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White MJ, Prathibha S, Praska C, Ankeny JS, LaRocca CJ, Owen MJ, Rao M, Tuttle TM, Marmor S, Hui JYC. Disparities in Postmastectomy Reconstruction Use among American Indian and Alaska Native Women. Plast Reconstr Surg 2024; 154:21e-32e. [PMID: 37467081 DOI: 10.1097/prs.0000000000010935] [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: 07/21/2023]
Abstract
BACKGROUND American Indian/Alaska Native (AI/AN) breast cancer patients undergo postmastectomy reconstruction (PMR) infrequently relative to non-Hispanic White (NHW) patients. Factors associated with low PMR rates among AI/AN women are poorly understood. The authors sought to describe factors associated with this disparity in surgical care. METHODS A retrospective cohort study of the National Cancer Database (2004 to 2017) identified AI/AN and NHW women, aged 18 to 64, who underwent mastectomy for stage 0 to III breast cancer. Patient characteristics, annual PMR rates, and factors associated with PMR were described with univariable analysis, the Cochran-Armitage test, and multivariable logistical regression. RESULTS A total of 414,036 NHW and 1980 AI/AN women met inclusion criteria. Relative to NHW women, AI/AN women had more comorbidities (20% versus 12%; Charlson Comorbidity Index ≥ 1; P < 0.001), had nonprivate insurance (49% versus 20%; P < 0.001), and underwent unilateral mastectomy more frequently (69% versus 61%; P < 0.001). PMR rates increased over the study period, from 13% to 47% for AI/AN women and from 29% to 62% for NHW women ( P < 0.001). AI/AN race was independently associated with decreased likelihood of PMR (OR, 0.62; 95% CI, 0.56 to 0.69). Among AI/AN women, decreased likelihood of PMR was significantly associated with older age at diagnosis, more remote year of diagnosis, advanced disease (tumor size >5 cm, positive lymph nodes), unilateral mastectomy, nonprivate insurance, and lower educational attainment in patient's area of residence. CONCLUSIONS PMR rates among AI/AN women with stage 0 to III breast cancer have increased, yet they remain significantly lower than rates among NHW women. Further research should elicit AI/AN perspectives on PMR, and guide early breast cancer detection and treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
| | | | - Corinne Praska
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Clinical Science Center
| | | | | | - Mary J Owen
- Center of American Indian and Minority Health, University of Minnesota Duluth
| | - Madhuri Rao
- From the Department of Surgery
- Masonic Cancer Center
| | | | - Schelomo Marmor
- From the Department of Surgery
- Masonic Cancer Center
- Center for Clinical Quality & Outcomes Discovery & Evaluation, University of Minnesota
| | - Jane Y C Hui
- From the Department of Surgery
- Masonic Cancer Center
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Oleru OO, Seyidova N, Taub PJ, Rohde CH. Out-of-Pocket Costs and Payments in Autologous and Implant-Based Breast Reconstruction: A Nationwide Analysis. Ann Plast Surg 2024; 92:S262-S266. [PMID: 38556686 DOI: 10.1097/sap.0000000000003864] [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: 04/02/2024]
Abstract
BACKGROUND Many factors influence a patient's decision to undergo autologous versus implant-based breast reconstruction, including medical, social, and financial considerations. This study aims to investigate differences in out-of-pocket and total spending for patients undergoing autologous and implant-based breast reconstruction. METHODS The IBM MarketScan Commercial Databases were queried to extract all patients who underwent inpatient autologous or implant-based breast reconstruction from 2017 to 2021. Financial variables included gross payments to the provider (facility and/or physician) and out-of-pocket costs (total of coinsurance, deductible, and copayments). Univariate regressions assessed differences between autologous and implant-based reconstruction procedures. Mixed-effects linear regression was used to analyze parametric contributions to total gross and out-of-pocket costs. RESULTS The sample identified 2079 autologous breast reconstruction and 1475 implant-based breast reconstruction episodes. Median out-of-pocket costs were significantly higher for autologous reconstruction than implant-based reconstruction ($597 vs $250, P < 0.001) as were total payments ($63,667 vs $31,472, P < 0.001). Type of insurance plan and region contributed to variable out-of-pocket costs (P < 0.001). Regression analysis revealed that autologous reconstruction contributes significantly to increasing out-of-pocket costs (B = $597, P = 0.025) and increasing total costs (B = $74,507, P = 0.006). CONCLUSION The US national data demonstrate that autologous breast reconstruction has higher out-of-pocket costs and higher gross payments than implant-based reconstruction. More study is needed to determine the extent to which these financial differences affect patient decision-making.
