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Vangsness KL, Juste J, Sam AP, Munabi N, Chu M, Agko M, Chang J, Carre AL. Post-Mastectomy Breast Reconstruction Disparities: A Systematic Review of Sociodemographic and Economic Barriers. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1169. [PMID: 39064597 PMCID: PMC11279340 DOI: 10.3390/medicina60071169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 06/19/2024] [Accepted: 07/04/2024] [Indexed: 07/28/2024]
Abstract
Background: Breast reconstruction (BR) following mastectomy is a well-established beneficial medical intervention for patient physical and psychological well-being. Previous studies have emphasized BR as the gold standard of care for breast cancer patients requiring surgery. Multiple policies have improved BR access, but there remain social, economic, and geographical barriers to receiving reconstruction. Threats to equitable healthcare for all breast cancer patients in America persist despite growing awareness and efforts to negate these disparities. While race/ethnicity has been correlated with differences in BR rates and outcomes, ongoing research outlines a multitude of issues underlying this variance. Understanding the current and continuous barriers will help to address and overcome gaps in access. Methods: A systematic review assessing three reference databases (PubMed, Web of Science, and Ovid Medline) was carried out in accordance with PRISMA 2020 guidelines. A keyword search was conducted on 3 February 2024, specifying results between 2004 and 2024. Studies were included based on content, peer-reviewed status, and publication type. Two independent reviewers screened results based on title/abstract appropriateness and relevance. Data were extracted, cached in an online reference collection, and input into a cloud-based database for analysis. Results: In total, 1756 references were populated from all databases (PubMed = 829, Ovid Medline = 594, and Web of Science = 333), and 461 duplicate records were removed, along with 1147 results deemed ineligible by study criteria. Then, 45 international or non-English results were excluded. The screening sample consisted of 103 publications. After screening, the systematic review produced 70 studies with satisfactory relevance to our study focus. Conclusions: Federal mandates have improved access to women undergoing postmastectomy BR, particularly for younger, White, privately insured, urban-located patients. Recently published studies had a stronger focus on disparities, particularly among races, and show continued disadvantages for minorities, lower-income, rural-community, and public insurance payers. The research remains limited beyond commonly reported metrics of disparity and lacks examination of additional contributing factors. Future investigations should elucidate the effect of these factors and propose measures to eliminate barriers to access to BR for all patients.
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Affiliation(s)
- Kella L. Vangsness
- City of Hope, 1500 E Duarte Rd, Duarte, CA 91010, USA; (J.J.); (A.-P.S.); (N.M.); (M.C.); (M.A.); (J.C.); (A.L.C.)
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Pleasant V. A Public Health Emergency: Breast Cancer Among Black Communities in the United States. Obstet Gynecol Clin North Am 2024; 51:69-103. [PMID: 38267132 DOI: 10.1016/j.ogc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
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.
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Affiliation(s)
- Versha Pleasant
- Department of Obstetrics and Gynecology, Cancer Genetics & Breast Health Clinic, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Amiri S, Robison J, Pflugeisen C, Monsivais P, Amram O. Travel Burden to Cancer Screening and Treatment Facilities Among Washington Women: Data From an Integrated Healthcare Delivery System. COMMUNITY HEALTH EQUITY RESEARCH & POLICY 2023:2752535X231215881. [PMID: 37975231 DOI: 10.1177/2752535x231215881] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
PURPOSE To characterize distance traveled for breast cancer screening and to sites of service for breast cancer treatment, among rural and urban women served by a Washington State healthcare network. METHODS Data for this study came from one of the largest not-for-profit integrated healthcare delivery systems in Washington State. Generalized linear mixed models with gamma log link function were used to examine the associations between travel distance and sociodemographic and contextual characteristics of patients. RESULTS Median travel distance for breast cancer screening facilities, hematologist/oncologists, radiation oncologists, or surgeons was 11, 19, 23, or 11 miles, respectively. Travel distance to breast cancer screening or referral facilities was longer in non-core metropolitan ZIP codes compared to metropolitan ZIP codes. AI/AN and Hispanic women travelled longer distances to reach referral facilities compared to other racial and ethnic groups. CONCLUSION Disparities exist in travel distance to breast cancer screening and treatment. Further research is needed to describe sociodemographic and system level characteristics that contribute to such disparities and to discover novel approaches to alleviate this burden.
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Affiliation(s)
- Solmaz Amiri
- Institute for Research and Education to Advance Community Health (IREACH), Washington State University, Seattle, WA, USA
| | - Jeanne Robison
- Multicare Deaconess Cancer & Blood Specialty Centers, Spokane, WA, USA
| | | | - Pablo Monsivais
- Department of Nutrition and Exercise Physiology, Washington State University, Spokane, WA, USA
| | - Ofer Amram
- Department of Nutrition and Exercise Physiology, Washington State University, Spokane, WA, USA
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Beaulieu-Jones BR, Fefferman A, Woods AP, Shewmaker G, Zhang T, Roh DS, Sachs TE, Merrill A, Ko NY, Cassidy MR. Impact of Race, Ethnicity, Primary Language, and Insurance on Reconstruction after Mastectomy for Patients with Breast Cancer at an Urban, Academic Safety-Net Hospital. J Am Coll Surg 2023; 236:1071-1082. [PMID: 36524735 DOI: 10.1097/xcs.0000000000000531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Disparities in breast reconstruction have been observed in national cohorts and single-institution studies based on race, ethnicity, insurance, and language. However, little is known regarding whether safety-net hospitals deliver more or less equitable breast reconstruction care in comparison with national cohorts. STUDY DESIGN We performed a retrospective study of patients with either invasive breast cancer or ductal carcinoma in situ diagnosed and treated at our institution (January 1, 2009, to December 31, 2014). The rate of, timing of, and approach to breast reconstruction were assessed by race, ethnicity, insurance status, and primary language among women who underwent mastectomy. Reasons for not performing reconstruction were also analyzed. RESULTS A total of 756 women with ductal carcinoma in situ or nonmetastatic invasive cancer were identified. The median age was 58.5 years, 56.2% were non-White, 33.1% were non-English-speaking, and 48.9% were Medicaid/uninsured patients. A total of 142 (18.8%) underwent mastectomy during their index operation. A total of 47.9% (n = 68) did not complete reconstruction. Reasons for not performing reconstruction included patient preference (n = 22), contraindication to immediate reconstruction (ie, locoregionally advanced disease prohibiting immediate reconstruction) without follow-up for consideration of delayed reconstruction (n = 12), prohibitive medical risk or contraindication (ie, morbid obesity; n = 8), and progression of disease, prohibiting reconstruction (n = 7). Immediate and delayed reconstruction were completed in 43.7% and 8.5% of patients. The rate of reconstruction was inversely associated with tumor stage (odds ratio 0.52, 95% CI 0.31 to 0.88), but not race, ethnicity, insurance, or language, on multivariate regression. CONCLUSIONS At a safety-net hospital, we observed rates of reconstruction at or greater than national estimates. After adjustment for clinical attributes, rates did not vary by race, ethnicity, insurance or language. Future research is needed to understand the role of reconstruction in breast cancer care and how to advance shared decision-making among diverse patients.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- Department of Surgery (Beaulieu-Jones), Boston University, Boston, MA
- Boston Medical Center, and School of Medicine (Beaulieu-Jones, Fefferman, Shewmaker, Roh, Sachs, Merrill, Ko, Cassidy), Boston University, Boston, MA
| | - Ann Fefferman
- Boston Medical Center, and School of Medicine (Beaulieu-Jones, Fefferman, Shewmaker, Roh, Sachs, Merrill, Ko, Cassidy), Boston University, Boston, MA
| | - Alison P Woods
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Woods)
| | - Grant Shewmaker
- Boston Medical Center, and School of Medicine (Beaulieu-Jones, Fefferman, Shewmaker, Roh, Sachs, Merrill, Ko, Cassidy), Boston University, Boston, MA
| | - Tina Zhang
- Department of Medicine (Zhang), Boston University, Boston, MA
| | - Daniel S Roh
- Section of Plastic and Reconstructive Surgery (Roh), Boston University, Boston, MA
- Boston Medical Center, and School of Medicine (Beaulieu-Jones, Fefferman, Shewmaker, Roh, Sachs, Merrill, Ko, Cassidy), Boston University, Boston, MA
| | - Teviah E Sachs
- Section of Surgical Oncology (Sachs, Merrill, Cassidy), Boston University, Boston, MA
- Boston Medical Center, and School of Medicine (Beaulieu-Jones, Fefferman, Shewmaker, Roh, Sachs, Merrill, Ko, Cassidy), Boston University, Boston, MA
| | - Andrea Merrill
- Section of Surgical Oncology (Sachs, Merrill, Cassidy), Boston University, Boston, MA
- Boston Medical Center, and School of Medicine (Beaulieu-Jones, Fefferman, Shewmaker, Roh, Sachs, Merrill, Ko, Cassidy), Boston University, Boston, MA
| | - Naomi Y Ko
- Section of Hematology and Oncology (Ko), Boston University, Boston, MA
- Boston Medical Center, and School of Medicine (Beaulieu-Jones, Fefferman, Shewmaker, Roh, Sachs, Merrill, Ko, Cassidy), Boston University, Boston, MA
| | - Michael R Cassidy
- Section of Surgical Oncology (Sachs, Merrill, Cassidy), Boston University, Boston, MA
- Boston Medical Center, and School of Medicine (Beaulieu-Jones, Fefferman, Shewmaker, Roh, Sachs, Merrill, Ko, Cassidy), Boston University, Boston, MA
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5
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Stankowski TJ, Alagoz E, Jacobson N, Neuman HB. Factors Associated With Socioeconomic Disparities in Breast Reconstruction: Perspectives of Wisconsin Surgeons. Clin Breast Cancer 2023; 23:461-467. [PMID: 37069035 PMCID: PMC10664705 DOI: 10.1016/j.clbc.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/20/2023] [Accepted: 03/23/2023] [Indexed: 03/30/2023]
Abstract
INTRODUCTION The objective is to expand our understanding of the factors associated with receipt of breast reconstruction for socioeconomically disadvantaged women within Wisconsin. METHODS A purposeful sample of general/breast and plastic surgeons were identified. One-on-one interviews were conducted, audio-recorded, and transcribed in full (n = 15). Conventional content analysis was performed to identify themes. RESULTS Both general/breast and plastic surgeons perceived that general/breast surgeons served as gatekeepers to which patients are offered a referral for reconstruction. Given the additional recovery time, frequent clinic visits, and potential for complications associated with reconstruction, general/breast surgeons perceived that not all women prioritize it. Surgeons perceived this to be especially true for socioeconomically disadvantaged women. Surgeons identified time off work, travel for visits, and out-of-pocket costs as specific challenges to reconstruction experienced by socioeconomically disadvantaged women. Surgeons perceived that early education, incorporating financial considerations into discussions, and reducing travel burden may help to improve access to reconstruction. CONCLUSION Wisconsin surgeons described factors they perceived contributed to lower rates of reconstruction for socioeconomically disadvantaged women and described ways to increase reconstruction access.
