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

Predictors of Clavien-Dindo Grade III-IV or Grade V Complications after Metastatic Spinal Tumor Surgery: An Analysis of Sociodemographic, Socioeconomic, Clinical, Oncologic, and Operative Parameters

The rate of major complications and 30-day mortality after surgery for metastatic spinal tumors is relatively high. While most studies have focused on baseline comorbid conditions and operative parameters as risk factors, there is limited data on the influence of other parameters such as sociodemographic or socioeconomic data on outcomes. We retrospectively analyzed data from 165 patients who underwent surgery for spinal metastases between 2012-2023. The primary outcome was development of major complications (i.e., Clavien-Dindo Grade III-IV complications), and the secondary outcome was 30-day mortality (i.e., Clavien-Dindo Grade V complications). An exploratory data analysis that included sociodemographic, socioeconomic, clinical, oncologic, and operative parameters was performed. Following multivariable analysis, independent predictors of Clavien-Dindo Grade III-IV complications were Frankel Grade A-C, lower modified Bauer score, and lower Prognostic Nutritional Index. Independent predictors of Clavien-Dindo Grade V complications) were lung primary cancer, lower modified Bauer score, lower Prognostic Nutritional Index, and use of internal fixation. No sociodemographic or socioeconomic factor was associated with either outcome. Sociodemographic and socioeconomic factors did not impact short-term surgical outcomes for metastatic spinal tumor patients in this study. Optimization of modifiable factors like nutritional status may be more important in improving outcomes in this complex patient population.

Racial Disparities in Postoperative Breast Reconstruction Outcomes: A National Analysis

BACKGROUND

Studies have shown that Black patients are more likely to experience complications following breast reconstruction compared to other racial groups. Most of these studies have been conducted on patient populations focusing on either autologous or implant-based reconstruction without possible predictive indicators for complication disparities for all types of reconstruction procedures. The aim of this study is to elucidate disparities among patient demographics by identifying predictors of complications and postoperative outcomes among different racial/ethnic patients undergoing breast reconstruction utilizing multi-state, multi-institution, and national level data.

METHODS

Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction were identified via CPT codes. Demographics, medical history, and postoperative outcome data were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. Outcomes analysis was limited to the 90-day global postoperative period. A multivariable logistic-regression analysis was performed to ascertain the effects of age, patient reported ethnicity, coexisting conditions, and reconstruction type on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated.

RESULTS

From over 86 million longitudinal patient records, our study population included 104,714 encounters for 57,468 patients who had undergone breast reconstruction between January 2003 and June 2019. Black race (relative to White), autologous reconstruction, hypertension, type II diabetes mellitus, and tobacco use were independent predictors of increased likelihood of complication. Specifically, the odds ratios for complication occurrence for Black, Hispanic, and Asian ethnicity (relative to White) were 1.09, 1.03, and 0.77, respectively. Black patients had an overall breast reconstruction complication rate of 20.4%, while the corresponding rate for White, Hispanic, and Asian patients were 17.0%, 17.9%, and 13.2%, respectively.

CONCLUSION

Our analysis of a national-level database shows that Black patients undergoing implant-based or autologous reconstruction have increased risk of complications, likely due to multifactorial components that play a role in the care of this patient population. While higher rates of comorbidities have been cited as a possible cause, providers must consider racial influences involving cultural context, historical mistrust in medicine, and physician/health institution factors that may drive this disparity of outcomes among our patients.

Masculinizing Chest Reconstruction in Adolescents and Young Adults: An Analysis of National Surgical Quality Improvement Program Data

BACKGROUND

Masculinizing chest reconstruction (MCR) has been shown to improve quality of life and gender dysphoria in transmasculine adult patients. As nationwide access to gender-affirming care expands, more adolescents are seeking MCR. However, there is a paucity of literature examining patient characteristics, safety, and disparities among this population.

METHODS

Cases of MCR were selected from the pediatric and adult American College of Surgeons and National Surgical Quality Improvement Program. Adolescent (18 years and older) and young adult (aged 19-25 years) transgender patients were analyzed for differences in demographics, comorbidities, surgical characteristics, and postoperative complications.

RESULTS

A total of 1287 cases were identified, with an adolescent cohort of 189 patients. The proportion of White patients to other races was greater among adolescents than young adults (91.2% vs 82.4%, P = 0.007). Of adolescents and young adults, 6.0% and 11.1% identified as Hispanic/Latino, respectively (P = 0.059). Rates of all-cause postoperative complications were similar between adolescents (4.2%) and young adults (4.1%). Multivariate binary logistic regression showed that Black or African American patients experienced more all-cause postoperative complications than other races after controlling for American Society of Anesthesiologists classification, age group, and body mass index (odds ratio, 2.8; 95% confidence interval, 1.3-5.9; P = 0.008).

