Disparities in Use and Access to Postmastectomy Breast Reconstruction Among African American Women: A Targeted Review of the Literature

African Americans have worse in-hospital outcomes in autologous and implant-based breast reconstruction: a population-based study from the National Inpatient Sample from 2015 to 2020

African Americans have a long history of disparities in healthcare. However, whether their racial disparity exists in breast reconstruction outcomes is less clear. This study compared short-term outcomes of African Americans and Caucasians who underwent autologous (ABR) and implant-based breast reconstruction (IBR). Patients having ABR or IBR were identified in the National Inpatient Sample from Q4 2015-2020. Multivariable logistic regressions were used to compare in-hospital outcomes between African Americans and Caucasians, adjusted for demographics, socioeconomic status, comorbidities, and hospital characteristics. In ABR, there were 8296 (63.89%) Caucasians and 1809 (13.93%) African Americans. In IBR, there were 12,258 (68.24%) Caucasians and 1847 (10.28%) African Americans. During the same period, 32,406 (64.87%) Caucasians and 7702 (15.42%) African Americans underwent mastectomy, indicating a lower reconstruction rate in African Americans, particularly in IBR. African Americans presented with significant preoperative differences, including younger age, higher comorbid burden, and pronounced socioeconomic disadvantages. After accounting for preoperative differences, in ABR, African Americans had higher renal complications (aOR = 1.575, 95 CI = 1.024-2.423, p = 0.04) hemorrhage/hematoma (aOR = 1.355, 95 CI = 1.169-1.571, p < 0.01), and transfer rate (aOR = 2.176, 95 CI = 1.257-3.768, p = 0.01). In IBR, African Americans had higher superficial wound complications (aOR = 1.303, 95 CI = 1.01-1.681, p = 0.04), flap revision (aOR = 4.19, 95 CI = 1.229-14.283, p = 0.02), and hemorrhage/hematoma (aOR = 1.791, 95 CI = 1.401-2.291, p < 0.01). In both ABR and IBR, African Americans had longer hospital length of stay (p < 0.01). These results highlight evident racial disparities in breast reconstruction for African Americans. Targeted interventions are needed to guarantee equitable access to breast reconstruction services and to address postoperative complications in African Americans.

Are There Disparities in Breast Reconstruction After Contralateral Prophylactic Mastectomy?

INTRODUCTION

Despite national guidelines against contralateral prophylactic mastectomy (CPM) in low- to moderate-risk breast cancer, CPM use continues to rise. Breast reconstruction improves health-related quality of life and satisfaction among women undergoing mastectomy. Given the lack of data regarding factors associated with reconstruction after CPM and the known benefits of reconstruction, we sought to investigate whether disparities exist in receipt of reconstruction after CPM.

METHODS

The 2004-2017 National Cancer Database was queried to identify women diagnosed with breast cancer who underwent unilateral mastectomy with CPM. Patients were divided into two groups: those who underwent planned reconstruction at any timepoint and those who did not. A secondary analysis comparing types of reconstruction (tissue, implant, combined) was conducted. Patient, tumor, and demographic characteristics were analyzed using chi-square test and odds ratios were calculated using generalized estimating equations.

RESULTS

The cohort included 1,73,249 women: 95,818 (55.3%) underwent reconstruction and 77,431 (45.7%) did not. Both the rate CPM and the proportion of women undergoing reconstruction after CPM increased between 2004 and 2017. Of the women who had reconstruction, 40,840 (51.7%) received implants, 29,807 (37.7%) had tissue, and 8352 (10.6%) had combined reconstruction. After adjusted analysis, factors associated with reconstruction were young age, Hispanic ethnicity, private insurance, and living in an area with the highest education and median income (P < 0.01). Patients who underwent reconstruction were less likely to have radiation (P < 0.01) and chemotherapy (P < 0.01), more likely to have stage I disease (P < 0.01), and to be treated at an integrated cancer center (P < 0.01).

CONCLUSIONS

Reconstruction after CPM is disproportionately received by younger women, Hispanics, those with private insurance, and higher socioeconomic status and education. While the rate of reconstruction after CPM is increasing, there remain significant disparities. Conscious efforts must be made to eliminate these disparities, especially given the known benefits of reconstruction after mastectomy.

