Breast reconstruction among inner city women with breast carcinoma

Disparities in Access to Postmastectomy Breast Reconstruction: Does Living in a Specific ZIP Code Determine the Patient's Reconstructive Journey?

BACKGROUND

Postmastectomy breast reconstruction (BR) has been shown to provide long-term quality of life and psychosocial benefits. Despite the policies initiated to improve access to BR, its delivery continues to be inequitable, suggesting that barriers to access have not been fully identified and/or addressed. The purpose of this study was to assess the influence of geographic location, socioeconomic status, and race in access to immediate BR (IBR).

METHODS

An institutional review board-approved observational study was conducted. All patients who underwent breast cancer surgery from 2014 to 2019 were queried from our institutional Breast Cancer Registry. A geographical analysis was conducted using demographic characteristics and patient's ZIP codes. Euclidean distance from patient home ZIP code to UPMC Magee Women's Hospital was calculated, and χ2, Student t test, Mann-Whitney, and Kruskal-Wallis tests was used to evaluate differences between groups, as appropriate. Statistical significance was set at P < 0.05.

RESULTS

Overall, 5835 patients underwent breast cancer surgery. A total of 56.7% underwent lumpectomy or segmental mastectomy, and 43.3% underwent modified, total, or radical mastectomy. From the latter group, 33.5% patients pursued BR at the time of mastectomy: 28.6% autologous, 48.1% implant-based, 19.4% a combination of autologous and implant-based, and 3.9% unspecified reconstruction. Rates of IBR varied among races: White or European (34.1%), Black or African American (27.7%), and other races (17.8%), P = 0.022. However, no difference was found between type of BR among races (P = 0.38). Moreover, patients who underwent IBR were significantly younger than those who did not pursue reconstruction (P < 0.0001). Patients who underwent reconstruction resided in ZIP codes that had approximately US $2000 more annual income, a higher percentage of White population (8% vs 11% non-White) and lower percentage of Black or African American population (1.8% vs 2.9%) than the patients who did not undergo reconstruction.

CONCLUSIONS

While the use of postmastectomy BR has been steadily rising in the United States, racial and socioeconomic status disparities persist. Further efforts are needed to reduce this gap and expand the benefits of IBR to the entire population without distinction.

Patient reported outcome measures (PROMs) following mastectomy with breast reconstruction or without reconstruction: a systematic review

The cornerstone of reconstructive surgery following mastectomy is to restore cosmesis and improve physical and psychological health. Consequently, it has become essential for instruments that measure surgical outcomes to include the direct perspective of patients. Many reviews have failed to show significant improvements in quality of life domains following breast reconstruction compared to mastectomy alone. However, with advances in surgical techniques and patient reported outcome measure (PROM) assessment tools designed precisely for breast reconstruction patients, a modern systematic review is warranted. An electronic literature review was performed using CINAHL, Cochrane Library and Medline (using PubMed) comparing patient reported outcome measures of patients undergoing mastectomy alone versus patients undergoing mastectomy with breast reconstruction. Studies in the English and Portuguese languages since the year 2000 were included. The review was undertaken adhering to PRISMA guidelines with last entry on the 31/5/2018. Full text review yield 42 articles of relevance to the inclusion criteria. The most widely used PROM instruments such as Breast-Q, EORTC-Q30/Q23, Short Form 36, FACT-B and others are explored. The specific difficulties conducting such studies and biases identified are investigated further. Studies comparing mastectomy alone against mastectomy with reconstruction show difficulties forming groups with similar clinical and epidemiological characteristics. There are inherent limitations to performing a randomised controlled trial on this topic, including matching patient groups in terms of age, socioeconomical background and cancer staging, and this affects the results of the PROM instruments. Within these limitations, the literature suggests that PROM support the use of breast reconstruction following mastectomy but care must be made selecting patients. The finding is supported by the National Institute for Health and Clinical Excellence (NICE) guidelines which state that breast reconstruction should be offered to all women undergoing breast cancer surgery.

Barriers of Access to Breast Reconstruction: A Systematic Review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The pedicled TRAM flap in breast reconstruction

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains a viable option in breast reconstruction. This article documents the history of the TRAM flap and puts in context the vascular anatomy through a discussion of the vascular zones. Options for flap delay are discussed and an algorithm is presented for patient selection. Finally, the issue of unipedicle versus bipedicle flap harvest is discussed and complications are examined.

