Importance Most women undergoing mastectomy for breast cancer do not undergo breast reconstruction. Objective To examine correlates of breast reconstruction after mastectomy and to determine if a significant unmet need for reconstruction exists. Design, Setting, and Participants We used Surveillance, Epidemiology, and End Results registries from Los Angeles, California, and Detroit, Michigan, for rapid case ascertainment to identify a sample of women aged 20 to 79 years diagnosed as having ductal carcinoma in situ or stages I to III invasive breast cancer. Black and Latina women were oversampled to ensure adequate representation of racial/ethnic minorities. Eligible participants were able to complete a survey in English or Spanish. Of 3252 women sent the initial survey a median of 9 months after diagnosis, 2290 completed it. Those who remained disease free were surveyed 4 years later to determine the frequency of immediate and delayed reconstruction and patient attitudes toward the procedure; 1536 completed the follow-up survey. The 485 who remained disease free at follow-up underwent analysis. Exposures Disease-free survival of breast cancer. Main Outcomes and Measures Breast reconstruction at any time after mastectomy and patient satisfaction with different aspects of the reconstruction decision-making process. Results Response rates in the initial and follow-up surveys were 73.1% and 67.7%, respectively (overall, 49.4%). Of 485 patients reporting mastectomy at the initial survey and remaining disease free, 24.8% underwent immediate and 16.8% underwent delayed reconstruction (total, 41.6%). Factors significantly associated with not undergoing reconstruction were black race (adjusted odds ratio [AOR], 2.16 [95% CI, 1.11-4.20]; P  = .004), lower educational level (AOR, 4.49 [95% CI, 2.31-8.72]; P P P  = .048), and chemotherapy (AOR, 1.82 [95% CI, 0.99-3.31]; P  = .05). Only 13.3% of women were dissatisfied with the reconstruction decision-making process, but dissatisfaction was higher among nonwhite patients in the sample (AOR, 2.87 [95% CI, 1.27-6.51]; P  = .03). The most common patient-reported reasons for not having reconstruction were the desire to avoid additional surgery (48.5%) and the belief that it was not important (33.8%), but 36.3% expressed fear of implants. Reasons for avoiding reconstruction and systems barriers to care varied by race; barriers were more common among nonwhite participants. Residual demand for reconstruction at 4 years was low, with only 30 of 263 who did not undergo reconstruction still considering the procedure. Conclusions and Relevance Reconstruction rates largely reflect patient demand; most patients are satisfied with the decision-making process about reconstruction. Specific approaches are needed to address lingering patient-level and system factors with a negative effect on reconstruction among minority women.

https://jamanetwork.com/journals/jamasurgery/articlepdf/1893807/soi140034.pdf

Access to Breast Reconstruction After Mastectomy and Patient Perspectives on Reconstruction Decision Making

Access to health care is a major source of outcomes variation among populations.1 Inadequate access to breast reconstruction was a motivating factor underlying passage of the Women’s Health and Cancer Rights Act in 1998, which mandated all-payer coverage for postmastectomy reconstruction.2 Although passage of this law represented progress, additional legislation was needed to ensure that patients were aware of this health insurance benefit. For example, New York State passed legislation requiring surgeons to discuss the availability of breast reconstruction with patients before mastectomy, provide information about insurance coverage and, if necessary, refer them to a hospital where reconstruction is available.3 Ratification of such laws may be one reason immediate breast reconstruction rates rose in the United States from 20.8 percent to 37.8 percent between 1998 and 2008.4 Despite these improvements, it is unclear whether all patients interested in breast reconstruction are aware of or undergo this procedure.

The impact of disparities, such as race and insurance type, on access to services such as breast reconstruction has been documented.5–9 Geography is an additional barrier10 evaluated to a lesser extent. Geographic disparities within breast reconstruction may arise from regional differences in plastic surgeon density. In addition, greater numbers of autologous transfers are now being performed in a limited number of centers (i.e., market concentration), potentially restricting patient access to this method of reconstruction.11 The impact of geography on the method of breast reconstruction (i.e., implants versus autologous tissue) has not been specifically evaluated.

Travel distance serves as a quantitative measurement to assess the presence of geographic disparities. The aim of this study is to determine whether travel distance influences the rate and method of breast reconstruction services. The primary hypothesis is that a greater travel distance to undergo reconstruction is necessary compared with mastectomy alone. The secondary hypothesis is that a greater travel distance is needed for autologous than for prosthetic reconstruction because of a recent market concentration for these procedures.12

/pdf/the-impact-of-travel-distance-on-breast-reconstruction-in-48gtzttu8i.pdf

The Impact of Travel Distance on Breast Reconstruction in the United States.

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.

Barriers of Access to Breast Reconstruction: A Systematic Review.

Satisfaction with treatment decision-making and treatment regret among Latinas and non-Latina whites with DCIS

Background/aim The aim of this study was to analyze how race, income, insurance, and education, affect breast reconstruction rates. Materials and methods We reviewed the National Cancer Database. χ2 test and binary logistic regression were used to analyze the association between demographic characteristics and reconstruction rate. Results White race and private insurance were associated with a higher risk of getting reconstruction when compared to black race (odd ratio [OR]=0.939; 95%CI=0.909-0.970) and government insurance (OR=0.459; 95%CI=0.447-0.471). Patients with an estimated income >$63,000 were found to have higher odds of receiving breast reconstruction than patients with income less than $38,000 (OR=1.868; 95%CI=1.792-1.948). Patients who live in a zip code area with a higher education average have higher odds of receiving postmastectomy breast reconstruction than patients living in a zip code with a lower education average (OR=1.152, 95%CI=1.104-1.203). Conclusion Differences in reconstruction rates exist based on race, income, insurance, and education level.

Influence of Race, Income, Insurance, and Education on the Rate of Breast Reconstruction.

Treatment decisions associated with ductal carcinoma in situ (DCIS), including the decision to undergo breast reconstruction, may be more problematic for Latinas due to access and language issues. To help understand the factors that influence patients’ receipt of reconstruction following mastectomy for DCIS, we conducted a population-based study of English- and Spanish-speaking Latina and non-Latina white women from 35 California counties. The objectives of this study were to identify the role of ethnicity and language in the receipt of reconstruction, the relationship between system-level factors and the receipt of reconstruction, and women’s reasons for not undergoing reconstruction. Women aged 18 and older, who self-identified as Latina or non-Latino white and were diagnosed with DCIS between 2002 and 2005 were selected from eight California Cancer Registry (CCR) regions encompassing 35 counties. Approximately 24 months after diagnosis, they were surveyed about their DCIS treatment decisions. Survey data were merged with CCR records to obtain tumor and treatment data. The survey was successfully completed by 745 women, 239 of whom had a mastectomy and represent the sample included in this study. Whites had a higher completion rate than Latinas (67 and 55%, respectively). Analysis included descriptive statistics and logistic regression modeling. Mean age was 54 years. A greater proportion of whites had reconstruction (72%) compared to English-speaking Latinas (69%) and Spanish-speaking Latinas (40%). Multivariate analysis showed that women who were aged 65 and older, unemployed, and had a lower ratio of plastic surgeons in their county were less likely to have reconstructive surgery after mastectomy. The most frequent reasons mentioned not to receive reconstruction included lack of importance and desire to avoid additional surgery. Although ethnic/language differences in treatment selection were observed, multivariable analysis suggests that these differences could be explained by differential employment levels and geographic availability of plastic surgeons.

Dana Nickleach

Papers

The effect of system-level access factors on receipt of reconstruction among Latina and white women with DCIS