologous and prosthetic postmastectomy reconstruction after medicaid expansion in New York state. Plast Reconstr Surg 2015; 135:53-62. [PMID: 25539296 DOI: 10.1097/prs.0000000000000808] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND With Medicaid expansion beginning in 2014, it is important to understand the effects of access to reconstructive services for new beneficiaries. The authors assessed changes in use of breast cancer reconstruction for Medicaid beneficiaries after expansion in New York State in 2001. METHODS The authors used the State Inpatient Database for New York (1998 to 2006) for all patients aged 19 to 64 years who underwent breast reconstruction. An interrupted time series design with linear regression modeling evaluated the effect of Medicaid expansion on the proportion of breast reconstruction patients that were Medicaid beneficiaries. RESULTS The proportion of breast reconstructions provided to Medicaid beneficiaries increased by 0.28 percent per quarter after expansion (p < 0.001), resulting in a 5.5 percent increase above predicted trajectory without expansion. This corresponds to a population-adjusted increase of 1.8 Medicaid cases per 1 million population per quarter. On subgroup analysis, there was no significant increase in the proportion of autologous reconstructions (p = 0.4); however, the proportion of prosthetic reconstructions for Medicaid beneficiaries had a significant increase of 0.41 percent per quarter (p < 0.001), resulting in a 7.5 percent cumulative increase. This indicates that 135 additional prosthetic reconstruction operations were provided to Medicaid beneficiaries within 5 years of expansion. CONCLUSIONS Surgeons increased the volume of breast reconstructions provided to Medicaid beneficiaries after expansion. However, there are disparities between autologous and prosthetic reconstruction. If Medicaid expansion is to provide comprehensive care, with adequate access to all reconstructive options, these disparities must be addressed.
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Connors SK, Goodman MS, Noel L, Chavakula NN, Butler D, Kenkel S, Oliver C, McCullough I, Gehlert S. Breast cancer treatment among African American women in north St. Louis, Missouri. J Urban Health 2015; 92:67-82. [PMID: 24912599 PMCID: PMC4338122 DOI: 10.1007/s11524-014-9884-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Shahnjayla K Connors
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, 660 South Euclid, Campus Box 8100, St. Louis, MO, 63110, USA,
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Does Immediate Tissue Expander Placement Increase Immediate Postoperative Complications in Patients with Breast Cancer? Am Surg 2015. [DOI: 10.1177/000313481508100225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objectives of this study were to evaluate 1) the rate of immediate breast reconstruction; 2) the frequency of immediate tissue expander placement; and 3) to compare perioperative outcomes in patients who underwent breast reconstruction after mastectomy for breast cancer with immediate tissue expander placement (TE) with those with no reconstruction (NR). Using the Nationwide Inpatient Sample database, we examined the clinical data of patients with breast cancer who underwent mastectomy with or without immediate TE from 2006 to 2010 in the United States. A total of 344,253 patients with breast cancer underwent mastectomy in this period in the United States. Of these patients, 31 per cent had immediate breast reconstruction. We only included patients with mastectomy and no reconstruction (NR: 237,825 patients) and patients who underwent only TE placement with no other reconstruction combination (TE: 61,178 patients) to this study. Patients in the TE group had a lower overall postoperative complication rate (2.6 vs 5.5%; P < 0.01) and lower in-hospital mortality rate (0.01 vs 0.09%; P < 0.01) compared with the NR group. Fifty-three per cent of patients in the NR group were discharged the day of surgery compared with 36 per cent of patients in the TE group. Using multivariate regression analyses and adjusting patient characteristics and comorbidities, patients in the TE group had a significantly lower overall complication rate (adjusted odds ratio [AOR], 0.6) and lower in-hospital mortality (AOR, 0.2) compared with the NR group. The rate of immediate reconstruction is 31 per cent. TE alone is the most common type of immediate reconstruction (57%). There is a lower complication rate for the patients who underwent immediate TE versus the no-reconstruction cohort.