CONCLUSIONS

Masculinizing chest reconstruction is equally safe for transmasculine adolescent and young adult patients. However, our data point to racial disparities in access to care and postoperative outcomes. An intersectional approach is needed to better understand the unique health care needs and barriers to care of minority transgender youth.

Racial Disparities in Breast Cancer: from Detection to Treatment

PURPOSE OF REVIEW

Update on current racial disparities in the detection and treatment of breast cancer.

RECENT FINDINGS

Breast cancer remains the leading cause of cancer death among Black and Hispanic women. Mammography rates among Black and Hispanic women have surpassed those among White women, with studies now advocating for earlier initiation of breast cancer screening in Black women. Black, Hispanic, Asian, and American Indian and Alaskan Native women continue to experience delays in diagnosis and time to treatment. Further, racial discrepancies in receipt of guideline-concordant care, access to genetic testing and surgical reconstruction persist. Disparities in the initiation, completion, toxicity, and efficacy of chemotherapy, endocrine therapy, and targeted drug therapy remain for racially marginalized women. Efforts to evaluate the impact of race and ethnicity across the breast cancer spectrum are increasing, but knowledge gaps remain and further research is necessary to reduce the disparity gap.

Does body mass index influence surgical options and overall survival in breast cancer patients?

Obesity is a relevant risk factor in breast cancer (BC), but little is known about the effects of overweight and obesity in surgical outcomes of BC patients. The aim of this study is to analyse surgical options and associated overall survival (OS) in overweight and obese women with BC. In this study, 2143 women diagnosed between 2012 and 2016 at the Portuguese Oncology Institute of Porto (IPO-Porto) were included, and the clinicopathological information was retrieved from the institutional database. Patients were stratified by body mass index (BMI). Statistical analysis included Pearson's chi-squared test with statistical significance set at p < 0.05. Multinomial, binary logistic regression and cox proportional-hazards model were also performed to calculate odd ratios and hazard ratios with 95% confidence intervals for adjusted and non-adjusted models. The results revealed no statistical difference in histological type, topographic localization, tumour stage and receptor status and in the number of surgical interventions. Overweight women have increased probability to be subjected to sentinel node biopsy. Obese and overweight women are more likely to be submitted to conservative surgery and contrariwise, less likely to undergo total mastectomy. Patients submitted to conservative surgery and not submitted to total mastectomy had a favourable OS although without statistical significance. No significant differences were observed in OS when stratified by BMI. Our results revealed significant variations regarding the surgical options in overweight and obese patients, but these were not translated in OS difference. More research is recommended to better address treatment options in overweight and obese BC patients.

Addressing Inequalities in Breast Cancer Care Delivery

Breast cancer treatment, timeliness of care, and clinical outcomes are inferior for patients of Black race and Hispanic ethnicity, and the origin of these inequities is multifactorial. Owing to aggregate reporting of data in the United States for patients of Asian, Native Hawaiian, and Pacific Islander ancestry, disparities within and across these groups are difficult to appreciate. In large part due to low prevalence, male breast cancer remains understudied, and treatment algorithms are primarily extrapolated from research conducted in female patients.

Outcomes of Negative Pressure Wound Therapy on Immediate Breast Reconstruction after Mastectomy

Immediate expander/implant-based breast reconstruction after mastectomy has become more sought after by patients. Although many patients choose this technique due to good aesthetic outcomes, lack of donor site morbidity, and shorter procedure times, it is not without complications. The most reported complications include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, and implant exposure, with an overall complication rate as high as 45%. Closed incision negative pressure therapy (ciNPT) has shown value in wound healing and reducing complications; however, the current literature is inconclusive. We aimed to examine if ciNPT improves outcomes for patients receiving this implant-based reconstruction.

Methods

This is a retrospective single-institution study evaluating the ciNPT device, 3M Prevena Restor BellaForm, on breast reconstruction patients. The study was performed between July 1, 2019 and October 30, 2020, with 125 patients (232 breasts). Seventy-seven patients (142 breasts) did not receive the ciNPT dressing, and 48 patients (90 breasts) received the ciNPT dressing. Primary outcomes were categorized by major or minor complications. Age, BMI, and final drain removal were summarized using medians and quartiles, and were compared with nonparametric Mann-Whitney test. Categorical variables were compared using chi-square or Fisher exact test.