Paradigm Shifts in Alloplastic Breast Reconstruction: A Nationwide Analysis of Direct-to-Implant Trends

BACKGROUND

Direct-to-implant breast reconstruction is an attractive choice for appropriately selected patients, as a single-stage procedure can enhance global metrics of care. In an era of high-value health care, therefore, it is important to investigate use of such procedures. This study investigated direct-to-implant trends over the past decade on a nationwide basis.

METHODS

This was a retrospective investigation of direct-to-implant reconstruction between 2010 and 2018 in the United States, using the National Inpatient Sample database. All study analyses were undertaken using Stata version 15.0.

RESULTS

The weighted sample included 287,093 women who underwent implant-based reconstruction between 2010 and 2018, of whom 43,064 (15%) underwent direct-to-implant reconstruction. Across the study period, the proportion of direct-to-implant procedures increased significantly ( P = 0.03), relative to staged and delayed implant-based procedures. Although direct-to-implant patients were younger and more likely to be White and privately insured, the proportion of non-White, publicly insured patients undergoing direct-to-implant reconstruction increased significantly by 2018 ( P < 0.05). Furthermore, direct-to-implant use among Medicaid patients was 2.2 times the rate in Medicaid expansion states compared with nonexpansion states. Direct-to-implant patients had significantly higher All Patient Refined Diagnosis Related Group risk scores in 2018 than in 2010 ( P = 0.02), indicating expanding clinical indications for this procedure. Direct-to-implant reconstruction had significantly lower inpatient charges than staged procedures ( P = 0.03), when considering expander placement and expander-to-implant exchange.

CONCLUSIONS

Overall, use of direct-to-implant breast reconstruction has significantly increased over the past decade, facilitated by expanding clinical indications and improved insurance coverage. However, certain disparities continue to exist. Further work should investigate drivers of disparities to allow continued expansion of direct-to-implant reconstruction as clinically appropriate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Gynecologic Care of Black Breast Cancer Survivors

Purpose of Review

Black patients suffer from breast cancer-related racial health disparities, which could have implications on their gynecologic care. This review explores considerations in the gynecologic care of Black breast cancer survivors.

Recent Findings

Black people have a higher risk of leiomyoma and endometrial cancer, which could confound bleeding patterns such as in the setting of tamoxifen use. As Black people are more likely to have early-onset breast cancer, this may have implications on long-term bone and heart health. Black patients may be more likely to have menopausal symptoms at baseline and as a result of breast cancer treatment. Furthermore, Black patients are less likely to utilize assisted reproductive technology and genetic testing services.

Summary

It is important for healthcare providers to be well-versed in the intersections of breast cancer and gynecologic care. Black breast cancer survivors may have unique considerations for which practitioners should be knowledgeable.

A Public Health Emergency: Breast Cancer Among Black Communities in the United States

While Black people have a similar incidence of breast cancer compared to White people, they have a 40% increased death rate. Black people are more likely to be diagnosed with aggressive subtypes such as triple-negative breast cancer. However, despite biological factors, systemic racism and social determinants of health create delays in care and barriers to treatment. While genetic testing holds incredible promise for Black people, uptake remains low and results may be challenging to interpret. There is a need for more robust, multidisciplinary, and antiracist interventions to reverse breast cancer-related racial disparities.

Disparities in Breast Cancer Care-How Factors Related to Prevention, Diagnosis, and Treatment Drive Inequity

Breast cancer survival has increased significantly over the last few decades due to more effective strategies for prevention and risk modification, advancements in imaging detection, screening, and multimodal treatment algorithms. However, many have observed disparities in benefits derived from such improvements across populations and demographic groups. This review summarizes published works that contextualize modern disparities in breast cancer prevention, diagnosis, and treatment and presents potential strategies for reducing disparities. We conducted searches for studies that directly investigated and/or reported disparities in breast cancer prevention, detection, or treatment. Demographic factors, social determinants of health, and inequitable healthcare delivery may impede the ability of individuals and communities to employ risk-mitigating behaviors and prevention strategies. The disparate access to quality screening and timely diagnosis experienced by various groups poses significant hurdles to optimal care and survival. Finally, barriers to access and inequitable healthcare delivery patterns reinforce inequitable application of standards of care. Cumulatively, these disparities underlie notable differences in the incidence, severity, and survival of breast cancers. Efforts toward mitigation will require collaborative approaches and partnerships between communities, governments, and healthcare organizations, which must be considered equal stakeholders in the fight for equity in breast cancer care and outcomes.