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Affiliation(s)
- Olachi O Oleru
- From the Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai
| | - Nargiz Seyidova
- From the Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai
| | - Peter J Taub
- From the Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai
| | - Christine H Rohde
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Columbia University Irving Medical Center New York Presbyterian Hospital, New York, NY
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Li Y, Chen YY, Wang SX, Dai ZY, Cui JS, Xing YF, Wu Q, Fang Q. Empowerment-Led Guided Self-Help Intervention for Symptom Burden in Breast Cancer Women Treated With Ovarian Function Suppression: A Randomized Trial Protocol. World J Oncol 2024; 15:325-336. [PMID: 38545479 PMCID: PMC10965257 DOI: 10.14740/wjon1817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/06/2024] [Indexed: 09/28/2024] Open
Abstract
Background Ovarian function suppression (OFS) treatment causes breast cancer patients' estrogens to fall rapidly to postmenopausal levels, and the 5-year treatment duration and 28-day treatment cycles place a heavy physical and psychological symptom burden on them, which in turn directly or indirectly affects the survival benefit. Managing symptom burden early in treatment is critical, but OFS-related studies have yet to be seen. Self-management is essential for patients' symptom burden. However, self-help management is hampered by patients' lack of knowledge, skills, motivation, etc. Guided self-help intervention (GSH) provides a feasible approach. Empowerment theory is a promising theoretical framework to guide self-management. Methods A prospective two-arm parallel randomized controlled single-blind clinical trial will be conducted to investigate the effect of symptom burden GSH based on empowerment theory in breast cancer patients in the early stages of OFS treatment. A block randomization method is used to allocate 144 patients to either the control or intervention group. The program is conducted according to the OFS return-to-hospital treatment cycle. The intervention group will receive a total of two rounds and five sessions of empowering GSH, lasting at least 15 weeks in total; the control group will receive only usual nursing care. Symptom burden and related metrics will be assessed at baseline and 1, 3, and 6 months after OFS treatment, and changes between and within groups will be explored. This paper adhered to the SPIRIT and CONSORT guidelines. Conclusion These results will help to validate the GSH in symptom burden management for breast cancer patients in OFS treatment early stages. It enriches its symptom burden management research and may provide implications for the whole cycle of OFS treatment patients.
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Affiliation(s)
- Yuan Li
- School of Nursing, Shanghai Jiao Tong University, Shanghai, China
| | - Yun Yun Chen
- Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Su Xing Wang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, China
| | - Zheng Yue Dai
- School of Nursing, Shanghai Jiao Tong University, Shanghai, China
| | - Jia Song Cui
- Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yu Fei Xing
- School of Nursing, Shanghai Jiao Tong University, Shanghai, China
| | - Qing Wu
- School of Nursing, Shanghai Jiao Tong University, Shanghai, China
| | - Qiong Fang
- School of Nursing, Shanghai Jiao Tong University, Shanghai, China
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Knoedler S, Kauke-Navarro M, Knoedler L, Friedrich S, Matar DY, Diatta F, Mookerjee VG, Ayyala H, Wu M, Kim BS, Machens HG, Pomahac B, Orgill DP, Broer PN, Panayi AC. Racial disparities in surgical outcomes after mastectomy in 223 000 female breast cancer patients: a retrospective cohort study. Int J Surg 2024; 110:684-699. [PMID: 38052017 PMCID: PMC10871660 DOI: 10.1097/js9.0000000000000909] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/02/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Breast cancer mortality and treatment differ across racial groups. It remains unclear whether such disparities are also reflected in perioperative outcomes of breast cancer patients undergoing mastectomy. STUDY DESIGN The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2021) to identify female patients who underwent mastectomy for oncological purposes. The outcomes were stratified by five racial groups (white, Black/African American, Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander) and included 30-day mortality, reoperation, readmission, surgical and medical complications, and non-home discharge. RESULTS The study population included 222 947 patients, 68% ( n =151 522) of whom were white, 11% ( n =23 987) Black/African