Results

There was a statistically significant reduction in major complications in the ciNPT group versus the standard dressing group (P = 0.0247). Drain removal time was higher in the ciNPT group.

Conclusion

Our study shows that ciNPT may help reduce major complication rates in implant-based breast reconstruction patients.

Smoking Behaviors Among Black and Hispanic Cancer Patients: A Systematic Review of the Literature

Smoking is the leading cause of preventable disease and death in the United States. The risk of smoking poses an even greater threat for racial/ethnic minorities, particularly Black and Hispanic cancer patients who face a range of existing disparities in healthcare. Despite these risks for poor health outcomes among this population, little is known about the smoking behaviors of Black and Hispanic cancer patients. The purpose of this review was to understand differences in smoking prevalence, intensity, and cessation between Black, Hispanic, and non-Hispanic White cancer patients and survivors. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach as our framework, we conducted a systematic review of the literature. Our review discusses the methods, population, and implications of 37 included articles. Conclusions reflect the need to establish intentional and systematic measurement of smoking behaviors to best understand the risks of smoking among Black and Hispanic cancer patients.

Disparity in Breast Cancer Care: Current State of Access to Screening, Genetic Testing, Oncofertility, and Reconstruction

Breast cancer is the most common cancer diagnosed in women, accounting for an estimated 30% of all new cancer diagnoses in women in 2022. Advances in breast cancer treatment have reduced the mortality rate over the past 25 years by up to 34% but not all groups have benefitted equally from these improvements. These disparities span the continuum of care from screening to the receipt of guideline-concordant therapy and survivorship. At the 2022 American College of Surgeons Clinical Congress, a panel session was dedicated to educating and discussing methods of addressing these disparities in a coordinated manner. While there are multilevel solutions to address these disparities, this article focuses on screening, genetic testing, reconstruction, and oncofertility.

Mitigating disparities in breast cancer treatment at an academic safety-net hospital

PURPOSE

Among women with non-metastatic breast cancer, marked disparities in stage at presentation, receipt of guideline-concordant treatment and stage-specific survival have been shown in national cohorts based on race, ethnicity, insurance and language. Little is published on the performance of safety-net hospitals to achieve equitable care. We evaluate differences in treatment and survival by race, ethnicity, language and insurance status among women with non-metastatic invasive breast cancer at a single, urban academic safety-net hospital.

METHODS

We conducted a retrospective study of patients with invasive ductal or lobular breast cancer, diagnosed and treated between 2009 and 2014 at an urban, academic safety-net hospital. Demographic, tumor and treatment characteristics were obtained. Stage at presentation, stage-specific overall survival, and receipt of guideline-concordant surgical and adjuvant therapies were analyzed. Chi-square analysis and ANOVA were used for statistical analysis. Unadjusted survival analysis was conducted by Kaplan-Meier method using log-rank test; adjusted 5 year survival analysis was completed stratified by early and late stage, using flexible parametric survival models incorporating age, race, primary language and insurance status.

RESULTS

520 women with stage 1-3 invasive breast cancer were identified. Median age was 58.5 years, 56.1% were non-white, 31.7% were non-English-speaking, 16.4% were Hispanic, and 50.1% were Medicaid/uninsured patients. There were no statistically significant differences in stage at presentation between age group, race, ethnicity, language or insurance. The rate of breast conserving surgery (BCS) among stage 1-2 patients did not vary by race, insurance or language. Among patients indicated for adjuvant therapies, the rates of recommendation and completion of therapy did not vary by race, ethnicity, insurance or language. Unadjusted survival at 5 years was 93.7% for stage 1-2 and 73.5% for stage 3. Adjusting for age, race, insurance status and primary language, overall survival at 5 years was 93.8% (95% CI 86.3-97.2%) for stage 1-2 and 83.4% (95% CI 35.5-96.9%) for stage 3 disease. Independently, for patients with early- and late-stage disease, age, race, language and insurance were not associated with survival at 5-years.

CONCLUSION

Among patients diagnosed and treated at an academic safety-net hospital, there were no differences in the stage at presentation or receipt of guideline-concordant treatment by race, ethnicity, insurance or language. Overall survival did not vary by race, insurance or language. Additional research is needed to assess how hospitals and healthcare systems mitigate breast cancer disparities.

Age and Racial Disparities in the Utilization of Anticancer, Antihypertension, and Anti-diabetes Therapies, and in Mortality in a Large Population-Based Cohort of Older Women with Breast Cancer

OBJECTIVE

This study examined the receipt of therapies for cancer, hypertension, and diabetes in association with age and racial disparities in mortality among women with breast cancer.