Diversity in online resources for breast reconstruction: What do patients see?

BACKGROUND

Online resources are commonly used by patients to obtain information on breast reconstruction. Despite the key role of these resources in patient decision-making, their visual content has not yet been evaluated. This study sought to 1) characterize the presence and content of visual aids in online patient education breast reconstruction resources and 2) determine if the women represented in these visual aids reflect the breast reconstruction patient population in the United States.

METHODS

The top 10 Google websites and the first 400 Google Images containing photographs/graphics depicting human skin for the search phrase "breast reconstruction" were analyzed. Images were categorized by content as "Before/After," "Surgical/Anatomical," "Step-by-Step," or "Breast-Centric Stock Images." Image subjects were classified by skin tone into "White" or "Non-White" using the Fitzpatrick scale and by body type into "Lean" or "Full-Figured."

RESULTS

In total, 471 images were analyzed. These were predominantly "Before/After" images (43.9%), followed by "Breast-Centric Stock Images" (27.4%), "Surgical/Anatomical" (24.2%), and "Step-by-Step" (4.5%). The majority of all images depicted "White" skin types (90.7%) and "Lean" body types (73.0%). "Before/After" images were more likely to show "Full-Figured" women than the other content categories (p < 0.0001) and had the highest percentage of "Non-White" skin types (35.3%).

CONCLUSIONS

Our findings demonstrate that breast reconstruction online resources are not reflective of the patient population seeking reconstruction. Improving the diversity of online image resources can both better represent our diverse patient population as well as better align patient expectations with postoperative outcomes, likely improving patient satisfaction.

Examining Race and Patient-Reported Outcomes After Contralateral Prophylactic Mastectomy with Reconstruction

BACKGROUND

Little is known regarding racial differences in satisfaction and quality of life (QOL) after contralateral prophylactic mastectomy (CPM). In this study, we aim to characterize associations between race, and postoperative satisfaction and well-being, utilizing the validated BREAST-Q patient-reported outcome measure.

PATIENTS AND METHODS

Patients were eligible if they were diagnosed with stage 0-III unilateral breast cancer and underwent mastectomy with immediate reconstruction at our institution between 2016 and 2022. BREAST-Q surveys were administered in routine clinical care preoperatively and postoperatively to assess QOL. We assessed whether the relationship between race, and domains of satisfaction with breasts and psychosocial well-being differed by receipt of CPM compared with unilateral mastectomy at 6 months, 1 year, 2 years, and 3 years following reconstruction.

RESULTS

Of 3334 women, 2040 (61%) underwent unilateral mastectomy and 1294 (39%) underwent CPM. Compared with White and Asian women who received CPM, Black women who underwent CPM were more likely to have higher BMI (p < 0.001), undergo autologous reconstruction (p = 0.006), and receive postmastectomy radiation (PMRT) (p < 0.001). There was no association between race and domains of satisfaction of breasts or psychosocial well-being for women who underwent unilateral mastectomy (p = 0.6 and p > 0.9, respectively) or CPM (p = 0.8 and p = 0.9, respectively). PMRT was negatively associated with both satisfaction with breasts (p < 0.001) and psychosocial well-being (p = 0.007).

CONCLUSIONS

Differences in satisfaction with breasts and psychosocial well-being at 3-year follow-up were not associated with race but rather treatment variables, particularly the receipt of PMRT. Further investigations with a larger and more diverse population are needed to validate these findings.

Patient-reported Quality of Life After Breast-conserving Surgery With Radiotherapy Versus Mastectomy and Reconstruction

OBJECTIVE

To compare long-term quality of life (QOL) outcomes in breast cancer survivors who received breast-conserving surgery with radiotherapy (BCS+RT) with those who received a mastectomy and reconstructive surgery (Mast+Recon) without radiotherapy and identify other important factors.

BACKGROUND

The long-term differences in patient-reported QOL outcomes following BCS+RT and Mast+Recon are not well understood.