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Affiliation(s)
- Trista J Stankowski
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Esra Alagoz
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Nora Jacobson
- Institute for Clinical and Translational Research and School of Nursing, University of Wisconsin-Madison, Madison, WI
| | - Heather B Neuman
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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Eden CM, Johnson J, Syrnioti G, Malik M, Ju T. The Landmark Series: The Breast Cancer Burden of the Asian American Population and the Need for Disaggregated Data. Ann Surg Oncol 2023; 30:2121-2127. [PMID: 36652024 PMCID: PMC9848042 DOI: 10.1245/s10434-023-13103-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/02/2023] [Indexed: 01/19/2023]
Abstract
The Asian American Pacific Islander (AAPI) population is a heterogeneous group of people from geographically and ethnically distinct regions of the world. Traditionally, these patients have been reported as one large aggregate in the breast cancer literature under the race category of "Asian." A detailed examination of this group shows compelling evidence that breast cancer manifests differently among Asian ethnic subgroups, resulting in overlooked health disparities when these races are grouped together. The AAPI community is the fastest growing ethnic group in the United States, and their incidence of breast cancer is increasing at rates greater than among their non-Asian counterparts. When these patients are disaggregated by race, they show wide variations in breast cancer screening, presentation, treatment, and outcomes. This population often faces additional unique challenges in the health care system due to cultural, social, health literacy, and language barriers, which can contribute to further disparity. Our landmark series aims to showcase the breadth of the breast cancer burden in the AAPI population and highlight the need for disaggregated ethnic data.
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Affiliation(s)
- Claire M Eden
- Department of Surgery New York Presbyterian Queens, Weill Cornell Medicine, Flushing, NY, USA
| | - Josh Johnson
- Department of Surgery New York Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Georgia Syrnioti
- Department of Surgery New York Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Manmeet Malik
- Department of Surgery New York Presbyterian Queens, Weill Cornell Medicine, Flushing, NY, USA
| | - Tammy Ju
- Department of Surgery New York Presbyterian Queens, Weill Cornell Medicine, Flushing, NY, USA.
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Racial Disparities in Breast Reconstruction at a Comprehensive Cancer Center. J Racial Ethn Health Disparities 2022; 9:2323-2333. [PMID: 34647274 DOI: 10.1007/s40615-021-01169-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Breast reconstruction after a mastectomy is an important component of breast cancer care that improves the quality of life in breast cancer survivors. African American women are less likely to receive breast reconstruction than Caucasian women. The purpose of this study was to further investigate the reconstruction disparities we previously reported at a comprehensive cancer center by assessing breast reconstruction rates, patterns, and predictors by race. METHODS Data were obtained from women treated with definitive mastectomy between 2000 and 2012. Sociodemographic, tumor, and treatment characteristics were compared between African American and Caucasian women, and logistic regression was used to identify significant predictors of reconstruction by race. RESULTS African American women had significantly larger proportions of public insurance, aggressive tumors, unilateral mastectomies, and modified radical mastectomies. African American women had a significantly lower reconstruction rate (35% vs. 49%, p < 0.01) and received a larger proportion of autologous reconstruction (13% vs. 7%, p < 0.01) compared to Caucasian women. The receipt of adjuvant radiation therapy was a significant predictor of breast reconstruction in Caucasian but not African American women. CONCLUSIONS We identified breast reconstruction disparities in rate and type of reconstruction. These disparities may be due to racial differences in sociodemographic, tumor, and treatment characteristics. The predictors of breast reconstruction varied by race, suggesting that the mechanisms underlying breast reconstruction may vary in African American women. Future research should take a target approach to examine the relative contributions of sociodemographic, tumor, and treatment determinants of the breast reconstruction disparities in African American women.
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8
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Dudley CM, Stankowski TJ, Tucholka JL, Schumacher JR, Poore SO, Neuman HB. Perspectives of Wisconsin Providers on Factors Influencing Receipt of Post-Mastectomy Breast Reconstruction. Clin Breast Cancer 2022; 22:840-846. [PMID: 36008204 PMCID: PMC10684062 DOI: 10.1016/j.clbc.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The objective is to determine perspectives of general surgeons, plastic surgeons, and cancer navigators on factors contributing to breast cancer patients' decision for post-mastectomy reconstruction, especially for women facing financial hardship. METHODS We mailed Wisconsin general and plastic surgeons who performed >5 breast cancer procedures annually a survey, including a postcard inviting cancer navigators to participate. Descriptive statistics summarize item responses. McNemar's chi-squared tests evaluated surgeons' perspectives of factors influencing reconstruction for all women compared to women facing financial hardship. RESULTS Respondents include 70 general surgeons, 18 plastic surgeons, and 9 navigators. Respondents perceived preference-related factors as important, including "does not want more surgery" (85% reported it important overall and 77% for financial hardship women) and "reconstructed breast is not important to her" (77% vs. 61%). Surgeons perceived logistical factors were more important for women facing financial hardship, including "capacity to be away from work or home responsibilities for recovery" (30% reported important overall and 60% for financial hardship women), "concerned about out-of-pocket costs" (26% vs. 57%), and "frequent visits to complete reconstruction too burdensome" (27% vs. 49%). CONCLUSION Our findings demonstrate Wisconsin surgeons and cancer navigators perceive logistical concerns influence reconstruction decisions for women facing financial hardship.
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Affiliation(s)
- Christina M Dudley
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Jessica R Schumacher
- University of Wisconsin School of Medicine and Public Health, Madison, WI; University of Wisconsin Carbone Cancer Center, Madison, WI
| | - Samuel O Poore
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Heather B Neuman
- University of Wisconsin School of Medicine and Public Health, Madison, WI; University of Wisconsin Carbone Cancer Center, Madison, WI.
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Woods AP, Papageorge MV, de Geus SWL, Alonso A, Merrill A, Cassidy MR, Roh DS, Sachs TE, McAneny D, Drake FT. Impact of Patient Primary Language upon Immediate Breast Reconstruction After Mastectomy. Ann Surg Oncol 2022; 29:8610-8618. [PMID: 35933541 DOI: 10.1245/s10434-022-12354-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 07/12/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Preoperative decision-making in patients who speak a primary language other than English is understudied. We investigated whether patient primary language is associated with differences in immediate breast reconstruction (IBR) after mastectomy. PATIENTS AND METHODS This retrospective observational study analyzed female patients undergoing mastectomy in the New Jersey State Inpatient Database (2009-2014). The primary outcome was the odds of IBR with a prespecified subanalysis of autologous tissue-based IBR. We used multivariable logistic regression and hierarchical generalized linear mixed models to control for patient characteristics and nesting within hospitals. RESULTS Of 13,846 discharges, 12,924 (93.3%) specified English as the patient's primary language, while 922 (6.7%) specified a language other than English. Among English-speaking patients, 6178 (47.8%) underwent IBR, including 2310 (17.9%) autologous reconstructions. Among patients with a primary language other than English, 339 (36.8%) underwent IBR, including 93 (10.1%) autologous reconstructions. Unadjusted results showed reduced odds of IBR overall [odds ratio (OR) 0.64, 95% CI 0.55-0.73], and autologous reconstruction specifically (OR 0.52, 95% CI 0.41-0.64) among patients with a primary language other than English. After adjustment for patient factors, this difference persisted among the autologous subgroup (OR 0.64, 95% CI 0.51-0.80) but not for IBR overall. A hierarchical model incorporating both patient characteristics and hospital-level effects continued to show a difference among the autologous subgroup (OR 0.75, 95% CI 0.58-0.97). CONCLUSIONS Primary language other than English was an independent risk factor for lower odds of autologous IBR after adjustments for patient and hospital effects. Focused efforts should be made to ensure that patients who speak a primary language other than English have access to high-quality shared decision-making for postmastectomy IBR.
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Affiliation(s)
- Alison P Woods
- Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA. .,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Marianna V Papageorge
- Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Susanna W L de Geus
- Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Andrea Alonso
- Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Andrea Merrill
- Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Michael R Cassidy
- Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Daniel S Roh
- Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Teviah E Sachs
- Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - David McAneny
- Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Frederick Thurston Drake
- Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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10
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Lee RXN, Cardoso MJ, Cheung KL, Parks RM. Immediate breast reconstruction uptake in older women with primary breast cancer: systematic review. Br J Surg 2022; 109:1063-1072. [PMID: 35909248 PMCID: PMC10364779 DOI: 10.1093/bjs/znac251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/22/2022] [Accepted: 07/04/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Postmastectomy immediate breast reconstruction (PMIBR) may improve the quality of life of patients with breast cancer, of whom older women (aged 65 years or more) are a growing proportion. This study aimed to assess PMIBR in older women with regard to underlying impediments (if any). METHODS MEDLINE, Embase, and PubMed were searched by two independent researchers up to June 2022. Eligible studies compared PMIBR rates between younger and older women with invasive primary breast cancer. RESULTS A total of 10 studies (2012-2020) including 466 134 women were appraised, of whom two-thirds (313 298) were younger and one-third (152 836) older. Only 10.0 per cent of older women underwent PMIBR in contrast to 45.0 per cent of younger women. Two studies explored factors affecting uptake of PMIBR in older women; surgeon-associated (usual practice), patient-associated (socioeconomic status, ethnicity, and co-morbidities), and system-associated (insurance status and hospital location) factors were identified. CONCLUSION Uptake of PMIBR in older women is low with definable (and some correctable) barriers.
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Affiliation(s)
- Rachel Xue Ning Lee
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- Queen’s Medical Centre Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Maria Joao Cardoso
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- Breast Unit, Champalimaud Foundation and Nova Medical School Lisbon, Lisbon, Portugal
| | - Kwok Leung Cheung
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Ruth M Parks
- Correspondence to: Ruth M. Parks, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Uttoxeter Road, Derby DE22 3DT, UK (e-mail: )
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11
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Liston JM, Samuel A, Camacho TF, Anderson RT, Campbell CA, Stranix JT. The State of Breast Cancer Reconstruction in Virginia: An Evidence-Based Framework for Identifying Locoregional Health Disparities. Ann Plast Surg 2022; 89:365-372. [PMID: 36149976 DOI: 10.1097/sap.0000000000003276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Age, race, socioeconomic status, and proximity to plastic surgeons have been shown to impact receipt of reconstruction after mastectomy in several national studies. Given that targeted outreach efforts and programs to address these discrepancies would occur locoregionally, investigation of these reconstructive trends on a state level is warranted. STUDY DESIGN Patients diagnosed with breast cancer in Virginia between 2000 and 2018 were identified in the Virginia Department of Health Cancer Registry. Patients who underwent mastectomy breast conservation surgery, and/or breast reconstruction at the time of oncologic surgery were identified. Patient demographics were analyzed, and logistic regression analyses were used to determine the likelihood of receipt of mastectomy, receipt of mastectomy versus breast conservation surgery, receipt of mastectomy with reconstruction versus mastectomy alone, and receipt of mastectomy with reconstruction versus breast conservation surgery with respect to the demographic variables. Geographically weighted regression analyses were also performed to determine impact of geographic location on receipt of mastectomy and reconstruction after mastectomy. RESULTS A total of 78,682 patients in Virginia underwent surgical treatment for breast cancer between 2000 and 2018. Living outside a metropolitan area, increased age, lower socioeconomic status, non-White race, and lower number of plastic surgeons within 50 miles were associated with decreased rates of postmastectomy reconstruction. Rural setting, lower socioeconomic status, and lower plastic surgeon supply were also associated with decreased rates of breast conservation surgery. Reconstruction after mastectomy was lowest in the northwest, central, and southwest regions of Virginia. CONCLUSIONS Within the state of Virginia, programs to improve access to breast reconstruction for patients residing in rural regions, as well as non-White patients, older patients, and those in lower socioeconomic groups should be implemented. Future studies would implement and study the efficacy of such outreach programs, which could then be applied and tailored to other states or regions to address sociodemographic disparities in access to breast reconstruction.