METHODS

This study identified 92,829 women diagnosed with breast cancer at age ≥ 65 years in 2007-2015 with follow-up to 2016 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database.

RESULTS

There were substantial age and racial disparities in the prevalence of hypertension and diabetes, which was higher in women ≥ 75 (86.3% and 32.0%) than younger women 65-74 (72.8% and 29.3%), and the highest in Black women (91.1% and 49.1%), followed by Asian women (80.2% and 40.5%), and White women (77.6 and 27.8%). Black women were significantly less likely to receive chemotherapy (odds ratio: 0.70, 95% CI: 0.64-0.75), radiation therapy (0.87, 0.83-0.92), and hormone therapy (0.80, 0.76-0.85), but significantly more likely to receive antihypertensive (1.26, 1.19-1.33) and antidiabetic (1.19, 1.10-1.28) drugs than White women, after adjusting for sociodemographic and tumor factors. As compared to White women, Black women had a significantly higher risk of all-cause mortality (1.46, 1.41-1.52), but it became insignificant after adjusting for treatment factors (1.01, 0.97-1.06), whereas the adjusted risk of breast cancer-specific mortality remained significantly higher (1.08, 1.01-1.15) in Black women; Asian and other ethnic women had a significantly lower risk of all-cause and breast cancer-specific mortality.

CONCLUSIONS

There were substantial age and racial disparities in the prevalence of hypertension and diabetes and in the receipt of medications. Black women did not have a significantly higher risk of all-cause mortality but had a significantly higher risk of breast cancer-specific mortality as compared to White women.

Racial disparities in postmastectomy breast reconstruction following implementation of the affordable care act: A systematic review using a minority health and disparities research framework

BACKGROUND

This systematic review assesses racial disparities for African American (AA) women in breast reconstruction following the implementation of the Affordable Care Act.

METHODS

Four databases (Ovid Medline, PubMed, Scopus, Web of Science) were searched for peer-reviewed articles published between January 2011 and September 2021.

RESULTS

Out of 917 screened articles, 61 were included. The most common metrics were breast reconstruction rates (57.4%) and clinical outcomes (14.8%). Pooled reconstruction rates were 45.7% in white and 38.5% in AA women. 95.1% of studies found disparities in breast reconstruction rates. The greatest influencers on reconstruction rates were individual interactions in the healthcare system (54%), sociocultural environment (39%), behavioral factors (31%), and community interactions with the healthcare system (36%).

CONCLUSION

Racial disparities in postmastectomy breast reconstruction persist. Focusing on implicit bias, communication barriers and infrastructure are the most promising strategies to create equitable access to breast reconstruction for AA women.

African American Patients Experience Worse Outcomes than Hispanic Patients Following Bariatric Surgery: an Analysis Using the MBSAQIP Data Registry

BACKGROUND

Obesity rates in Hispanics and African Americans (AAs) are higher than in Caucasians in the USA, yet the rate of metabolic and bariatric surgery (MBS) for weight loss remains lower for both Hispanics and AAs.

METHODS

Patient demographics and outcomes of adult AA and Hispanic patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) procedures were analyzed using the MBSAQIP dataset [2015-2018] using unmatched and propensity-matched data.

RESULTS

In total, 173,157 patients were included, of whom 98,185 were AA [56.7%] [21,163-RYGB; 77,022-SG] and 74,972 were Hispanic [43.3%] [20,282-RYGB; 54,690-SG]). Preoperatively, the AA cohort was older, had more females, and higher BMIs with higher rates of all tracked obesity-related medical conditions except for diabetes, venous stasis, and prior foregut surgery. Intra- and postoperatively, AAs were more likely to experience major complications including unplanned ICU admission, 30-day readmission/reintervention, and mortality. After propensity matching, the differences in ED visits, treatment for dehydration, 30-day readmission, 30-day intervention, and pulmonary embolism remained for both SG and RYGB cohorts. Progressive renal insufficiency and ventilator use lost statistical significance in both cohorts. Conversely, 30-day reoperation, postoperative ventilator requirement, unplanned intubation, unplanned ICU admission, and mortality lost significance in the RYGB cohort, but not SG patients.

CONCLUSION

Outcomes for AA patients were worse than for Hispanic patients, even after propensity matching. After matching, differences in major complications and mortality lost significance for RYGB, but not SG. These data suggest that outcomes for RYGB may be driven by the presence and severity of pre-existing patient-related factors.