METHODS

We identified patients from the Texas Cancer Registry with stage 0-II breast cancer diagnosed in 2009-2014 after BCS+RT or Mast+Recon without radiotherapy. Sampling was stratified by age and race and ethnicity. A paper survey was sent to 4800 patients which included validated BREAST-Q and PROMIS modules. Multivariable linear regression models were implemented for each outcome. Minimal clinically important difference for BREAST-Q and PROMIS modules, respectively, was 4 points and 2 points.

RESULTS

Of 1215 respondents (25.3% response rate), 631 received BCS+RT and 584 received Mast+Recon. The median interval from diagnosis to survey completion was 9 years. In adjusted analysis, Mast+Recon was associated with worse BREAST-Q psychosocial well-being (effect size: -3.80, P =0.04) and sexual well-being (effect size: -5.41, P =0.02), but better PROMIS physical function (effect size: 0.54, P =0.03) and similar BREAST-Q satisfaction with breasts, physical well-being, and PROMIS upper extremity function ( P >0.05) compared with BCS+RT. Only the difference in sexual well-being reached clinical significance. Older (≥65) patients receiving BCS+RT and younger (<50) patients receiving autologous Mast+Recon typically reported higher QOL scores. Receipt of chemotherapy was associated with detriments to multiple QOL domains.

CONCLUSIONS

Patients who underwent Mast+Recon reported worse long-term sexual well-being compared with BCS+RT. Older patients derived a greater benefit from BCS+RT, while younger patients derived a greater benefit from Mast+Recon. These data inform preference-sensitive decision-making for women with early-stage breast cancer.

Examining a decade of racial disparity in partial mastectomy and oncoplastic surgery

BACKGROUND AND OBJECTIVES

Understanding racial disparity is crucial to addressing health equity and access to care. Our study aims to examine racial differences in breast conserving surgery (BCS) utilization rates and determine how these rates have changed over time.

METHODS

This retrospective cohort analysis utilized the NSQIP database to identify women diagnosed with breast cancer who underwent BCS procedures between 2008 and 2019. Racial utilization trends were analyzed using a Cochran-Armitage test and Index of Disparity analysis.

RESULTS

In the 12-year period, 202 492 women underwent a breast cancer surgery, of which 47% underwent BCS. Within the BCS subgroup, oncoplastic surgery utilization increased from 3% to 10%, leading to a declining proportion of partial mastectomies: 97% to 90.0% (both p < 0.01). The racial index of disparity for overall BCS patients decreased from 7% to 6%, remained unchanged (1%) for partial mastectomies, and significantly decreased in oncoplastics (23%-7.6%).

CONCLUSION

BCS represents a mainstay option for early-staged breast cancer interventions, this study demonstrate promising progress in decreasing the index of disparity among races and persistent racial inequalities.

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.

Racial Disparities in Breast Reconstruction at a Comprehensive Cancer Center

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.

Community collaboration to improve access and outcomes in breast cancer reconstruction: protocol for a mixed-methods qualitative research study

INTRODUCTION

Breast reconstruction plays an important role for many in restoring form and function of the breast after mastectomy. However, rates of breast reconstruction in the USA vary significantly by race, ethnicity and socioeconomic status. The lower rates of breast reconstruction in non-white women and in women of lower socioeconomic status may reflect a complex interplay between patient and physician factors and access to care. It remains unknown what community-specific barriers may be impacting receipt of breast reconstruction.

METHODS AND ANALYSIS

This is a mixed-methods study combining qualitative patient interview data with quantitative practice patterns to develop an actionable plan to address disparities in breast reconstruction in the local community. The primary aims are to (1) capture barriers to breast reconstruction for patients in the local community, (2) quantitatively evaluate practice patterns at the host institution and (3) identify issues and prioritise interventions for change using community-based engagement.

ETHICS AND DISSEMINATION

Ethics approval was obtained at the investigators' institution. Results from both the quantitative and qualitative portions of the study will be circulated via peer-review publication. These findings will also serve as pilot data for extramural funding to implement and evaluate these proposed solutions.

One Size Does Not Fit All; Patient Preference for Breast Reconstruction

BACKGROUND

A myriad of patient education modalities for breast reconstruction exist, although the optimal tools for patient education remain undetermined. The aim of this study is to determine patient preferences for breast reconstruction education modalities based on demographic variables.