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Affiliation(s)
| | | | - T Fabian Camacho
- Public Health Sciences, University of Virginia Health System, Charlottesville, VA
| | - Roger T Anderson
- Public Health Sciences, University of Virginia Health System, Charlottesville, VA
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12
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Chawla S, Shihadeh H, Patel A. An Analysis of Racial Diversity in the Breast Reconstruction and Aesthetic Surgery Literature. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4487. [PMID: 35999873 PMCID: PMC9390813 DOI: 10.1097/gox.0000000000004487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 06/27/2022] [Indexed: 11/25/2022]
Abstract
Background Racial disparities in the visual representation of patients in the plastic surgery literature can contribute to health inequities. This study evaluates racial diversity in photographs published in the aesthetic and breast reconstruction literature. Methods A photogrammetric analysis of plastic surgery journals from the USA, Canada, and Europe was performed. Color photographs depicting human skin, pertaining to breast reconstruction and aesthetic surgery in 2000, 2010, and 2020, were categorized as White (1-3) or non-White (4-6) based on the Fitzpatrick scale. Results All journals demonstrated significantly more White skin images than non-White for all procedures (P < 0.05) except blepharoplasty and rhinoplasty. Blepharoplasty was the only procedure with more non-White images (P = 0.02). When examining USA journals, significant differences were not found in blepharoplasty, rhinoplasty, and male chest surgery. European journals published a greater proportion of non-White images than USA journals (P < 0.0001). There was a decreasing rate of change in diversity with 15.5% of images being non-White in 2000, 32.7% in 2010, and 40.7% in 2020 (P < 0.01). Percentage of non-White images varied by geographical region and ranged from 3.6% in Oceania to 93.5% in Asia (P < 0.01). Conclusions Diversity of patient populations depicted in plastic surgery literature has increased over the past two decades. Despite this improvement, the racial diversity seen in photographs published in the literature does not adequately reflect this demographic for aesthetic and breast procedures. Equitable visual representation may promote cultural competency and improve care for the populations we serve.
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Affiliation(s)
- Sahil Chawla
- From the Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hanaa Shihadeh
- Division of Plastic Surgery, Department of Surgery, Albany Medical College, Albany, N.Y
| | - Ashit Patel
- Division of Plastic Surgery, Department of Surgery, Albany Medical College, Albany, N.Y
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Burke J, Friedman-Eldar O, Halfteck G, Silva IDC, Baumrucker CC, Reyes FV, Lessard AS, Kassira W, Franceschi D, Kesmodel SB, Avisar E, Goel N, Möller MG. Persistent and interdependent: Racial disparities and their mechanisms in postmastectomy breast reconstruction. Surgery 2022; 172:25-30. [PMID: 35241302 DOI: 10.1016/j.surg.2022.01.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Racial disparities in accessing postmastectomy breast reconstruction persist despite expansion of insurance coverage. An updated examination with a broad assessment of mediating factors in a "majority minority" community is needed. METHODS Data were collected on all patients undergoing mastectomy for breast cancer from 2011 to 2019 in a private academic center and adjacent safety-net hospital. Multivariable logistic regression was used to assess the effect of race on postmastectomy breast reconstruction, controlling for predetermined potentially mediating and confounding variables. RESULTS Of 1,554 patients, 63.8% (n = 203) of non-Hispanic White, 33.4% (n = 102) of Black, and 47.9% (n = 438) of Hispanic patients underwent postmastectomy breast reconstruction. Multivariable logistic regression showed that Black patients (odds ratio [OR] 3.6, 95% confidence internal [CI]: 2.2-5.9; P < .0001) undergo significantly less postmastectomy breast reconstruction than White patients. Age, insurance status, stage, and hospital type mediated this relationship. CONCLUSION Black patients have substantially reduced rates of postmastectomy breast reconstruction compared with White patients, which is mediated by socioeconomic factors.
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Affiliation(s)
- Jonathan Burke
- Department of Surgery, New York University School of Medicine, NY.
| | - Orli Friedman-Eldar
- University of Miami Miller School of Medicine, FL; Jackson Memorial Hospital, Miami, FL
| | - Gili Halfteck
- University of Miami Miller School of Medicine, FL; Jackson Memorial Hospital, Miami, FL
| | | | | | | | - Anne-Sophie Lessard
- Division of Plastic Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, FL
| | - Wrood Kassira
- Division of Plastic Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, FL
| | - Dido Franceschi
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, FL
| | - Susan B Kesmodel
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, FL
| | - Eli Avisar
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, FL
| | - Neha Goel
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, FL
| | - Mecker G Möller
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, FL. https://twitter.com/MeckeritaMoller
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Fasano G, Bayard S, Tamimi R, An A, Zenilman ME, Davis M, Newman L, Bea VJ. Postmastectomy Breast Reconstruction Patterns at an Urban Academic Hospital and the Impact of Surgeon Gender. Ann Surg Oncol 2022; 29:5437-5444. [PMID: 35583690 PMCID: PMC9116063 DOI: 10.1245/s10434-022-11807-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/08/2022] [Indexed: 11/18/2022]
Abstract
Background Postmastectomy breast reconstruction is an essential element of multidisciplinary breast cancer care but may be underutilized. Methods This retrospective study analyzed mastectomy patients (2018–2021) at an urban hospital. Multivariable logistic regression was performed, and a mixed-effects logistic regression model was constructed to determine patient-level factors (age, race, body mass index, comorbidities, smoking status, insurance, type of surgery) and provider-level factors (breast surgeon gender, participation in multidisciplinary breast clinic) that influence reconstruction. Results Overall, 167 patients underwent mastectomy. The reconstruction rate was 35%. In multivariable analysis, increasing age (odds ratio [OR] 0.95; 95% confidence interval [CI] 0.91–0.99) and Medicaid insurance (OR 0.18; 95% CI 0.06–0.53) relative to private insurance were negative predictors, whereas bilateral mastectomy was a positive predictor (OR 7.07; 95% CI 2.95–17.9) of reconstruction. After adjustment for patent age, race, insurance, and type of surgery, female breast surgeons had 3.7 times greater odds of operating on patients who had reconstruction than males (95% CI 1.20–11.42). Conclusion Both patient- and provider-level factors have an impact on postmastectomy reconstruction. Female breast surgeons had nearly four times the odds of caring for patients who underwent reconstruction, suggesting that a more standardized process for plastic surgery referral is needed.
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Affiliation(s)
- Genevieve Fasano
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Solange Bayard
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Rulla Tamimi
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Anjile An
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Michael E Zenilman
- Department of Surgery, New York-Presbyterian, Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Melissa Davis
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Lisa Newman
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Vivian J Bea
- Department of Surgery, New York-Presbyterian, Brooklyn Methodist Hospital, Brooklyn, NY, USA.
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Moroni EA, Bustos SS, Mehta M, Munoz-Valencia A, Douglas NKO, Bustos VP, Evans S, Diego EJ, De La Cruz C. Disparities in Access to Postmastectomy Breast Reconstruction: Does Living in a Specific ZIP Code Determine the Patient's Reconstructive Journey? Ann Plast Surg 2022; 88:S279-S283. [PMID: 35513331 DOI: 10.1097/sap.0000000000003195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Elizabeth A Moroni
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Samyd S Bustos
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Meeti Mehta
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Nerone K O Douglas
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Steven Evans
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Emilia J Diego
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Carolyn De La Cruz
- From the Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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Erdrich J, Cordova-Marks F, Monetathchi AR, Wu M, White A, Melkonian S. Disparities in Breast-Conserving Therapy for Non-Hispanic American Indian/Alaska Native Women Compared with Non-Hispanic White Women. Ann Surg Oncol 2022; 29:1019-1030. [PMID: 34490527 PMCID: PMC8724083 DOI: 10.1245/s10434-021-10730-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/12/2021] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Jennifer Erdrich
- Division of Surgical Oncology, Department of Surgery, College of Medicine, University of Arizona, Tucson, USA.
| | - Felina Cordova-Marks
- Department of Health Promotion Sciences, College of Public Health, University of Arizona, Tucson, USA
| | | | - Manxia Wu
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, USA
| | - Arica White
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, USA
| | - Stephanie Melkonian
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Albuquerque, USA
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Goldenberg AR, Willcox LM, Abolghasemi DM, Jiang R, Wei ZZ, Arciero CA, Subhedar PD. Did Medicaid Expansion Mitigate Disparities in Post-mastectomy Reconstruction Rates? Am Surg 2022; 88:846-851. [DOI: 10.1177/00031348211060452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patient and socioeconomic factors both contribute to disparities in post-mastectomy reconstruction (PMR) rates. We sought to explore PMR patterns across the US and to determine if PMR rates were associated with Medicaid expansion. Methods The NCDB was used to identify women who underwent PMR between 2004-2016. The data was stratified by race, state Medicaid expansion status, and region. A multivariate model was fit to determine the association between Medicaid expansion and receipt of PMR. Results In comparison to Caucasian women receiving PMR in Medicaid expansion states, African American (AA) women in Medicaid expansion states were less likely to receive PMR (OR .96 [.92-1.00] P < .001). Patients in the Northeast (NE) had better PMR rates vs any other region in the US, for both Caucasian and AA women (Caucasian NE ref, Caucasian-South .80 [.77-.83] vs AA NE 1.11 [1.04-1.19], AA-South (.60 [.58-.63], P < .001). Interestingly, AA patients residing in the NE had the highest receipt of PMR 1.11 (1.04-1.19), even higher than their Caucasian counterparts residing in the same region (ref). Rural AA women had the lowest rates of PMR vs rural Caucasian women (.40 [.28-.58] vs .79 [.73-.85], P < .001]. Discussion Racial disparities in PMR rates persisted despite Medicaid expansion. When stratified by region, however, AA patients in the NE had higher rates of PMR than AA women in other regions. The largest disparities were seen in AA women in the rural US. Breast cancer disparities continue to be a complex problem that was not entirely mitigated by improved insurance coverage.