Socioeconomic Disparities in Neoadjuvant Chemotherapy for Early-Stage Breast Cancer

Background

Neoadjuvant chemotherapy (NCT) is often used for patients with early-stage breast cancer. Disparities in the use of NCT based on clinical, demographic, and socioeconomic factors have not been evaluated.

Methods

Data from the National Cancer Database was analyzed for patients with T1-2, N0-1 breast cancer from 2006 to 2015. Univariate and multivariate analysis determined which factors predicted for the receipt of NCT.

Results

We found 159 946 eligible patients. Factors associated with receipt of NCT included T2 vs. T1 disease, N1 vs. N0, and treatment at an academic facility. Race itself was not significant; however, a higher level of education amongst Black populations correlated with the receipt of NCT.

Discussion

Clinical factors are the greatest determinants for receipt of NCT in early-stage breast cancer. Disparities exist that cannot be explained by race alone; socioeconomic and demographic factors are important. Cancer care should be evaluated in the context of the intersectionality of these health determinants.

Trends in surgical treatment of early-stage breast cancer reveal decreasing mastectomy use between 2003 and 2016 by age, race, and rurality

PURPOSE

To examine trends in the surgical treatment of breast cancer by age, rurality, and among Black women in a populous, racially diverse, state in the Southeastern United States of America.

METHODS

We identified women diagnosed with localized or regional breast cancer between 2003 and 2016 in the North Carolina Central Cancer Registry (n = 86,776). Using Joinpoint regression we evaluated the average annual percentage change in proportion of women treated with mastectomy versus breast-conserving surgery overall, by age group, among Black women, and for women residing in rural areas.

RESULTS

Overall, the rate of mastectomy usage in the population declined 2.5% per year between 2003 and 2016 (95% CI - 3.2, - 1.7). Over this same time interval, breast-conserving surgery increased by 1.6% per year (95% CI 0.9, 2.2). These temporal trends in surgery were also observed among Black women and rural residing women. Trends in surgery type varied by age group: mastectomy declined over time among women > 50 years, but not among women aged 18-49 at diagnosis.

DISCUSSION

In contrast to national studies that reported increasing use of mastectomy, we found declining mastectomy rates in the early 2000s in a Southern US state with a racially and geographically diverse population. These decreasing trends were consistent among key subgroups affected by cancer inequities, including Black and White rural women.

Clinical Outcomes of Acellular Dermal Matrix (SimpliDerm and AlloDerm Ready-to-Use) in Immediate Breast Reconstruction

Background

The use of acellular dermal matrix (ADM) for post-mastectomy reconstruction is considered by many surgeons to be an accepted component of surgical technique. Early clinical experience is described for SimpliDerm® - a novel human ADM (Aziyo Biologics, Silver Spring, USA), and AlloDerm® Ready-To-Use (RTU) - an established ADM (Allergan Medical, Irvine, USA).

Methods

Records were retrospectively reviewed from four sites between 2016 and 2021 of patients who underwent immediate, two-stage reconstruction with either SimpliDerm (n=38) or AlloDerm RTU (n=69) after mastectomy and were followed out to exchange to permanent implant(s), tissue expander(s) explant, or death.

Results

Immediate breast reconstruction with tissue expanders and ADM was performed on 107 patients (181 breasts). Overall mean patient age was 51.4 ± 12.4 years, and mean BMI was 28.0 ± 5.8 kg/m². Significantly more patients in the SimpliDerm group were of Hispanic or Latino ethnicity (34.2% vs. 7.2%; P<.001). Reconstructions were predominantly prepectoral (82.3%). A total of 35 adverse events (AEs) occurred in 27 (25.2%) patients, with no difference in AE type, classification, or rates between ADM groups. No AEs were considered related to either ADM. The observed AE profiles and rates are similar to those published for other ADMs in immediate breast reconstruction.

Conclusions

There continues to be a need for additional clinically equivalent ADMs to provide physicians with more availability and options for their practice. This retrospective, multisite study describes comparable clinical outcomes with SimpliDerm and AlloDerm RTU through a median of 133.5 days (~four months) following immediate two-stage breast reconstruction.

Disparities in Breast-Conserving Therapy for Non-Hispanic American Indian/Alaska Native Women Compared with Non-Hispanic White Women

BACKGROUND

Little is known about the surgical patterns of American Indian/Alaska Native (AI/AN) breast cancer patients. The purpose of this study is to determine whether there are disparities in breast cancer surgery and radiation therapy between non-Hispanic AI/AN (NH-AI/AN) women and non-Hispanic White (NHW) women.