METHODS

A prospective observational study at a tertiary care university health system was conducted between November 2020 and May 2021. A questionnaire was administered to breast reconstruction patients to collect information on demographics, research sources used before the initial appointment, and preferred education modalities. Differences based on age were analyzed using an independent samples t test, whereas a Fisher exact test was used to analyze differences based on ethnicity and education level. Statistical significance was defined as P < .05.

RESULTS

The most preferred patient education tools overall were books/written materials and videos. Younger patients were significantly more likely than older patients to have referenced additional physician sources (P = .0174) and to seek out information on the institution's website (P = .0465). Those with a college degree were significantly more likely to have performed research prior to the initial appointment (P = .0206). White patients were significantly more likely than nonwhite patients to talk to friends/family as a research source (P = .0150).

CONCLUSIONS

Regardless of age, education, or ethnicity, most patients prefer books/written materials and video presentations for education on breast reconstruction. Providers should strive to include written and video options to meet the needs of this diverse patient population.

Racial and Ethnic Disparities in Surgical Outcomes after Postmastectomy Breast Reconstruction

BACKGROUND

Women of color with breast cancer are less likely to undergo post-mastectomy reconstruction compared with White women, but it is unclear whether their perioperative outcomes are worse. The goal of this study was to investigate differences in preoperative comorbidities and postoperative complications by race/ethnicity among women with breast cancer undergoing postmastectomy reconstruction.

STUDY DESIGN

Data were collected from the National Inpatient Sample database of the Healthcare Cost and Utilization Project from 2012 to 2016. Patient demographics, types of reconstruction, comorbid conditions, Charlson-Deyo Combined Comorbidity (CDCC) scores, length of stay (LOS), and perioperative complications were abstracted. Multivariate linear and logistic regression were performed to model LOS and likelihood of postoperative complications, respectively.

RESULTS

Compared with White women (n = 19,730), Black women (n = 3,201) underwent autologous reconstruction more frequently (40.7% vs 28.3%), had more perioperative comorbidities (eg diabetes: 12.9% vs 5.8%), higher CDCC scores (% CDCC ≥ 4: 5.5% vs 2.7%), and longer LOS (median 3 vs 2 days, all p < 0.001). Being Black (vs White: +0.13 adjusted days, 95% CI 0.06 to 0.19) was also associated with longer LOS and an increased likelihood of surgical complications (vs White: odds ratio 1.24, 95% CI 1.09 to 1.42, both p < 0.01), but this association did not persist when outcomes were limited to microsurgical complications.

CONCLUSION

Disparities in postmastectomy breast reconstruction between Black and White women extend beyond access to care and include perioperative factors and outcomes. These findings suggest an important opportunity to mitigate inequities in reconstruction through perioperative health optimization and improved access to and co-management with primary care.

Current Trends in Breast Reconstruction following Bilateral Prophylactic Mastectomy

Background:

Individuals with genetic susceptibility to breast cancer may pursue bilateral prophylactic mastectomy (BPM) and subsequent breast reconstruction. This study aimed to characterize immediate reconstructive trends following BPM.

Methods:

The ACS-NSQIP database (2010 -2019) was used to examine differences in demographics and operative outcomes based on breast reconstruction technique following BPM and factors predicting reconstruction type.

Results:

Of 1945 patients (mean age, 43.8 ± 11.3 years), implant-based reconstruction (IBR) was most frequently (71.8%) performed following BPM. Patients who underwent IBR (n = 1396) were younger (42.6 years, P < 0.001), more likely to be White (P < 0.05), and more likely to have a BMI less than 25 (P < 0.001). Patients who underwent autologous reconstruction (AR) (n = 186, 45.8 years) were more likely to be Black or African American and have a BMI of 25–30. Patients who underwent mastectomy only (MO) without immediate reconstruction (n = 363) were older (47.6 years), more likely to be Asian, and more likely to have a BMI greater than 35. The MO cohort had the highest frequency of diabetes or smoking history. AR was associated with longer operations, longer lengths of stay, and increased complications. Increasing age and BMI were predictive of AR or MO compared to IBR. Smoking was predictive of MO.