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Affiliation(s)
- Alison R. Goldenberg
- Novant Health UVA Health System Prince William Medical Center, Haymarket, VA, USA
| | - Lauren M. Willcox
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA
| | | | - Renjian Jiang
- Department of Biostatistics, Emory University School of Medicine, Atlanta, GA, USA
| | - Zheng Z. Wei
- Department of Biostatistics, Emory University School of Medicine, Atlanta, GA, USA
| | - Cletus A. Arciero
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA
| | - Preeti D. Subhedar
- Department of Surgery, School of Medicine, Emory University, Atlanta, GA, USA
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18
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Mandelbaum A, Nakhla M, Seo YJ, Dobaria V, Attai DJ, Baker JL, Thompson CK, DiNome ML, Benharash P, Lee MK. National trends and predictors of mastectomy with immediate breast reconstruction. Am J Surg 2021; 222:773-779. [PMID: 33627231 DOI: 10.1016/j.amjsurg.2021.02.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/14/2021] [Accepted: 02/07/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE This study aimed to evaluate national trends in utilization, resource use, and predictors of immediate breast reconstruction (IR) after mastectomy. METHODS The 2005-2014 National Inpatient Sample database was used to identify adult women undergoing mastectomy. IR was defined as any reconstruction during the same inpatient stay. Multivariable regression models were utilized to identify factors associated with IR. RESULTS Of 729,340 patients undergoing mastectomy, 41.3% received IR. Rates of IR increased from 28.2% in 2005 to 58.2% in 2014 (NP-trend<0.001). Compared to mastectomy alone, IR was associated with increased length of stay (2.5 vs. 2.1 days, P < 0.001) and hospitalization costs ($17,628 vs. $8,643, P < 0.001), which increased over time (P < 0.001). Predictors of IR included younger age, fewer comorbidities, White race, private insurance, top income quartile, teaching hospital designation, high mastectomy volume, and performance of bilateral mastectomy. CONCLUSION Mastectomy with IR is increasingly performed with resource utilization rising at a steady pace. Our study points to persistent sociodemographic and hospital level disparities associated with the under-utilization of IR. Efforts are needed to alleviate disparities in IR.
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Affiliation(s)
- Ava Mandelbaum
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Morcos Nakhla
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Young Ji Seo
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Deanna J Attai
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States
| | - Jennifer L Baker
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States
| | - Carlie K Thompson
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States
| | - Maggie L DiNome
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - Minna K Lee
- Division of General Surgery, Department of Surgery, University of California, Los Angeles, CA, United States.
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Lee RXN, Yogeswaran G, Wilson E, Oni G. Barriers and facilitators to breast reconstruction in ethnic minority women-A systematic review. J Plast Reconstr Aesthet Surg 2020; 74:463-474. [PMID: 33309318 DOI: 10.1016/j.bjps.2020.10.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 07/02/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Post-mastectomy breast reconstruction (PMBR) is an important component of the multidisciplinary care of breast cancer patients. Despite the improved quality of life, significant racial disparities exist in the receipt of PMBR. Given the increasing population of Black, Asian and minority ethnic (BAME) women in UK, it is important to address this disparity. Our review aims to identify the barriers and facilitators influencing the uptake of PMBR in BAME women and raise awareness for physicians on interventions that could improve uptake of PMBR in BAME women. METHODS The methodology outlined by the Cochrane guidelines was used to structure this systematic review. Systematic searches for qualitative studies on barriers and/or facilitators to PMBR in ethnic women published in English were conducted. The following databases were searched from their inception up to June 2019: MEDLINE, EMBASE, PubMed, Cochrane Library, Google Scholar and Scopus. Reference lists of all included articles and relevant systematic reviews were also hand-searched for possible additional publications. Publication year or status restrictions were not applied. Only full text articles published in English and by peer reviewed journals are included. Exclusion criteria were as follows: quantitative studies on barriers and/or facilitators to PMBR, abstracts, conference proceedings, non-English language and non-specific to BAME women. A thematic synthesis approach was used through the development of sub-themes and themes from the findings of the included qualitative studies. RESULTS Five studies satisfied the inclusion and exclusion criteria. Three overarching themes emerged from our review: physician-associated factors (physician recommendations), patient-associated factors (knowledge, language, community and cultural, emotions, logistics, patient characteristics) and system-associated factors (insurance coverage, income status). CONCLUSION Our systematic review suggests that there is a paucity of data in the literature on the barriers and facilitators to PMBR in BAME women. Considering the expanding population of BAME women and increasing breast cancer incidence, it is imperative that future research in this field is carried out. Physician and patient-associated factors were identified as the most important yet modifiable factors. Adopting a combination of culturally tailored interventions targeting these factors may help improve the access of PMBR in BAME women. REGISTRATION Prospero ID: CRD42019133233.
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Affiliation(s)
- Rachel Xue Ning Lee
- Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
| | - Gowsika Yogeswaran
- University of Nottingham, School of Medicine, Nottingham, United Kingdom
| | - Emma Wilson
- University of Nottingham, School of Medicine, Nottingham, United Kingdom
| | - Georgette Oni
- Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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Restrepo DJ, Huayllani MT, Boczar D, Sisti A, Nguyen MDT, Cochuyt JJ, Spaulding AC, Rinker BD, Perdikis G, Forte AJ. Disparities in Access to Autologous Breast Reconstruction. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E281. [PMID: 32521732 PMCID: PMC7353892 DOI: 10.3390/medicina56060281] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/26/2020] [Accepted: 06/04/2020] [Indexed: 01/09/2023]
Abstract
Background and objectives: This study aimed to determine if age, race, region, insurance, and comorbidities affect the type of breast reconstruction that patients receive. Materials and methods: This analysis used the Florida Inpatient Discharge Dataset from 1 January 2013 to 30 September 2017, which contains deidentified patient-level administrative data from all acute care hospitals in the state of Florida. We included female patients, diagnosed with breast cancer, who underwent mastectomy and a subsequent breast reconstruction. We performed an χ2 test and logistic regression in this analysis. Results: On the multivariable analysis, we found that age, race, patient region, insurance payer, and Elixhauser score were all variables that significantly affected the type of reconstruction that patients received. Our results show that African American (odds ratio (OR): 0.68, 95%CI: 0.58-0.78, p < 0.001) and Hispanic or Latino (OR: 0.82, 95%CI: 0.72-0.93, p = 0.003) patients have significantly lower odds of receiving implant reconstruction when compared to white patients. Patients with Medicare (OR: 1.57, 95%CI: 1.33-1.86, p < 0.001) had significantly higher odds and patients with Medicaid (OR: 0.61, 95%CI: 0.51-0.74, p < 0.001) had significantly lower odds of getting autologous reconstruction when compared to patients with commercial insurance. Conclusions: Our study demonstrated that, in the state of Florida over the past years, variables, such as race, region, insurance, and comorbidities, play an important role in choosing the reconstruction modality. More efforts are needed to eradicate disparities and give all patients, despite their race, insurance payer, or region, equal access to health care.
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Affiliation(s)
- David J. Restrepo
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL 32224, USA; (D.J.R.); (M.T.H.); (D.B.); (B.D.R.)
| | - Maria T. Huayllani
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL 32224, USA; (D.J.R.); (M.T.H.); (D.B.); (B.D.R.)
| | - Daniel Boczar
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL 32224, USA; (D.J.R.); (M.T.H.); (D.B.); (B.D.R.)
| | - Andrea Sisti
- Department of Plastic Surgery, Cleveland Clinic, OH 44195, USA;
| | | | - Jordan J. Cochuyt
- Department of Health Science Research, Mayo Clinic, Jacksonville, FL 32224, USA; (J.J.C.); (A.C.S.)
| | - Aaron C. Spaulding
- Department of Health Science Research, Mayo Clinic, Jacksonville, FL 32224, USA; (J.J.C.); (A.C.S.)
| | - Brian D. Rinker
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL 32224, USA; (D.J.R.); (M.T.H.); (D.B.); (B.D.R.)
| | - Galen Perdikis
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
| | - Antonio J. Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL 32224, USA; (D.J.R.); (M.T.H.); (D.B.); (B.D.R.)
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21
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Hart SE, Momoh AO. Breast Reconstruction Disparities in the United States and Internationally. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00366-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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22
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Siotos C, Lagiou P, Cheah MA, Bello RJ, Orfanos P, Payne RM, Broderick KP, Aliu O, Habibi M, Cooney CM, Naska A, Rosson GD. Determinants of receiving immediate breast reconstruction: An analysis of patient characteristics at a tertiary care center in the US. Surg Oncol 2020; 34:1-6. [PMID: 32103789 DOI: 10.1016/j.suronc.2020.02.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/14/2020] [Accepted: 02/14/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Breast reconstruction is an option for women undergoing mastectomy for breast cancer. Previous studies have reported underutilization of reconstructive surgery. This study aims to examine the role demographic, clinical and socio-economic factors may have on patients' decisions to undergo breast reconstruction. METHODS We analyzed data from our institutional database. Using multivariable and multinomial logistic regression, we compared breast cancer patients who had undergone mastectomy-only to those who had immediate breast reconstruction (overall and by type of reconstruction). RESULTS We analyzed data on 1459 women who underwent mastectomy during the period 2003-2015. Of these, 475 (32.6%) underwent mastectomy-only and 984 (67.4%) also underwent immediate breast reconstruction. After adjusting for potential confounders, older age (OR = 0.18, 95%CI:0.08-0.40), Asian race (OR = 0.29, 95%CI:0.19-0.45), bilateral mastectomy (OR = 0.71, 95%CI:0.56-0.90), and higher stage of disease (OR = 0.44, 95%CI:0.26-0.74) were independent risk factors for not receiving immediate breast reconstruction. Furthermore, patients with Medicare or Medicaid insurance were less likely than patients with private insurance to receive an autologous reconstruction. There was no evidence for changes over time in the way socio-demographic and clinical factors were related to receiving immediate breast reconstruction after mastectomy. CONCLUSIONS Clinical characteristics, sociodemographic factors like age, race and insurance coverage affect the decision for reconstructive surgery following mastectomy.