Variables affecting patient satisfaction in breast surgery: a cross-sectional sample of Turkish women with breast cancer

OBJECTIVE

In Turkey, despite the fact that breast cancer accounts for 24.1% of all cancer in women, a very small number of these patients receive breast reconstruction. This low percentage would seem to indicate that there are several factors affecting the decision of which surgical procedure should be selected. The aim of this study was to establish the demographical, medical, and psychological factors associated with the breast cancer patient's decision-making process, and assess their satisfaction with the type of surgery received.

METHOD

We assessed long-term satisfaction with the type of surgery received; satisfaction with the information process by which the surgery decision is taken; feelings of ambivalence or regret regarding the type of surgery received in both mastectomy (n = 50) and breast reconstruction patients (n = 25). Additionally, breast cancer survivors were compared with age-matched healthy control volunteers (n = 50) in terms of demographics, body image and self-esteem, which could be expected to affect their preferences. We administered a demographical and medical information form, Structured Clinical Interview for DSM-IV, Clinical Version (SCID-I), the Body Cathexis Scale (BCS); and the Rosenberg Self-Esteem Scale (RSE).

RESULTS

In both groups, women with a low income and less education were more likely to experience decision regret or low satisfaction. Moreover, total mastectomy-alone patients had lower self-esteem compared to reconstructive surgery patients and healthy women.

CONCLUSION

Early stage breast cancer is a chronic disease and patients have to live with the consequences of their decision for many years. At the same time, the type of surgery is decided on when patients are in an acute phase and under intense pressure. Therefore, the decision making process needs to be explored more, especially breast cancer patients with less education and low income need better assistance and more detailed explanation of their options.

Population-based study of the relationship of treatment and sociodemographics on quality of life for early stage breast cancer

OBJECTIVE

To examine the relationship between cancer stage, surgical treatment and chemotherapy on quality of life (QOL) after breast cancer and determine if sociodemographic characteristics modify the observed relationships.

METHODS

A population-based sample of women with Stages 0-II breast cancer in the United States (N = 1357) completed surveys including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), and the Breast Cancer-Specific Quality of Life Questionnaire (QLQ BR-23). Regression models calculated mean QOL scores across primary surgical treatment and chemotherapy. Clinically significant differences in QOL were defined as > or = 10 point difference (out of 100) between groups.

RESULTS

Meaningful differences in QOL by surgical treatment were limited to body image with women receiving mastectomy with reconstruction reporting lower scores than women receiving breast conserving surgery (p < 0.001). Chemotherapy lowered QOL scores overall across four QOL dimensions (p values < 0.001), with a disproportionately greater impact on those with lower levels of education. Younger women reported lower QOL scores for seven of nine QOL dimensions (p values < 0.001).

CONCLUSIONS

Women should be reassured that few QOL differences exist based on surgical treatment, however, clinicians should recognize that the impact of treatment on QOL does vary by a woman's age and educational level.

Demand for plastic surgical operations after primary breast cancer surgery

BACKGROUND AND AIMS

The aim of this study is to evaluate the demand for plastic operations after primary breast cancer surgery. In addition, this study aims to increase knowledge on factors affecting the wish of women for breast reconstruction.

MATERIAL AND METHODS

A questionnaire was sent to some 111 patients who had undergone either mastectomy or breast conserving surgery. The response rate was 76%. The questionnaire consisted of 20 structured questions. The data was analysed statistically using the t test and the chi-square test.

RESULTS

28% of the mastectomized patients wanted a breast reconstruction. Factors found to affect the patient's wish for reconstruction were age (p < 0.001) and whether the patient had received radio- (p < 0.05) or chemotherapy (p < 0.05). A difference was found between the mastectomy group and the breast conserving surgery group as to satisfaction in the general (p < 0.05) and the cosmetic (p < 0.05) outcome of the surgery, as well as patient's expectations regarding the outcome (p < 0.01).

CONCLUSIONS

Rather fewer mastectomized patients wanted a reconstruction. The proportion, however, grew significantly larger in the younger age groups. This study also shows that receiving radio- or chemotherapy seems to predict a woman's choice against a reconstruction. Patients who receive radio- or chemotherapy may consider their illness more severe and life-threatening than those not receiving such treatments.