Conclusion:

This is the first large-scale study of genetically susceptible patients who underwent BPM demonstrating a significant relationship between patient demographics, operative outcomes, and immediate reconstruction technique. These results provide valuable insight for surgeons and patients during the shared decision-making process.

The Impact of Race on Perioperative and Patient-Reported Outcomes following Autologous Breast Reconstruction

BACKGROUND

Racial disparities are evident in multiple aspects of the perioperative care of breast cancer patients, but data examining whether such differences translate to clinical and patient-reported outcomes are limited. This study examined the impact of race on perioperative outcomes in autologous breast reconstruction.

METHODS

A retrospective cohort study including all breast cancer patients who underwent immediate autologous breast reconstruction at a single institution from 2010 to 2017 was conducted. Self-reported race was used to classify patients into three groups: white, African American, and other. The primary and secondary endpoints were occurrence of any major complications within 30 days of surgery and patient-reported outcomes (measured with the BREAST-Q), respectively. Regression models were constructed to identify factors associated with the outcomes.

RESULTS

Overall, 404 patients, including 259 white (64 percent), 63 African American (16 percent), and 82 patients from other minority groups (20 percent), were included. African American patients had a significantly higher proportion of preoperative comorbidities. Postoperatively, African American patients had a higher incidence of 30-day major complications (p = 0.004) and were more likely to return to the operating room (p = 0.006). Univariable analyses examining complications demonstrated that race was the only factor associated with 30-day major complications (p = 0.001). Patient-reported outcomes were not statistically different at each time point through 3 years postoperatively.

CONCLUSIONS

African American patients continue to present with increased comorbidities and may be more likely to experience major complications following immediate autologous breast reconstruction. However, patient-reported satisfaction or physical well-being outcomes may not differ between groups.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Satisfaction With Expectations-Based Education in Women Undergoing Breast Reconstruction

Women undergoing breast reconstruction sometimes have unrealistic or unformed expectations regarding the reconstructive process and outcomes. The objectives of this study were to assess preoperative expectations in women undergoing mastectomy and initial breast reconstruction, provide expectations-based education, and evaluate satisfaction with education. Fifty-one women undergoing mastectomy and breast tissue expander placement participated in this study. At a preoperative education appointment, participants completed a questionnaire to determine whether their expectations were realistic, unrealistic, or unformed. A nurse practitioner reviewed the results and provided patient-centered, expectations-based education to modify expectations from unrealistic to realistic or to set expectations from unformed to realistic. Four to 6 weeks after surgery, a second questionnaire was provided to assess perceived satisfaction with education. Unrealistic and unformed expectations were identified related to complications, pain, scarring, sensation, symmetry, and aesthetic results. After receiving patient-centered, expectations-based preoperative education, participants agreed they had received the appropriate amount of information and felt well prepared for their surgery and recovery. Most participants reported they were aware of possible complications, had effective tools to manage their pain, and had received adequate information about scarring and sensation changes. Some participants continued to have unrealistic or unformed expectations related to aesthetic results. Women undergoing breast reconstruction often have unrealistic or unformed expectations before surgery. Identifying these expectations and proving expectations-based education resulted in satisfaction with information provided.

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.

What's in a Name? Implicit Bias Affects Patient Perception of Surgeon Skill

BACKGROUND

Implicit bias is the unconscious associations and beliefs held toward specific demographic groups. Instagram is commonly used by plastic surgeons to market their practice. This study investigates whether a surgeon's name on a social media platform influences perception of their competence and their likelihood of gaining a new patient.

METHODS

A mock Instagram post was created using before-and-after photographs of a breast augmentation patient. Eight different ethnicities were selected, and common female and male names were selected based on U.S. Census data for each ethnicity. Surveys using the Instagram post were distributed asking responders to evaluate the competency of the surgeon and how likely they are to become a patient of that plastic surgeon. The surgeon's name was the only variable in the survey.

RESULTS

A total of 2965 survey responses were analyzed. The majority of responders were Caucasian (57 percent); 55 percent were men and 45 percent were women. Overall, competence and recruitment likelihood scores between surgeons of different ethnicities were not significantly different. Caucasian and Latinx responders both assigned higher competence and recruitment likelihood scores to their own respective ethnicities.