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Affiliation(s)
- Charalampos Siotos
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Mikras Asias 75, Athens, 115 27, Greece; Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287.
| | - Pagona Lagiou
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Mikras Asias 75, Athens, 115 27, Greece
| | - Michael A Cheah
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Ricardo J Bello
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287; Department of Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Phillipos Orfanos
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Mikras Asias 75, Athens, 115 27, Greece
| | - Rachael M Payne
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Kristen P Broderick
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Oluseyi Aliu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Mehran Habibi
- Department of Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
| | - Androniki Naska
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Mikras Asias 75, Athens, 115 27, Greece
| | - Gedge D Rosson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, 601 N. Caroline Street, Baltimore, 21287, Maryland, USA, 21287
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Disparities in Postmastectomy Breast Reconstruction: A Systematic Review of the Literature and Modified Framework for Advancing Research Toward Intervention. Ann Plast Surg 2019; 81:495-502. [PMID: 29851727 DOI: 10.1097/sap.0000000000001503] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND As the United States' population diversifies, eliminating disparities in health and healthcare has become increasingly important across all disciplines of medicine, including plastic and reconstructive surgery. This is evidenced by the growing body of literature in recent years focusing on disparities in postmastectomy breast reconstruction. No study to date has evaluated whether this research is progressing appropriately to promote tangible evidence-based interventions to reduce these disparities. METHODS A systematic literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was performed to identify studies focusing on disparities in postmastectomy breast reconstruction. A previously established public health framework for advancing health disparities research was used to inform analysis of the quality and progression of the included studies. This triphasic framework categorizes disparities research as follows: detecting (identifies and measures disparities in vulnerable populations), understanding (establishes determinants of disparities), or reducing (proposes and evaluates interventions for eliminating disparities). RESULTS Ninety-five studies were identified between 1979 and 2016, with 61 (64.2%) published after 2010. The majority of studies (51.6%) were retrospective cohort or case-control studies (American Society of Plastic Surgery level III evidence). Fifty-eight (63.7%), 31 (34.1%), and 2 (2.2%) studies provided detecting-, understanding- and reducing-phase disparities research, respectively. Non-plastic and reconstructive surgery journals accounted for 70.5% of all articles and for most higher phase research articles, publishing 83.9% and 100% of second and third phase studies, respectively. Disparity categories investigated included race/ethnicity, age, income, insurance status/type, geography, and education level, with race/ethnicity being the most common (73.7%). The most commonly measured outcome was percent of subpopulation receiving reconstruction (63, 66.3%), followed by reconstruction type (14, 16.7%). Patient-, provider-, system-, and research-level factors were all identified as potential targets for interventions to reduce disparities. CONCLUSIONS Despite a recent increase in literature focusing on postmastectomy breast reconstruction disparities, the majority focuses on identifying vulnerable populations with inadequate progression to second (understanding) and third (reducing) phases. Increasing research funding, availability of language-concordant and culturally concordant educational materials, and advocacy and sociopolitical awareness within the plastic surgery community is necessary to advance research on postmastectomy breast reconstruction and, ultimately, eliminate it.
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Abstract
BACKGROUND The purpose of this systematic review was to comprehensively summarize barriers of access to breast reconstruction and evaluate access using the Penchansky and Thomas conceptual framework based on the six dimensions of access to care. METHODS The authors performed a systematic review that focused on (1) breast reconstruction, (2) barriers, and (3) breast cancer. Eight databases (i.e., EMBASE, MEDLINE, PsycINFO, CINHAL, ePub MEDLINE, ProQuest, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials) were searched. English peer-reviewed articles published between 1996 and 2016 were included. RESULTS The authors' search retrieved 4282 unique articles. Two independent reviewers screened texts, selecting 99 articles for inclusion. All studies were observational and qualitative in nature. The availability of breast reconstruction was highest in teaching hospitals, private hospitals, and national cancer institutions. Accessibility affected access, with lower likelihood of breast reconstruction in rural geographic locations. Affordability also impacted access; high costs of the procedure or poor reimbursement by insurance companies negatively influenced access to breast reconstruction. Acceptability of the procedure was not universal, with unfavorable physician attitudes toward breast reconstruction and specific patient and tumor characteristics correlating with lower rates of breast reconstruction. Lastly, lack of patient awareness of breast reconstruction reduced the receipt of breast reconstruction. CONCLUSIONS Using the access-to-care framework by Penchansky and Thomas, the authors found that barriers to breast reconstruction existed in all six domains and interplayed at many levels. The authors' systematic review analyzed this complex relationship and suggested multiprong interventions aimed at targeting breast reconstruction barriers, with the goal of promoting equitable access to breast reconstruction for all breast cancer patients.
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Saveliyev VN, Tkachev MV, Borisov AP. [The method of endoprosthesis deployment in breast cancer surgery]. Khirurgiia (Mosk) 2019:50-52. [PMID: 30789608 DOI: 10.17116/hirurgia201901150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To improve immediate results of treatment in patients with breast cancer using a new method of reconstruction. MATERIAL AND METHODS Prospective study included 215 patients with breast cancer. Patients were treated at the Samara Regional Clinical Oncology Center in 2013-2016. Patients of the control group (n=111) underwent subcutaneous mastectomy followed by conventional endoprosthesis deployment with its complete muscular covering. Patients of the main group (n=104) underwent subcutaneous mastectomy with a new method of single-stage reconstruction. RESULTS Mean time of operation was 115±15 min in the control group and 90±10 min in the main group (p=0.000). Intraoperative blood loss reached 115±15 ml in the control group, 70±10 ml - in the main group (p=0.000). Duration of postoperative lymphorrhea was 14.6±3.5 days in the control group, 10±3.4 days - in the main group (p=0.000). Postoperative hospital-stay was 17.1±3.7 day in the control group and 14.2±2.4 days in the main group (p=0.001). CONCLUSION New surgical approach significantly improves early outcomes in patients with breast cancer in comparison with those who undergo conventional surgical repair.
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Affiliation(s)
- V N Saveliyev
- Samara Regional Clinical Oncology Center, Samara, Russia
| | - M V Tkachev
- Samara Regional Clinical Oncology Center, Samara, Russia
| | - A P Borisov
- Samara Regional Clinical Oncology Center, Samara, Russia
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Mets EJ, Chouairi FK, Gabrick KS, Avraham T, Alperovich M. Persistent disparities in breast cancer surgical outcomes among hispanic and African American patients. Eur J Surg Oncol 2019; 45:584-590. [PMID: 30683449 DOI: 10.1016/j.ejso.2019.01.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/24/2018] [Accepted: 01/11/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Racial disparities among patients who receive breast mastectomy and reconstruction have not been well characterized. METHODS Records of patients undergoing breast extirpative and reconstructive surgery at a high-volume university-affiliated hospital over 5 consecutive years were reviewed. Patient demographics, breast cancer profiles, reconstructive modality, and outcomes were compared by race. RESULTS A total of 1045 patients underwent 1678 breast reconstructions during the five-year period. Mean age and standard deviation was 49.8 ± 10.6 years with a BMI of 27.9 ± 6.5. Hispanic and African American patients had significantly higher BMIs (p < 0.001), higher rates of ASA class III or IV (p = 0.025), obesity, diabetes, hypertension (p < 0.001 for these three comparisons), and smoking (p = 0.003), and had more prior abdominal surgeries (p = 0.007). Comparing oncologic characteristics, this population subset had higher rates of neoadjuvant chemotherapy (p = 0.036), history of radiation (p = 0.016), and were more likely to undergo modified radical mastectomy (p = 0.002) over nipple-sparing mastectomy (p = 0.035). Reconstructive complications revealed a higher overall complication rate (p = 0.023), higher rates of partial mastectomy flap necrosis (p = 0.043), as well as arterial (p = 0.009) and venous insufficiency (p = 0.026) during microvascular reconstruction among Hispanic and African American patients. CONCLUSIONS Compared to other patients, the present study identifies higher comorbidity burdens, higher rates of prior radiation and neoadjuvant chemotherapy, and higher post-surgical complication rates among Hispanic and African American patients with breast cancer.
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Affiliation(s)
- Elbert J Mets
- Yale School of Medicine, Department of Surgery, Section of Plastic and Reconstructive Surgery, New Haven, CT, USA
| | - Fouad K Chouairi
- Yale School of Medicine, Department of Surgery, Section of Plastic and Reconstructive Surgery, New Haven, CT, USA
| | - Kyle S Gabrick
- Yale School of Medicine, Department of Surgery, Section of Plastic and Reconstructive Surgery, New Haven, CT, USA
| | - Tomer Avraham
- Yale School of Medicine, Department of Surgery, Section of Plastic and Reconstructive Surgery, New Haven, CT, USA
| | - Michael Alperovich
- Yale School of Medicine, Department of Surgery, Section of Plastic and Reconstructive Surgery, New Haven, CT, USA.
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Variations in the breast reconstruction rate in France: A nationwide study of 19,466 patients based on the French medico-administrative database. Breast 2018; 42:74-80. [DOI: 10.1016/j.breast.2018.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/02/2018] [Accepted: 07/22/2018] [Indexed: 01/29/2023] Open
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Yang RL, Wapnir I. Hispanic Breast Cancer Patients Travel Further for Equitable Surgical Care at a Comprehensive Cancer Center. Health Equity 2018; 2:109-116. [PMID: 30283856 PMCID: PMC6071895 DOI: 10.1089/heq.2017.0021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Purpose: Disparities in surgical breast cancer care have been documented for racial and ethnic minorities. On average, these minorities are less likely to utilize National Cancer Institute (NCI)-designated cancer centers and travel shorter distances to receive care. With the growing population of Hispanic patients in California, we analyzed the travel distance and surgical care of Hispanic and non-Hispanic patients at our large referral cancer center. Methods: Patients included were those who initiated treatment for a new diagnosis of ductal carcinoma in situ or invasive breast cancer at our NCI-designated cancer center during the period 2010–2014. Ethnicity was dichotomized as Hispanic and non-Hispanic. Google Maps were used to determine the distance from patient zip code to our institution, classified as 0–10, 10–30, 30–60, and >60 miles. Results: A total of 1765 non-Hispanic and 173 Hispanic patients were identified. Clinical stage by tumor size and nodal status were comparable between the two groups. Hispanic patients were younger (p<0.001) and more had Medicaid insurance (p<0.001). Hispanic patients traveled further when compared with non-Hispanics (p<0.001). In non-Hispanics and Hispanics, rates of breast conservation were 57.4% and 52.3% (p=0.30), unilateral mastectomy 34.2% and 36.2% (p=0.44), bilateral mastectomy 8.4% and 11.5% (p=0.24), and immediate postmastectomy reconstruction 42.6% and 50.6% (p=0.34), respectively. Hispanic ethnicity was not associated with different odds of receiving breast conservation (odds ratio [OR] 1.01, confidence interval [CI] 0.73–1.40), unilateral mastectomy (OR 1.05, CI 0.75–1.44), bilateral mastectomy (OR 1.37, CI 0.81–2.31), or immediate postmastectomy breast reconstruction (OR 1.27, CI 0.86–1.88), when compared with non-Hispanic ethnicity, after controlling for patient age, insurance status, and distance traveled. Conclusions: Surgical care was similar for Hispanic and non-Hispanic patients treated at our NCI-designated cancer center. However, this Hispanic population traveled further than non-Hispanic patients. Our findings suggest that accessibility to transportation and institutional practices are instrumental in delivering equitable breast cancer surgical care for Hispanic patients.
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Affiliation(s)
- Rachel L Yang
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Irene Wapnir
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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Suga H, Shiraishi T, Tsuji N, Takushima A. Risk Factors for Complications in Expander-Based Breast Reconstruction: Multivariate Analysis in Asian Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1563. [PMID: 29263965 PMCID: PMC5732671 DOI: 10.1097/gox.0000000000001563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 09/22/2017] [Indexed: 11/25/2022]
Abstract
Background: There have been many studies examining risk factors for complications in expander-based breast reconstruction after mastectomy, and some patient factors have been identified as risk factors. However, most of the previous studies were based on Caucasian patients. Methods: Asian patients who had a tissue expander placed for immediate breast reconstruction between January 2006 and December 2015 (363 patients and 371 expanders) were analyzed retrospectively. Univariate and multivariate analyses were performed to elucidate risk factors for complications. Results: The rate of skin necrosis was significantly higher in nipple-sparing mastectomy than in other types of mastectomies (12 patients among 107 patients, P = 0.001). The weight of the resected specimen was significantly higher in the group with complications than in the group without complications (444 g compared with 363 g, P = 0.027). Other factors (age, body mass index, smoking, expander type, preoperative chemotherapy, axillary dissection) had no significant effect on complications. Multivariate analysis with a logistic regression showed that a large breast (over 500 g) was the only significant risk factor for complications, with an odds ratio of 3.20 and a 95% confidence interval of 1.33–7.54 (P = 0.010). Conclusion: In this series of Asian patients, breast size, rather than body mass index, is the most important predictor for complications in expander-based breast reconstruction.