METHODS

Data from the National Program of Cancer Registries of the Centers for Disease Control and Surveillance, Epidemiology, and End Results were used for this cross-sectional study. Female patients with invasive breast cancer diagnosed 2010-2015 were stratified by race/ethnicity, surgical procedure, radiation, and region. Percentage distributions of mastectomy and lumpectomy were compared overall and by region and stage.

RESULTS

From 2010 to 2015 there were 3292 NH-AI/AN women and 165,225 NHW women diagnosed with breast cancer. For early stage (AJCC stage 1 and 2), NH-AI/AN women had overall significantly higher percentage of mastectomy (41% vs 34.4%, p < 0.001) and significantly lower percentage of lumpectomy (59% vs 65.6%) compared with NHW women, without significant differences in post-lumpectomy radiation (71% vs 70%). There were regional variations, notably in the Northern Plains, where the percentage of mastectomy for early-stage disease was 48.9% for NH-AI/AN women versus 35.9% for NHW women, and in Alaska with 47% for NH-AI/AN women versus 33.3% for NHW women (p < 0.001). There were no overall significant differences in type of surgery or radiation for late-stage disease between groups.

CONCLUSION

This is the first study to show disparities in surgical management of NH-AI/AN women with breast cancer. For early-stage disease, NH-AI/AN women undergo a higher percentage of mastectomy. Future clinical directions could focus on the factors that drive awareness, decision-making, and access to breast conservation.

Does Surgeon Training Affect Patient Perception of Surgeon Skill in DIEP Flap Breast Reconstruction?

BACKGROUND

 The aim of this study is to investigate whether a surgeon's training background and years of experience advertised on a social media platform influences perception of surgeon competence, patient recruitment likelihood, and referral likelihood.

METHODS

 A mockup of an Instagram post was created using a before and after picture of a deep inferior epigastric perforator (DIEP) flap patient. The caption under each post was changed to reflect one of six possible training categories: 1 year of experience, 10 years of experience, 20 years of experience, fellowship, Ivy League training, and a null case (with no training information against which all other cases were compared). Surveys asked female responders to evaluate surgeon competence, likelihood of becoming a patient, and likelihood of making a referral to their friends or family. Amazon MTurk crowdsourcing platform was used to distribute the survey.

RESULTS

 A total of 1,878 responses were recorded, with the majority identifying as Caucasian (59%). The surgeon with 20 years of experience had the highest patient recruitment scores when compared with the null, 1 year, 10 year, and Ivy League training backgrounds (p = 0.0314, p = 0.0065, p = 0.0207, and p = 0.0244, respectively). The majority of responders (67%) preferred a female surgeon. Responders with a history of breast reconstruction assigned lower surgeon competence scores compared with women without a history of breast cancer (p <0.0001). Women who underwent breast reconstruction were also less likely to make referrals to their family and friends (p <0.0001).

CONCLUSION

 Surgeon's experience influences whether a patient is likely to seek care from a plastic surgeon. Personal history of breast cancer has a negative impact on perceived surgeon competence as well as patient recruitment likelihood and referral likelihood. Emphasizing fewer years of training or Ivy League training did not make an appreciable difference in patient perception of competence or likelihood of recruiting a new patient.

Persistent Disparities in Postmastectomy Breast Reconstruction and Strategies for Mitigation

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

Assessing Disparities in Reduction Mammaplasty: There Is Room for Improvement

BACKGROUND

Racial and socioeconomic disparities in access and quality of surgical care are well documented in many surgical subspecialties, including plastic surgery.

OBJECTIVES

The authors aimed to determine if demographic disparities exist in preoperative and postoperative satisfaction after breast reduction mammaplasty, utilizing patient-reported quality of life (QoL) scores.

METHODS

Patients who underwent breast reduction mammaplasty between 2015 and 2020 were identified. Patients who underwent complex concomitant procedures were excluded. Patient demographics and QoL, as measured by the BREAST-Q, were extracted. Wilcoxon Rank Sum and Kruskal-Wallis tests were employed to compare QoL scores across demographic subgroups.

RESULTS

A total of 115 patients met the inclusion criteria. QoL improved across all 4 BREAST-Q domains (all P < 0.001). Disparities were shown to exist in the following: median income vs postoperative satisfaction with information (P < 0.001), BMI vs preoperative physical well-being (P < 0.001), and ethnicity vs preoperative physical well-being (P = 0.003). A sub-group analysis of Caucasian patients compared with Black/African American patients revealed significant inequalities in BMI (P < 0.001), median income by zip code (P < 0.001), improvement in satisfaction with breasts (P = 0.039), satisfaction with information (P = 0.007), and satisfaction with office staff (P = 0.044).