CONCLUSIONS

Implicit bias plays a role in whether or not a patient is likely to seek care from a surgeon with an ethnically identifiable name. The two most common cosmetic surgery demographic groups, Caucasians and Latinxs, were also the only two ethnic groups to display in-group favoritism. Public education should be directed toward surgeon qualifications and experience in an effort to reduce implicit bias on patient decision-making.

Satisfaction With Expectations-Based Education in Women Undergoing Breast Reconstruction

Women undergoing breast reconstruction sometimes have unrealistic or unformed expectations regarding the reconstructive process and outcomes. The objectives of this study were to assess preoperative expectations in women undergoing mastectomy and initial breast reconstruction, provide expectations-based education, and evaluate satisfaction with education. Fifty-one women undergoing mastectomy and breast tissue expander placement participated in this study. At a preoperative education appointment, participants completed a questionnaire to determine whether their expectations were realistic, unrealistic, or unformed. A nurse practitioner reviewed the results and provided patient-centered, expectations-based education to modify expectations from unrealistic to realistic or to set expectations from unformed to realistic. Four to 6 weeks after surgery, a second questionnaire was provided to assess perceived satisfaction with education. Unrealistic and unformed expectations were identified related to complications, pain, scarring, sensation, symmetry, and aesthetic results. After receiving patient-centered, expectations-based preoperative education, participants agreed they had received the appropriate amount of information and felt well prepared for their surgery and recovery. Most participants reported they were aware of possible complications, had effective tools to manage their pain, and had received adequate information about scarring and sensation changes. Some participants continued to have unrealistic or unformed expectations related to aesthetic results. Women undergoing breast reconstruction often have unrealistic or unformed expectations before surgery. Identifying these expectations and proving expectations-based education resulted in satisfaction with information provided.

Empowered Choices: African-American Women's Breast Reconstruction Decisions

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.

Equity of access to post-mastectomy breast reconstruction at a regional plastic surgery centre

BACKGROUND

The Plastic and Reconstructive Surgery Department at the Counties Manukau District Health Board provides tertiary-level access to post-mastectomy breast reconstruction for all women in the northern region of New Zealand. Access to breast reconstruction is not always equitable. We aim to assess equity of access to breast reconstruction in this department.

METHODS

A retrospective review of all women referred to this service for immediate and delayed post-mastectomy breast reconstruction between January 2013 and June 2018 was performed. Demographic information and progression to reconstruction were assessed in comparison to expected population figures available from health statistics.

RESULTS

A total of 882 women were referred for breast reconstruction during this period. Significant discrepancies in ethnicity and geographical location were found between expected population proportions and the women referred for reconstruction. European women were more likely to be referred for, and receive, reconstruction. Māori women were proportionally represented in the cohort, whereas Asian and Pacific women were under-represented (P = 0.0016). Within the referral cohort, Māori and Asian women were less likely to proceed to reconstruction following first specialist assessment than European women (P = 0.0015 and 0.0193, respectively). Proportionally fewer referrals for reconstruction were received from health services further away from the treatment centre than were received from closer health services.

CONCLUSION

There is inequity in the rates of tertiary referral for breast reconstruction across ethnicities and geographical location in the northern region of New Zealand. Strategies to identify potential barriers such as access to transport may improve equity of access to breast reconstruction.

Identifying Disadvantaged Groups for Cochlear Implantation: Demographics from a Large Cochlear Implant Program

Objective:

To identify demographic predictors of patients undergoing cochlear implantation evaluation and surgery.

Methods:

Consecutive adult patients between 2009 and 2018 who underwent cochlear implantation evaluation at a university cochlear implantation program were retrospectively identified to determine (1) cochlear implantation qualification rate and (2) pursuit of surgery rate with respect to age, gender, race, primary spoken language, marital status, insurance type, and distance to the cochlear implantation center.