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Affiliation(s)
- Hirotaka Suga
- Department of Plastic Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Tomohiro Shiraishi
- Department of Plastic Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Naoko Tsuji
- Department of Plastic Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Akihiko Takushima
- Department of Plastic Surgery, Kyorin University School of Medicine, Tokyo, Japan
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Butler PD, Familusi O, Serletti JM, Fox JP. Influence of race, insurance status, and geographic access to plastic surgeons on immediate breast reconstruction rates. Am J Surg 2017; 215:987-994. [PMID: 29103529 DOI: 10.1016/j.amjsurg.2017.09.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 09/26/2017] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Paris D Butler
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Olatomide Familusi
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph M Serletti
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Justin P Fox
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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The Relationship Between Geographic Access to Plastic Surgeons and Breast Reconstruction Rates Among Women Undergoing Mastectomy for Cancer. Ann Plast Surg 2017; 78:324-329. [PMID: 28177978 DOI: 10.1097/sap.0000000000000849] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Despite a national health care policy requiring payers to cover breast reconstruction, rates of postmastectomy reconstruction are low, particularly among minority populations. We conducted this study to determine if geographic access to a plastic surgeon impacts breast reconstruction rates. METHODS Using 2010 inpatient and ambulatory surgery data from 10 states, we identified adult women who underwent mastectomy for breast cancer. Data were aggregated to the health service area (HSA) level and hierarchical generalized linear models were used to risk-standardize breast reconstruction rates (RSRR) across HSAs. The relationship between an HSA's RSRR and plastic surgeon density (surgeons/100,000 population) was quantified using correlation coefficients. RESULTS The final cohort included 22,997 patients across 134 HSAs. There was substantial variation in plastic surgeon density (median, 1.4 surgeons/100,000; interquartile range, [0.0-2.6]/100,000) and the use of breast reconstruction (median RSRR, 43.0%; interquartile range, [29.9%-62.8%]) across HSAs. Higher plastic surgeon density was positively correlated with breast reconstruction rates (correlation coefficient = 0.66, P < 0.001) and inversely related to time between mastectomy and reconstruction (correlation coefficient = -0.19, P < 0.001). Non-white and publicly insured women were least likely to undergo breast reconstruction overall. Among privately insured patients, racial disparities were noted in high surgeon density areas (white = 79.0% vs. non-white = 63.3%; P < 0.001) but not in low surgeon density areas (34.4% vs 36.5%; P = 0.70). CONCLUSIONS The lack of geographic access to a plastic surgeon serves as a barrier to breast reconstruction and may compound disparities in care associated with race and insurance status. Future efforts to improve equitable access should consider strategies to ensure access to appropriate clinical expertise.
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Schumacher JR, Taylor LJ, Tucholka JL, Poore S, Eggen A, Steiman J, Wilke LG, Greenberg CC, Neuman HB. Socioeconomic Factors Associated with Post-Mastectomy Immediate Reconstruction in a Contemporary Cohort of Breast Cancer Survivors. Ann Surg Oncol 2017; 24:3017-3023. [PMID: 28766209 DOI: 10.1245/s10434-017-5933-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Post-mastectomy reconstruction is a critical component of high-quality breast cancer care. Prior studies demonstrate socioeconomic disparity in receipt of reconstruction. Our objective was to evaluate trends in receipt of immediate reconstruction and examine socioeconomic factors associated with reconstruction in a contemporary cohort. METHODS Using the National Cancer Database, we identified women <75 years of age with stage 0-1 breast cancer treated with mastectomy (n = 297,121). Trends in immediate reconstruction rates (2004-2013) for the overall cohort and stratified by socioeconomic factors were examined using Join-point regression analysis, and annual percentage change (APC) was calculated. We then restricted our sample to a contemporary cohort (2010-2013, n = 145,577). Multivariable logistic regression identified socioeconomic factors associated with immediate reconstruction. Average adjusted predicted probabilities of receiving reconstruction were calculated. RESULTS Immediate reconstruction rates increased from 27 to 48%. Although absolute rates of reconstruction for each stratification group increased, similar APCs across strata led to persistent gaps in receipt of reconstruction. On multivariable logistic regression using our contemporary cohort, race, income, education, and insurance type were all strongly associated with immediate reconstruction. Patients with the lowest predicted probability of receiving reconstruction were patients with Medicaid who lived in areas with the lowest rates of high-school graduation (Black 42.4% [95% CI 40.5-44.3], White 45.7% [95% CI 43.9-47.4]). CONCLUSIONS Although reconstruction rates have increased dramatically over the past decade, lower rates persist for disadvantaged patients. Understanding how socioeconomic factors influence receipt of reconstruction, and identifying modifiable factors, are critical next steps towards identifying interventions to reduce disparities in breast cancer surgical care.
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Affiliation(s)
- Jessica R Schumacher
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Lauren J Taylor
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jennifer L Tucholka
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Samuel Poore
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Amanda Eggen
- Cancer Health Disparities Initiative, Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jennifer Steiman
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Lee G Wilke
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Caprice C Greenberg
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Heather B Neuman
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. .,University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Abstract
BACKGROUND Racial disparity continues to be a well-documented problem afflicting contemporary health care. Because the breast is a symbol of femininity, breast reconstruction is critical to mitigating the psychosocial stigma of a breast cancer diagnosis. Whether different races have equitable access to breast reconstruction remains unknown. METHODS Two thousand five hundred thirty-three women underwent first-time autologous versus implant-based reconstruction following mastectomy. Information regarding age, smoking, diabetes, obesity, provider, race, pathologic stage, health insurance type, charge to insurance, and socioeconomic status was recorded. Established statistics compared group medians and proportions. A backward-stepwise multivariate logistic regression model identified independent predictors of breast reconstruction type. RESULTS Compared with whites, African Americans were more likely to be underinsured (p < 0.01), face a lesser charge for reconstruction (p < 0.01), smoke (p < 0.01), have diabetes (p < 0.01), suffer from obesity (p < 0.01), live in a zip code with a lower median household income (p < 0.01), and undergo autologous-based reconstruction (p = 0.01). On multivariate analysis, only African American race (OR, 2.23; p < 0.01), charge to insurance (OR, 1.00; p < 0.01), and provider (OR, 0.96; p < 0.01) independently predicted type of breast reconstruction, whereas age (OR, 1.02; p = 0.06) and diabetes (OR, 0.48; p = 0.08) did not. CONCLUSIONS African American race remains the most clinically significant predictor of autologous breast reconstruction, even after controlling for age, obesity, pathologic stage, health insurance type, charge to patient, socioeconomic status, smoking, and diabetes. Future research may address whether this disparity stems from patient preferences or more profound sociocultural and economic forces, including discrimination. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Whitworth P, Beitsch P, Arnell C, Cox HC, Brown K, Kidd J, Lancaster JM. Impact of Payer Constraints on Access to Genetic Testing. J Oncol Pract 2016; 13:e47-e56. [PMID: 28084878 DOI: 10.1200/jop.2016.013581] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND With increased demand for hereditary cancer genetic testing, some large national health-care insurance payers (LNHPs) have implemented policies to minimize inappropriate testing by mandating consultation with a geneticist or genetic counselor (GC). We hypothesized such a restriction would reduce access and appropriate testing. METHODS Test cancellation rates (ie, tests ordered that did not result in a reported test result), mutation-positive rates, and turnaround times for comprehensive BRCA1/2 testing for a study LNHP that implemented a GC-mandate policy were determined over the 12 months before and after policy implementation (excluding a 4-month transition period). Cancellation rates were evaluated based on the reason for cancellation, National Comprehensive Cancer Network testing criteria, and self-identified ancestry. A control LNHP was evaluated over the same period for comparison. RESULTS The study LNHP cancellation rate increased from 13.3% to 42.1% ( P < .001) after policy implementation. This increase was also observed when only individuals who met National Comprehensive Cancer Network criteria for hereditary breast and ovarian cancer testing were considered (9.5% to 37.7%; P < .001). Cancellation rates increased after policy introduction for all ancestries; however, this was more pronounced among individuals of African or Latin American ancestry, for whom cancellation rates rose to 48.9% and 49.6%, respectively, compared with 33.9% for individuals of European ancestry. Over this same time period, control LNHP cancellation rates decreased or stayed the same for all subgroups. CONCLUSION These findings demonstrate that a GC-mandate policy implemented by a LNHP substantially decreased access to appropriate genetic testing, disproportionately impacting minority populations without any evidence that inappropriate testing was decreased.
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Affiliation(s)
- Pat Whitworth
- Nashville Breast Center, Nashville, TN; Dallas Surgical Group, Dallas, TX; and Myriad Genetic Laboratories, Inc., Salt Lake City, UT
| | - Peter Beitsch
- Nashville Breast Center, Nashville, TN; Dallas Surgical Group, Dallas, TX; and Myriad Genetic Laboratories, Inc., Salt Lake City, UT
| | - Christopher Arnell
- Nashville Breast Center, Nashville, TN; Dallas Surgical Group, Dallas, TX; and Myriad Genetic Laboratories, Inc., Salt Lake City, UT
| | - Hannah C Cox
- Nashville Breast Center, Nashville, TN; Dallas Surgical Group, Dallas, TX; and Myriad Genetic Laboratories, Inc., Salt Lake City, UT
| | - Krystal Brown
- Nashville Breast Center, Nashville, TN; Dallas Surgical Group, Dallas, TX; and Myriad Genetic Laboratories, Inc., Salt Lake City, UT
| | - John Kidd
- Nashville Breast Center, Nashville, TN; Dallas Surgical Group, Dallas, TX; and Myriad Genetic Laboratories, Inc., Salt Lake City, UT
| | - Johnathan M Lancaster
- Nashville Breast Center, Nashville, TN; Dallas Surgical Group, Dallas, TX; and Myriad Genetic Laboratories, Inc., Salt Lake City, UT
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Connors SK, Goodman MS, Myckatyn T, Margenthaler J, Gehlert S. Breast reconstruction after mastectomy at a comprehensive cancer center. SPRINGERPLUS 2016; 5:955. [PMID: 27429869 PMCID: PMC4930439 DOI: 10.1186/s40064-016-2375-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 05/20/2016] [Indexed: 11/23/2022]
Abstract
Background Breast reconstruction after mastectomy is an integral part of breast cancer treatment that positively impacts quality of life in breast cancer survivors. Although breast reconstruction rates have increased over time, African American women remain less likely to receive breast reconstruction compared to Caucasian women. National Cancer Institute-designated Comprehensive Cancer Centers, specialized institutions with more standardized models of cancer treatment, report higher breast reconstruction rates than primary healthcare facilities. Whether breast reconstruction disparities are reduced for women treated at comprehensive cancer centers is unclear. The purpose of this study was to further investigate breast reconstruction rates and determinants at a comprehensive cancer center in St. Louis, Missouri. Methods Sociodemographic and clinical data were obtained for women who received mastectomy for definitive surgical treatment for breast cancer between 2000 and 2012. Logistic regression was used to identify factors associated with the receipt of breast reconstruction. Results We found a breast reconstruction rate of 54 % for the study sample. Women who were aged 55 and older, had public insurance, received unilateral mastectomy, and received adjuvant radiation therapy were significantly less likely to receive breast reconstruction. African American women were 30 % less likely to receive breast reconstruction than Caucasian women. Conclusion These findings suggest that racial disparities in breast reconstruction persist in comprehensive cancer centers. Future research should further delineate the determinants of breast reconstruction disparities across various types of healthcare institutions. Only then can we develop interventions to ensure all eligible women have access to breast reconstruction and the improved quality of life it affords breast cancer survivors.