CONCLUSIONS

Racial and socioeconomic inequalities exist in preoperative and postoperative satisfaction for patients undergoing breast reduction mammaplasty. Institutions should focus on developing tools for equitable and inclusive patient education and perioperative counseling.

LEVEL OF EVIDENCE: 2

Health Equity and Healthcare Disparities in Plastic Surgery: What We Can Do

Amidst the unexpected losses and challenges of 2020, healthcare disparities and health equity have presided as noteworthy topics of national discussion among healthcare workers, governmental officials, and society at large. Health equity, defined as the opportunity for everyone to be as healthy as possible, may be achieved through the alleviation of healthcare disparities. Healthcare disparities are defined as "preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations." While these concepts may be perceived as a departure from the core responsibility of plastic surgeons, it is of paramount importance to recognize how race, socioeconomic status (SES), and physical environment impact access to care, surgical outcomes, and postoperative recovery for vulnerable populations. In this communication, our purpose is two-fold: 1) to elucidate the existent healthcare disparities and associations with race and SES in craniofacial, trauma, breast, hand, and gender-affirming reconstruction; and 2) provide tangible recommendations to incorporate the concepts of health equity and healthcare disparities in clinical, research, community, and recruitment settings for plastic surgeons. Through such knowledge, plastic surgeons may glean important insights that may enhance the delivery of equitable and accessible care for patients.

A narrative review of sociodemographic risk and disparities in screening, diagnosis, treatment, and outcomes of the most common extrathoracic malignancies in the United States

There is a well-established association between multiple sociodemographic risk factors and disparities in cancer care. These risk factors include minority race and ethnicity, low socioeconomic status (SES) including low income and education level, non-English primary language, immigrant status, and residential segregation, and distance to facilities that deliver cancer care. As cancer care advances, existing disparities in screening, treatment, and outcomes have become more evident. Lung cancer remains the most common and fatal malignancy in the United States, with breast, colorectal, and prostate cancer being the three most common and deadly extrathoracic malignancies. Achieving the best outcomes for patients with these malignancies relies on strong physician-patient relationships leading to robust screening, early diagnosis, and early referral to facilities that can deliver multidisciplinary care and multimodal therapy. It is likely that challenges experienced in developing patient trust and understanding, providing access to screening, and building referral pipelines for definitive therapy in lung cancer care to vulnerable populations are paralleled by those in extrathoracic malignancies. Likewise, progress made in delivering optimal care to all patients across sociodemographic and geographic barriers can serve as a roadmap. Therefore, we provide a narrative review of current disparities in screening, treatment, and outcomes for patients with breast, prostate, and colorectal malignancies.

Inadequate prediction of postoperative complications in breast cancer surgery: An evaluation of the ACS Surgical Risk Calculator

BACKGROUND

The American College of Surgeon (ACS) Surgical Risk Calculator is an online tool that helps surgeons estimate the risk of postoperative complications for numerous surgical procedures across several surgical specialties.

METHODS

We evaluated the predictive performance of the calculator in 385 cancer patients undergoing breast surgery. Calculator-predicted complication rates were compared with observed complication rates; calculator performance was evaluated using calibration and discrimination analyses.

RESULTS

The mean calculator-predicted rates for any complication (4.1%) and serious complication (3.2%) were significantly lower than the observed rates (11.2% and 5.2%, respectively). The area under the curve was 0.617 for any complication and 0.682 for serious complications. p Values for the Hosmer-Lemeshow test were significant (<.05) for both outcomes. Brier scores were 0.102 for any complication and 0.048 for serious complication.

CONCLUSIONS

The ACS risk calculator is not an ideal tool for predicting individual risk of complications following breast surgery in a Mexican cohort. The most valuable use of the calculator may reside in its role as an aid for patient-led surgery planning. The possibility of introducing breast surgery-specific data could improve the performance of the calculator. Furthermore, a disease-specific calculator could provide more accurate predictions and include complications more frequently found in breast cancer surgery.

Evidence for racial/ethnic disparities in emergency department visits following breast cancer surgery among women in California: a population-based study

PURPOSE

Racial/ethnic disparities in breast cancer outcomes may be related to quality of care and reflected in emergency department (ED) visits following primary treatment. We examined racial/ethnic variation in ED visits following breast cancer surgery.

METHODS

Using linked data from the California Cancer Registry and California Office of Statewide Health Planning and Development, we identified 151,229 women diagnosed with stage 0-III breast cancer between 2005 and 2013 who received surgical treatment. Differences in odds of having at least one breast cancer-related ED visit within 90 days post-surgery were estimated with logistic regression controlling for clinical and sociodemographic variables. Secondary analyses examined health care-related moderators of disparities.