Results:

A total of 823 cochlear implantation evaluations were analyzed. Overall, 76.3% of patients qualified for cochlear implantation and 61.5% of these patients pursued surgery. Age was the only independent predictor for cochlear implantation qualification, such that, for each year younger, the odds of qualifying for cochlear implantation increased by 2.5% (OR 0.98; 95% CI: 0.96-0.99). Age, race, marital status, and insurance type were each independent predictors of the decision to pursue surgery. The odds of pursuing surgery increased by 2.8% for each year younger (OR 1.03; 95% CI: 1.01-1.05). Compared to White patients, non-Whites were half as likely to pursue surgery (OR 0.47; 95% CI: 0.25-0.88). Single (OR 0.49; 95% CI: 0.26-0.94) and widowed patients (OR 0.46; 95% CI: 0.23-0.95) were about half as likely to pursue surgery as compared to married patients. Patients with military insurance were 13 times more likely to pursue surgery as compared to patients with Medicare (OR 13.0; 95% CI: 1.67-101.4).

Conclusion:

Younger age is an independent predictor for a higher cochlear implantation qualification rate, suggesting the possibility for delayed candidacy referral. Rate of surgical pursuit in qualified cochlear implantation candidates is lower for racial minorities, single and widowed patients, and older patients.

Variations in the utilization of immediate post-mastectomy breast reconstruction

BACKGROUND

For female breast cancer (BC) patients undergoing mastectomy, post-mastectomy breast reconstruction (PMBR) confers significant psychosocial benefits and improved cosmetic outcomes. The objective of this study is to explore whether the utilization of PMBR varies by race, marital status, and geographical location of the patient.

METHODS

Women ≥18 years old who underwent mastectomy for breast cancer diagnosed between 2000 and 2014 were eligible. Women with inflammatory BC, Stage IV BC diagnoses, and bilateral BC were excluded. Multivariable logistic regression, adjusting for patient and cancer characteristics, were used to assess the association between of race, marital status, and region on immediate PMBR utilization.

RESULTS

321,206 women were included and 24% underwent immediate PMBR (<4 months after mastectomy). Compared to white women, black and other non-white women (OR 0.67, 95% CI 0.65, 0.70 and OR 0.52, 95% CI 0.50, 0.53, respectively) were significantly less likely to receive PMBR. Additionally, women who were single (OR 0.72, 95% CI 0.70, 0.75) or no longer married (OR 0.84, 95% CI 0.82, 0.86) were significantly less likely to undergo breast reconstruction, compared to married women. Regional differences were also seen, with women in the Northeast (OR 2.11, 95% CI 2.05,2.17), Midwest (OR 1.53, 95% CI 1.48, 1.58) and South (OR 1.20, 95%CI 1.17, 1.23) all being more likely to undergo breast reconstruction compared to the West.

DISCUSSION

Significant variations exist in the utilization of post-mastectomy breast reconstruction across race, marital status or geographical location of the patient. Further research is needed to elucidate these differences and identify areas for intervention to increase awareness, and access to reconstruction for all breast cancer patients.

Surgical treatment of young women with breast cancer: Public vs private hospitals

Disparities in breast cancer treatment have been documented in young and underserved women. This study aimed to determine whether surgical disparities exist among young breast cancer patients by comparing cancer treatment at a public safety-net hospital (BH) and private cancer center (PCC) within a single institution. This was a retrospective study of young women (<45) diagnosed with invasive breast cancer (stage I-III) from 2011-2016. Patient information was abstracted from the breast cancer database at BH and PCC. Demographic variables, surgery type, method of presentation, and stage were analyzed using Pearson's chi-square tests and binary logistic regression. A total of 275 patients between ages 25-45 with invasive breast cancer (Stage I-III) were included in the study. There were 69 patients from BH and 206 patients from PCC. At PCC, the majority of patients were Caucasian (68%), followed by Asian (11%), Hispanic (10%), and African American (8.7%). At BH, patients were mostly Hispanic (47.8%), followed by Asian (27.5%), and African American (10.1%). At PCC, 82% had a college/graduate degree versus 18.6% of patients at BH (P < 0.001). All patients at PCC reported English as their primary language versus 30% of patients at BH (P < 0.001). Patients at PCC were more likely to present with lower stage cancer (P = 0.04), and less likely to present with a palpable mass (P = 0.04). Hospital type was not a predictor of receipt of mastectomy (P = 0.5), nor was race, primary language, or education level. Of patients who received a mastectomy, 87% at BH and 76% at PCC had immediate reconstruction. Surgical management of young women with breast cancer in a public hospital versus private hospital setting was equivalent, even after controlling for race, primary language, stage, and education level.