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Affiliation(s)
- Shahnjayla K Connors
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA
| | - Melody S Goodman
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA
| | - Terence Myckatyn
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA
| | - Julie Margenthaler
- Division of Endocrine Oncologic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA
| | - Sarah Gehlert
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO USA ; George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, MO USA
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Butler PD, Nelson JA, Fischer JP, Wink JD, Chang B, Fosnot J, Wu LC, Serletti JM. Racial and age disparities persist in immediate breast reconstruction: an updated analysis of 48,564 patients from the 2005 to 2011 American College of Surgeons National Surgery Quality Improvement Program data sets. Am J Surg 2016; 212:96-101. [DOI: 10.1016/j.amjsurg.2015.08.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/29/2015] [Accepted: 08/06/2015] [Indexed: 11/28/2022]
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Patterns and Trends in Immediate Postmastectomy Reconstruction in California: Complications and Unscheduled Readmissions. Plast Reconstr Surg 2015; 136:10e-19e. [PMID: 26111325 DOI: 10.1097/prs.0000000000001326] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Immediate reconstruction rates after mastectomy are increasing but remain low. Little is known about hospital readmissions after these procedures. The authors studied unscheduled readmissions after immediate reconstruction. METHODS Using the Healthcare Cost and Utilization Project California State database, the authors identified patients undergoing mastectomy only or with immediate reconstruction for ductal carcinoma in situ and invasive breast cancer from 2005 to 2009. Immediate reconstruction included tissue expander/implant and autologous tissue reconstructions. The authors evaluated temporal trends in immediate reconstruction and factors associated with 30-day unscheduled readmissions after reconstruction. RESULTS The cohort contained 48,414 patients (mastectomy only, 35,648; immediate reconstruction, 12,766; tissue expander/implant, 10,437; autologous tissue, 2329). Readmission rates were not significantly different between mastectomy only and immediate reconstruction (3.55 percent versus 3.39 percent; p = 0.39); however, autologous tissue reconstruction was associated with a significantly higher readmission rate compared with tissue expander/implant reconstruction (4.08 percent versus 3.24 percent; p = 0.04). CONCLUSIONS Immediate reconstruction does not result in higher readmission rates compared with mastectomy only. All women undergoing mastectomy should be offered consultation for reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Effect of federal and state policy changes on racial/ethnic variation in immediate postmastectomy breast reconstruction. Plast Reconstr Surg 2015; 135:1285-1294. [PMID: 25919243 DOI: 10.1097/prs.0000000000001149] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Breast reconstruction after mastectomy has been shown to provide substantial clinical and psychosocial benefits for many patients; however, disparities in the use of immediate postmastectomy breast reconstruction persist. Using the unique dataset from the New York State Inpatient Database, the following developments were studied: (1) trends in immediate postmastectomy breast reconstruction between 1998 and 2006 among white, African American, and Hispanic women; (2) factors associated with its use; and (3) changes in racial/ethnic variation in immediate postmastectomy breast reconstruction before and after implementation of the New York State Medicaid expansion in 2001. METHODS A step-in multivariable logistic regression model was used to assess the effect of race/ethnicity, age, mastectomy type, number of comorbidities, socioeconomic status, and insurance on the probability of undergoing immediate postmastectomy breast reconstruction. Then, adjusted immediate postmastectomy breast reconstruction rates for before and after Medicaid expansion were predicted, stratified by race/ethnicity. RESULTS The probability of undergoing immediate postmastectomy breast reconstruction increased (p < 0.001); however, even with Medicaid expansion occurring during the 8 years studied, gaps in use between white and African American women and between white and Hispanic women increased by 6 percent (95% CI, 0.07 to 0.05) and 5 percent (95% CI, 0.07 to 0.04), respectively. Being younger, having greater income and education, and having private health insurance are associated with a greater probability of immediate postmastectomy breast reconstruction. CONCLUSION These findings indicate that expanding safety-net policies such as Medicaid without providing support such as consultation or health literacy education might not be effective in reducing disparities in health care. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Kwok AC, Goodwin IA, Ying J, Agarwal JP. National trends and complication rates after bilateral mastectomy and immediate breast reconstruction from 2005 to 2012. Am J Surg 2015; 210:512-6. [PMID: 26054659 DOI: 10.1016/j.amjsurg.2015.03.019] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 03/18/2015] [Accepted: 03/23/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND This study's purpose was to examine the national rate of breast cancer patients undergoing bilateral mastectomy (BM) and immediate breast reconstruction (IBR) and their associated complication rates. METHODS Using the National Surgical Quality Improvement Program database, breast cancer patients undergoing mastectomy between 2005 and 2012 were identified. Rates in BM and IBR as well as associated complication rates were evaluated. Logistic regression was used to identify predictors of BM, IBR, and complications. RESULTS A total of 56,905 breast cancer patients underwent mastectomy. The rate of BM tripled (9.14% vs 25.44%, P < .0001) and the rate of IBR increased by 50% (29.73% vs 44.68%, P < .0001). Complication rates were higher in patients undergoing BM compared with unilateral mastectomy (11.49% vs 9.52%, P < .0001) and in patients undergoing IBR compared with mastectomy alone (11.62% vs 8.91%, P < .0001). White race and age less than 40 years were predictors of patients undergoing BM and IBR. CONCLUSIONS The rates of BM and associated IBR have increased significantly since 2005 despite higher complication rates. Further research is needed to understand the reasons for these trends.
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Affiliation(s)
- Alvin C Kwok
- Division of Plastic Surgery, Department of Surgery, University of Utah, School of Medicine, 30 N 1900 E, 3B400, Salt Lake City, UT 84132, USA
| | - Isak A Goodwin
- Division of Plastic Surgery, Department of Surgery, University of Utah, School of Medicine, 30 N 1900 E, 3B400, Salt Lake City, UT 84132, USA
| | - Jian Ying
- Division of Epidemiology, Department of Family and Preventative Medicine, University of Utah, School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Jayant P Agarwal
- Division of Plastic Surgery, Department of Surgery, University of Utah, School of Medicine, 30 N 1900 E, 3B400, Salt Lake City, UT 84132, USA.
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Connors SK, Goodman MS, Noel L, Chavakula NN, Butler D, Kenkel S, Oliver C, McCullough I, Gehlert S. Breast cancer treatment among African American women in north St. Louis, Missouri. J Urban Health 2015; 92:67-82. [PMID: 24912599 PMCID: PMC4338122 DOI: 10.1007/s11524-014-9884-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Similar to disparities seen at the national and state levels, African American women in St. Louis, Missouri have higher breast cancer mortality rates than their Caucasian counterparts. We examined breast cancer treatment (regimens and timing) in a sample of African American breast cancer patients diagnosed between 2000 and 2008 while residing in a North St. Louis cluster (eight zip codes) of late stage at diagnosis. Data were obtained from medical record extractions of women participating in a mixed-method study of breast cancer treatment experiences. The median time between diagnosis and initiation of treatment was 27 days; 12.2% of the women had treatment delay over 60 days. These findings suggest that treatment delay and regimens are unlikely contributors to excess mortality rates for African American women diagnosed in early stages. Conflicting research findings on treatment delay may result from the inconsistent definitions of treatment delay and variations among study populations. Breast cancer treatment delay may reduce breast cancer survival; additional research is needed to better understand the points at which delays are most likely to occur and develop policies, programs, and interventions to address disparities in treatment delay. There may also be differences in treatment-related survivorship quality of life; approximately 54% of the women in this sample treated with mastectomies received breast reconstruction surgery. Despite the high reconstruction rates, most women did not receive definitive completion. African American women have higher reconstruction complication rates than Caucasian women; these data provide additional evidence to suggest a disparity in breast reconstruction outcomes by race.
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Affiliation(s)
- Shahnjayla K Connors
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, 660 South Euclid, Campus Box 8100, St. Louis, MO, 63110, USA,
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Factors Influencing Incidence and Type of Postmastectomy Breast Reconstruction in an Urban Multidisciplinary Cancer Center. Plast Reconstr Surg 2015; 135:270e-276e. [DOI: 10.1097/prs.0000000000000888] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Offodile AC, Tsai TC, Wenger JB, Guo L. Racial disparities in the type of postmastectomy reconstruction chosen. J Surg Res 2015; 195:368-76. [PMID: 25676466 DOI: 10.1016/j.jss.2015.01.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/11/2014] [Accepted: 01/08/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Racial disparities remain for women undergoing immediate breast reconstruction (IBR) after mastectomy. Understanding patterns of racial disparities in IBR utilization may present opportunities to tailor policies aimed at optimizing care across racial groups. The aim of this study was to determine if racial disparities exist for types of IBR chosen. METHODS A national, retrospective cohort study used the 2005-2011 American College of Surgeons National Surgical Quality Improvement Program database. Multivariable logistic regression models were created to detect the odds by race for receiving each subtype of IBR after mastectomy-prosthetic, pedicled-transfer autologous tissue, or free-transfer autologous tissue. Secondary outcome was trends in IBR rates over time. RESULTS There were 44,597 women identified in the data set who underwent mastectomy. Thirty-seven percent of women (N = 16, 642) were noted to undergo IBR after mastectomy. Prosthetic reconstruction (84.4%, n = 37, 640) was the most common form of IBR compared with pedicled-autologous reconstruction (15.4%, n = 6868) and free transfer autologous reconstruction (4.9%, n = 2185), P < 0.001. In multivariate analysis, minorities had lower odds of undergoing IBR compared with whites (odds ratio [OR] 0.37 and 95% confidence interval [CI] 0.33-0.42 for Asians, OR 0.57 and 95% CI 0.52-0.61 for blacks, and OR 0.64 and 95% CI 0.58-0.71 for Hispanics, all P < 0.001). Compared with whites, Hispanics (OR 0.70, 95% CI 0.58-0.83) and blacks (OR 0.53, 95% CI 0.46-0.60) were less likely to use prosthetic reconstruction and more likely to use free-transfer autologous reconstruction (OR 1.66, 95% CI 1.26-2.18 for Hispanics, OR 2.13, 95% CI 1.73-2.63 for blacks), all P < 0.001. Racial disparities persisted from 2005-2011; as minority patients were less likely to undergo IBR than whites (P < 0.001). CONCLUSIONS Utilization of IBR may be a sensitive measure of disparities in access to high-quality care and underlying cultures. Strategies aimed at reducing racial disparities in IBR should be tailored to specific patterns of disparities among Asian, black, and Hispanic women.