American, 5% ( n =11 217) Asian, 0.5% ( n =1198) American Indian/Alaska Native, and 0.5% ( n =1018) Native Hawaiian/Pacific Islander. While 136 690 (61%) patients underwent partial mastectomy, 54 490 (24%) and 31 767 (14%) women received simple and radical mastectomy, respectively. Overall, adverse events occurred in 17 222 (7.7%) patients, the largest portion of which were surgical complications ( n =7246; 3.3%). Multivariable analysis revealed that being of Asian race was protective against perioperative complications [odds ratio (OR)=0.71; P <0.001], whereas American Indian/Alaska Native women were most vulnerable to the complication occurrence (OR=1.41; P <0.001). Black/African American patients had a significantly lower risk of medical (OR=0.59; P <0.001) and surgical complications (OR=0.60; P <0.001) after partial and radical mastectomy, respectively, their likelihood of readmission (OR=1.14; P =0.045) following partial mastectomy was significantly increased. CONCLUSION The authors identified American Indian/Alaska Native women as particularly vulnerable to complications following mastectomy. Asian patients experienced the lowest rate of complications in the perioperative period. The authors' analyses revealed comparable confounder-adjusted outcomes following partial and complete mastectomy between Black and white races. Their findings call for care equalization in the field of breast cancer surgery.
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Affiliation(s)
- Samuel Knoedler
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Germany
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Leonard Knoedler
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sarah Friedrich
- Department of Mathematical Statistics and Artificial Intelligence in Medicine, University of Augsburg, Augsburg, Germany
| | - Dany Y. Matar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Fortunay Diatta
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Vikram G. Mookerjee
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Haripriya Ayyala
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Mengfan Wu
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Hans-Guenther Machens
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Dennis P. Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - P. Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital Munich, Munich, Germany
| | - Adriana C. Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Murray A, Francks L, Hassanein ZM, Lee R, Wilson E. Breast cancer surgical decision-making. Experiences of Non-Caucasian women globally. A qualitative systematic review. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107109. [PMID: 37866153 DOI: 10.1016/j.ejso.2023.107109] [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] [Received: 08/19/2023] [Revised: 09/24/2023] [Accepted: 10/05/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVES To perform a qualitative systematic review exploring the influencing factors within the surgical decision-making (SDM) processes following a breast cancer diagnosis in non-caucasian women globally. STUDY DESIGN Qualitative systemic review following PRISMA guidelines. METHODS A comprehensive search strategy was applied to four databases. 5243 papers were screened using a composed inclusion and exclusion criteria resulting in 10 total papers to be included. These papers underwent JBI quality assessment and ConQual assessment to ensure strength in validation, reliability, and quality. RESULTS Six main overarching themes relating to SDM were determined: fear, information, patient-doctor relationship, wellbeing, external influences, and culture. All ethnicities experienced fear in one way. Misinformation was widely experienced in concordance with either a lack of education (Iranian and Ghanian women) or language barriers (immigrant populations). Trust was overarching in all patient-doctor relationships, some being overshadowed by an authoritative dynamic in Ghanian and Iranian women. Well-being, both psychological and body image was noted in all but the Ghanian and Iranian women. Every ethnicity experienced external influences involving either others, time or cost. Lastly, cultural expectations and beliefs of the doctor was present in all native or immigrant Asian communities. CONCLUSIONS The study identified several factors which were common between ethnicities, notably multifactorial fear, well-being factors, opinions and trust of others, and timing. Conversely, information availability and the nature of patient-doctor relationships varied widely between ethnicities. The study has identified some realistic and achievable focus areas for practice improvement, but also notes the challenges of changing long-established cultural norms.