RESULTS

Hispanics and non-Hispanic (NH) Blacks had an increased likelihood of having an ED visit within 90 days of surgery compared to NH Whites [OR = 1.11 (1.04-1.18), p = 0.0016; OR = 1.38 (1.27-1.50), p < 0.0001, respectively]; the likelihood was reduced in Asian/Pacific Islanders [aOR = 0.77 (0.71-0.84), p < 0.0001]. Medicaid and Medicare (vs. commercial insurance) increased the likelihood of ED visit for NH Whites, and to a lesser degree for Hispanics and NH Blacks (p < 0.0001 for interaction). Receipt of surgery at an NCI-designated Comprehensive Cancer Center or at a for-profit (vs. non-profit) hospital was associated with reduced likelihood of ED visits for all groups.

CONCLUSION

Racial/ethnic disparities in ED visits following breast cancer surgery persist after controlling for clinical and sociodemographic variables. Improving quality of care following breast cancer surgery could improve outcomes for all groups.

Underrepresentation of Racial Minorities in Breast Surgery Literature: A Call for Increased Diversity and Inclusion

OBJECTIVE

In this study, the extent of racial diversity in images of breast-related plastic surgery published literature was investigated to better understand disparities that exist in breast surgery.

BACKGROUND

The lack of racial diversity in images of skin color in surgery literature can perpetuate implicit bias and stereotypes. Implicit bias can affect the way patients are evaluated, diagnosed, and treated. The visual aspects of plastic surgery make a lack of diversity in imagery especially impactful on patient care and outcomes.

METHODS

Published medical images and graphics depicting human skin were analyzed across 4 major plastic surgery journals. Up to 4 years were chosen a priori to evaluate from each journal and represented the initial year of color image publication, the year of study initiation (2016), and representative years for a given decade (2000 and 2010). Images and graphics were tabulated, rated by Fitzpatrick scale and categorized into "White" or "non-White." Data were evaluated with pair-wise and linear regression statistics.

RESULTS

Of the 2774 images and 353 graphics that met inclusion criteria, only 184 (8.18%) images and 9 graphics (6.34%) depicted non-White skin. Temporal analysis showed that there is an increased diversity of images published since 2010 with 0% of images being non-White before and 7.3% to 10.3% after 2010. International and multi-national authors tended to publish more non-White images.

CONCLUSIONS

There is insufficient racial diversity visually represented in the breast-related plastic surgery literature with a small degree of progress made towards more equitable imagery over time. Increasing awareness of image content, and the need for equitable visual representation may allow for improved racial diversity in surgical literature.

Residential Racial Segregation and Disparities in Breast Cancer Presentation, Treatment, and Survival

OBJECTIVE

To understand the role of racial residential segregation on Black-White disparities in breast cancer presentation, treatment, and outcomes.

SUMMARY OF BACKGROUND DATA

Racial disparities in breast cancer treatment and outcomes are well documented. Black individuals present at advanced stage, are less likely to receive appropriate surgical and adjuvant treatment, and have lower overall and stage-specific survival relative to White individuals.

METHODS

Using data from the Surveillance, Epidemiology, and End Results program, we performed a retrospective cohort study of Black and White patients diagnosed with invasive breast cancer from 2005 to 2015 within the 100 most populous participating counties. The racial index of dissimilarity was used as a validated measure of residential segregation. Multivariable regression was performed, predicting advanced stage at diagnosis (stage III/IV), surgery for localized disease (stage I/II), and overall stage-specific survival.

RESULTS

After adjusting for age at diagnosis, estrogen/progesterone receptor status, and region, Black patients have a 49% greater risk (relative risk [RR] 1.49 95% confidence interval [CI] 1.27, 1.74) of presenting at advanced stage with increasing segregation, while there was no observed difference in Whites (RR 1.04, 95% CI 0.93, 1.16). Black patients were 3% less likely to undergo surgical resection for localized disease (RR 0.97, 95% CI 0.95, 0.99) with increasing segregation, while Whites saw no significant difference. Black patients had a 29% increased hazard of death (RR 1.29, 95% CI 1.04, 1.60) with increasing segregation; there was no significant difference among White patients.

CONCLUSIONS

Our data suggest that residential racial segregation has a significant association with Black-White racial disparities in breast cancer. These findings illustrate the importance of addressing structural racism and residential segregation in efforts to reduce Black-White breast cancer disparities.