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Affiliation(s)
- Anaeze C Offodile
- Department of Plastic Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Thomas C Tsai
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
| | - Julia B Wenger
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lifei Guo
- Department of Plastic Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts.
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Butler PD, Nelson JA, Fischer JP, Chang B, Kanchwala S, Wu LC, Serletti JM. African-American women have equivalent outcomes following autologous free flap breast reconstruction despite greater preoperative risk factors. Am J Surg 2014; 209:589-96. [PMID: 25576165 DOI: 10.1016/j.amjsurg.2014.11.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/30/2014] [Accepted: 11/21/2014] [Indexed: 01/21/2023]
Abstract
BACKGROUND Disparities along racial and ethnic lines exist in breast cancer treatment and reconstruction. This study compares preoperative characteristics among female breast cancer patients who received autologous breast reconstruction to determine if race affects clinical outcomes. METHODS Women receiving autologous breast reconstruction at a single institution from 2005 to 2011 were identified within a prospectively maintained database. Preoperative risk factors and rates of postoperative morbidity and mortality were assessed with respect to race. RESULTS African-American patients had significantly higher rates of preoperative comorbidities than Caucasian patients. Despite the heightened preoperative risk factors, postoperative complications did not significantly differ between racial categories. CONCLUSION As the alleviation of healthcare disparities remains a focus of healthcare reform, these findings are beneficial in further educating African-American breast cancer patients and their providers of the safe and viable option of autologous tissue transfer for breast reconstruction.
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Affiliation(s)
- Paris D Butler
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Jonas A Nelson
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Benjamin Chang
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Suhail Kanchwala
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Liza C Wu
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Joseph M Serletti
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 10 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Saha D, Davila AA, Ver Halen JP, Jain UK, Hansen N, Bethke K, Khan SA, Jeruss J, Fine N, Kim JYS. Post-mastectomy reconstruction: a risk-stratified comparative analysis of outcomes. Breast 2014; 22:1072-80. [PMID: 24354013 DOI: 10.1016/j.breast.2013.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Although breast reconstruction following mastectomy plays a role in the psychological impact of breast cancer, only one in three women undergo reconstruction. Few multi-institutional studies have compared complication profiles of reconstructive patients to non-reconstructive. METHODS Using the National Surgical Quality Improvement database, all patients undergoing mastectomy from 2006 to 2010, with or without reconstruction, were identified and risk-stratified using propensity scored quintiles. The incidence of complications and comorbidities were compared. RESULTS Of 37,723 mastectomies identified, 30% received immediate breast reconstruction. After quintile matching for comorbidities, complications rates between reconstructive and non-reconstructives were similar. This trend was echoed across all quintiles, except in the sub-group with highest comorbidities. Here, the reconstructive patients had significantly more complications than the non-reconstructive (22.8% versus 7.0%, p < 0.001). CONCLUSION Immediate breast reconstruction is a well-tolerated surgical procedure. However, in patients with high comorbidities, surgeons must carefully counterbalance surgical risks with psychosocial benefits to maximize patient outcomes. LEVEL OF EVIDENCE Level 3.
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Onega T, Weiss J, Kerlikowske K, Wernli K, Buist DS, Henderson LM, Goodrich M, Alford-Teaster J, Virnig B, Tosteson AN, DeMartini W, Hubbard R. The influence of race/ethnicity and place of service on breast reconstruction for Medicare beneficiaries with mastectomy. SPRINGERPLUS 2014; 3:416. [PMID: 25140292 PMCID: PMC4137047 DOI: 10.1186/2193-1801-3-416] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 07/30/2014] [Indexed: 11/15/2022]
Abstract
Racial disparities in breast reconstruction for breast cancer are documented. Place of service has contributed to disparities in cancer care; but the interaction of race/ethnicity and place of service has not been explicitly examined. We examined whether place of service modified the effect of race/ethnicity on receipt of reconstruction. We included women with a mastectomy for incident breast cancer in SEER-Medicare from 2005–2009. Using Medicare claims, we determined breast reconstruction within 6 months. Facility characteristics included: rural/urban location, teaching status, NCI Cancer Center designation, cooperative oncology group membership, Disproportionate Share Hospital (DSH) status, and breast surgery volume. Using multivariable logistic regression, we analyzed reconstruction in relation to minority status and facility characteristics. Of the 17,958 women, 14.2% were racial/ethnic women of color and a total of 9.3% had reconstruction. Caucasians disproportionately received care at non-teaching hospitals (53% v. 42%) and did not at Disproportionate Share Hospitals (77% v. 86%). Women of color had 55% lower odds of reconstruction than Caucasians (OR = 0.45; 95% CI 0.37-0.55). Those in lower median income areas had lower odds of receiving reconstruction, regardless of race/ethnicity. Odds of reconstruction reduced at rural, non-teaching and cooperative oncology group hospitals, and lower surgery volume facilities. Facility effects on odds of reconstruction were similar in analyses stratified by race/ethnicity status. Race/ethnicity and facility characteristics have independent effects on utilization of breast reconstruction, with no significant interaction. This suggests that, regardless of a woman’s race/ethnicity, the place of service influences the likelihood of reconstruction.
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Affiliation(s)
- Tracy Onega
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, HB 7927 Rubin 8, Lebanon, NH 03756 USA ; Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH USA ; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH USA
| | - Julie Weiss
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, HB 7927 Rubin 8, Lebanon, NH 03756 USA
| | - Karla Kerlikowske
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, CA USA ; General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco, CA USA
| | - Karen Wernli
- Group Health Research Institute, Seattle, WA USA
| | | | - Louise M Henderson
- Department of Radiology, The University of North Carolina, Chapel Hill, NC USA
| | - Martha Goodrich
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, HB 7927 Rubin 8, Lebanon, NH 03756 USA ; Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH USA
| | - Jennifer Alford-Teaster
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, HB 7927 Rubin 8, Lebanon, NH 03756 USA ; Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH USA
| | - Beth Virnig
- School of Public Health, University of Minnesota, Minneapolis, MN USA
| | - Anna Na Tosteson
- Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH USA ; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH USA
| | - Wendy DeMartini
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792-3252 USA
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Wexelman B, Schwartz JA, Lee D, Estabrook A, Ma AMT. Socioeconomic and geographic differences in immediate reconstruction after mastectomy in the United States. Breast J 2014; 20:339-46. [PMID: 24861537 DOI: 10.1111/tbj.12274] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Disparities are evident in breast cancer diagnosis, treatment, and outcomes. This study examines multiple socioeconomic and geographic regions across the US to determine if disparities exist in the type of reconstruction obtained after mastectomy. This is a retrospective study evaluating socioeconomic and geographic variables of 14,764 women who underwent mastectomy in 2008 using the Nationwide Inpatient Sample (NIS). Statistical analysis was performed on three groups of women: patients without reconstruction (NR), patients who underwent breast implant/tissue expander reconstruction (TE), and patients with autologous reconstruction such as free or pedicled flaps (FLAP). The majority of patients (63.9%) had NR, while 23.9% had TE and 12.2% underwent FLAP. Compared to patients with NR, women with TE or FLAP were younger (64.9 years versus 51.3 and 51.1 years, p < 0.001), had fewer chronic conditions (2.60 and 2.54 chronic conditions for TE and FLAP respectively versus 3.85 for NR, p < 0.001) and higher mean hospital charges ($42,850 TE and $48,680 FLAP versus $22,300 NR, p < 0.001). Both Medicare and Medicaid insurance carriers had a higher proportion of women that did not get reconstructed compared to other insurance types (p < 0.001). Compared to NR, reconstructed women more often lived in urban areas and zip codes with higher average incomes (p < 0.001). This is the first national study analyzing insurance type and geographic variations to show statistically significant disparities in rate and type of immediate reconstruction after mastectomy. These inequalities need to be addressed to extend immediate reconstruction options to all women undergoing mastectomy.
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Affiliation(s)
- Barbara Wexelman
- Department of Surgery, St. Luke's-Roosevelt Hospital Center, New York, NY
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Shippee TP, Kozhimannil KB, Rowan K, Virnig BA. Health insurance coverage and racial disparities in breast reconstruction after mastectomy. Womens Health Issues 2014; 24:e261-9. [PMID: 24794541 PMCID: PMC4100699 DOI: 10.1016/j.whi.2014.03.001] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 02/11/2014] [Accepted: 03/03/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Breast reconstruction after mastectomy offers clinical, cosmetic, and psychological benefits compared with mastectomy alone. Although reconstruction rates have increased, racial/ethnic disparities in breast reconstruction persist. Insurance coverage facilitates access to care, but few studies have examined whether health insurance ameliorates disparities. METHODS We used the Nationwide Inpatient Sample for 2002 through 2006 to examine the relationships between health insurance coverage, race/ethnicity, and breast reconstruction rates among women who underwent mastectomy for breast cancer. We examined reconstruction rates as a function of the interaction of race and the primary payer (self-pay, private health insurance, government) while controlling for patient comorbidity, and we used generalized estimating equations to account for clustering and hospital characteristics. FINDINGS Minority women had lower breast reconstruction rates than White women (adjusted odds ratio [AOR], 0.57 for African American; AOR, 0.70 for Hispanic; AOR, 0.45 for Asian; p < .001). Uninsured women (AOR, 0.33) and those with public coverage were less likely to undergo reconstruction (AOR, 0.35; p < .001) than privately insured women. Racial/ethnic disparities were less prominent within insurance types. Minority women, whether privately or publicly insured, had lower odds of undergoing reconstruction than White women. Among those without insurance, reconstruction rates did not differ by race/ethnicity. CONCLUSIONS Insurance facilitates access to care, but does not eliminate racial/ethnic disparities in reconstruction rates. Our findings-which reveal persistent health care disparities not explained by patient health status-should prompt efforts to promote both access to and use of beneficial covered services for women with breast cancer.
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Affiliation(s)
- TP Shippee
- Division of Health Policy and Management, School of Public Health. 420 Delaware St. S.E., MMC 729, Minneapolis, MN 55455. Ph: 612-624-6151 Fax: 612-624-2196
| | - KB Kozhimannil
- Division of Health Policy and Management, School of Public Health. 420 Delaware St. S.E., MMC 729, Minneapolis, MN 55455. Ph: 612-624-6151 Fax: 612-624-2196
| | - K Rowan
- Division of Health Policy and Management, School of Public Health. 420 Delaware St. S.E., MMC 729, Minneapolis, MN 55455. Ph: 612-624-6151 Fax: 612-624-2196
| | - BA Virnig
- Division of Health Policy and Management, School of Public Health. 420 Delaware St. S.E., MMC 729, Minneapolis, MN 55455. Ph: 612-624-6151 Fax: 612-624-2196
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