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Affiliation(s)
- Annabel Murray
- Nottingham Centre for Public Health and Epidemiology, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
| | - Lucy Francks
- Nottingham Centre for Public Health and Epidemiology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Zeinab M Hassanein
- Nottingham Centre for Public Health and Epidemiology, School of Medicine, University of Nottingham, Nottingham, United Kingdom; Assiut University, Assiut, Egypt
| | - Rachel Lee
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Emma Wilson
- Nottingham Centre for Public Health and Epidemiology, School of Medicine, University of Nottingham, Nottingham, United Kingdom; Nottingham Centre for Evidence-Based Healthcare, University of Nottingham, United Kingdom; Nottingham Breast Institute, Nottingham University Hospitals NHS Trust, United Kingdom
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Mhaimeed N, Mhaimeed N, Mhaimeed O, Alanni J, Burney Z, Elshafeey A, Laws S, Choi JJ. Shared decision making with black patients: A scoping review. PATIENT EDUCATION AND COUNSELING 2023; 110:107646. [PMID: 36739706 DOI: 10.1016/j.pec.2023.107646] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 01/15/2023] [Accepted: 01/21/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE The purpose of this review is to explore the breadth of research conducted on SDM in the care of Black patients. METHODS We conducted a scoping review following the methodological framework outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. We searched articles related to original research on SDM in the care of Black patients in October 2022 using PubMed, Embase, and Google Scholar databases. Articles of all study designs (quantitative and qualitative), published or translated into English, were included. A standardized data extraction form and thematic analysis were used to facilitate data extraction by two independent reviewers. RESULTS After removal of duplicates and screening, 30 articles were included in the final analysis. Black patients and clinician were found to not share the same understanding of SDM, and patients highly valued SDM in their care. Interventions to improve SDM yielded mixed results to enhance intent, participation in SDM, as well as health outcomes. Decision aids were the most effective form of intervention to enhance SDM. The most common barrier to SDM was patient-clinician communication, and was exacerbated by racial discordance, clinician mistrust, past experiences, and paternalistic clinician-patient dynamics. CONCLUSIONS SDM has the potential to improve health outcomes in Black patients when implemented contextually within Black patients' experiences and concerns. Significant barriers such as clinician mistrust exist, and the overall perception in the Black community is that SDM does not occur sufficiently. Barriers to SDM seem to be most pronounced when there is patient-clinician racial discordance. Several interventions aimed at improving SDM with Black patients have shown mixed results. Future studies should evaluate larger-scale interventions with longer follow-up. Practice implications Shared decision making (SDM) has been proposed as a useful tool for improving quality and equity in Black patients' care. However, Black patients experience lower rates of SDM compared to other populations. SDM has the potential to improve health outcomes in Black patients when implemented contextually within Black patients' experiences and concerns.
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Affiliation(s)
| | | | - Omar Mhaimeed
- Department of Medicine, John Hopkins Medicine, Baltimore, MD, USA
| | - Jamal Alanni
- Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Zain Burney
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Sa'ad Laws
- Health Sciences Library, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Justin J Choi
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
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Doren EL, Park K, Olson J. Racial disparities in postmastectomy breast reconstruction following implementation of the affordable care act: A systematic review using a minority health and disparities research framework. Am J Surg 2023:S0002-9610(23)00013-2. [PMID: 36707301 DOI: 10.1016/j.amjsurg.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/03/2023] [Accepted: 01/11/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND This systematic review assesses racial disparities for African American (AA) women in breast reconstruction following the implementation of the Affordable Care Act. METHODS Four databases (Ovid Medline, PubMed, Scopus, Web of Science) were searched for peer-reviewed articles published between January 2011 and September 2021. RESULTS Out of 917 screened articles, 61 were included. The most common metrics were breast reconstruction rates (57.4%) and clinical outcomes (14.8%). Pooled reconstruction rates were 45.7% in white and 38.5% in AA women. 95.1% of studies found disparities in breast reconstruction rates. The greatest influencers on reconstruction rates were individual interactions in the healthcare system (54%), sociocultural environment (39%), behavioral factors (31%), and community interactions with the healthcare system (36%). CONCLUSION Racial disparities in postmastectomy breast reconstruction persist. Focusing on implicit bias, communication barriers and infrastructure are the most promising strategies to create equitable access to breast reconstruction for AA women.
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Affiliation(s)
- Erin L Doren
- Department of Plastic Surgery, Medical College of Wisconsin, 1155 N Mayfair Rd, Wauwatosa, WI, 53226, USA.
| | - Kelley Park
- Department of Plastic Surgery, Medical College of Wisconsin, 1155 N Mayfair Rd, Wauwatosa, WI, 53226, USA.
| | - Jessica Olson
- Institute for Health and Equity, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI, 53226, 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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