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Accordino MK, Wright JD, Buono D, Neugut AI, Hershman DL. Trends in use and safety of image-guided transthoracic needle biopsies in patients with cancer. J Oncol Pract 2015; 11:e351-9. [PMID: 25604594 DOI: 10.1200/jop.2014.001891] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Image-guided transthoracic needle biopsy (IGTTNB) is an important tool in the diagnosis of patients with cancer. Common complications include pneumothorax and chest tube placement, with rates ranging from 6% to 57%. We performed a population-based study to determine patterns of use, complications, and costs associated with IGTTNB. METHODS The Premier Perspective database was used to identify patients with cancer with ≥ one claim for IGTTNB from 2006 to 2012. Patients were stratified on the basis of inpatient versus outpatient setting. Pneumothorax was defined by a new claim within 1 month of IGTTNB; hospitalization and chest tube placement rates were analyzed. Multivariable analysis was used to identify factors associated with pneumothorax. RESULTS We Identified 79,518 patients with cancer who underwent IGTTNB: 42,955 (54.0%) outpatients and 36,563 (46.0%) inpatients. Of patients who underwent outpatient IGTTNB, 5,261 (12.2%) developed a pneumothorax. Of those, 1,006 (19.1%, 2.3% of total) were hospitalized, and 180 (3.4%, 0.42% of total) required chest tubes. Pneumothorax after outpatient IGTTNB was associated with number of comorbidities, rural site, hospital bed size of more than 600, and biopsy of parenchymal as opposed to pleural lesions. Of patients who underwent inpatient IGTTNB, 7,830 (21.4%) developed a pneumothorax, and 2,894 (36.0%, 7.9% of total) required chest tube. Over time, total IGTTNB volume increased by 40.6%, and mean outpatient cost per procedure increased by 24.4%. CONCLUSION While pneumothorax was frequent in outpatients, rates of hospitalization and chest tube placement were low. As screening for lung cancer increases, we anticipate an increased need for IGTNBB. Patients can be reassured by the low rate of serious complications.
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Affiliation(s)
- Melissa K Accordino
- Columbia University College of Physicians and Surgeons; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons; and Mailman School of Public Health, Columbia University, New York, NY
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons; and Mailman School of Public Health, Columbia University, New York, NY
| | - Donna Buono
- Columbia University College of Physicians and Surgeons; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons; and Mailman School of Public Health, Columbia University, New York, NY
| | - Alfred I Neugut
- Columbia University College of Physicians and Surgeons; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons; and Mailman School of Public Health, Columbia University, New York, NY
| | - Dawn L Hershman
- Columbia University College of Physicians and Surgeons; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons; and Mailman School of Public Health, Columbia University, New York, NY
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Unger JM, Hershman DL, Martin D, Etzioni RB, Barlow WE, LeBlanc M, Ramsey SR. The diffusion of docetaxel in patients with metastatic prostate cancer. J Natl Cancer Inst 2014; 107:dju412. [PMID: 25540245 DOI: 10.1093/jnci/dju412] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Diffusion of new cancer treatments can be both inefficient and incomplete. The uptake of new treatments over time (diffusion) has not been well studied. We analyzed the diffusion of docetaxel in metastatic prostate cancer. METHODS We identified metastatic prostate cancer patients diagnosed from 1995 to 2007 using the Surveillance, Epidemiology, and End Results Program (SEER)-Medicare database. Medicare claims through 2008 were analyzed. We assessed cumulative incidence of docetaxel by socioeconomic, demographic, and comorbidity variables, and compared diffusion patterns to landmark events including release of phase III results and FDA approval dates. We compared docetaxel diffusion patterns in prostate cancer to those in metastatic breast, lung, ovarian, and gastric cancers. To model docetaxel use over time, we used the classic "mixed influence" deterministic diffusion model. All statistical tests were two-sided. RESULTS We identified 6561 metastatic prostate cancer patients; 1350 subsequently received chemotherapy. Among patients who received chemotherapy, docetaxel use was 95% by 2008. Docetaxel uptake was statistically significantly slower (P < .01) for patients older than 65 years, blacks, patients in lower income areas, and those who experienced poverty. Eighty percent of docetaxel diffusion occurred prior to the May, 2004 release of phase III results showing superiority of docetaxel over standard-of-care. The maximum increase in the rate of use of docetaxel occurred nearly simultaneously for prostate cancer as for all other cancers combined (in 2000). CONCLUSION Efforts to increase the diffusion of treatments with proven survival benefits among disadvantaged populations could lead to cancer population survival gains. Docetaxel diffusion mostly preceded phase III evidence for its efficacy in castration-resistant prostate cancer, and appeared to be a cancer-wide-rather than a disease-specific-phenomenon. Diffusion prior to definitive evidence indicates the prevalence of off-label chemotherapy use.
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Affiliation(s)
- Joseph M Unger
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SRR, RBE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH).
| | - Dawn L Hershman
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SRR, RBE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH)
| | - Diane Martin
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SRR, RBE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH)
| | - Ruth B Etzioni
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SRR, RBE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH)
| | - William E Barlow
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SRR, RBE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH)
| | - Michael LeBlanc
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SRR, RBE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH)
| | - Scott R Ramsey
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SRR, RBE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH)
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