Disparities in Reconstruction Rates After Mastectomy: Patterns of Care and Factors Associated with the Use of Breast Reconstruction in Southern California

General and Oncologic Surgery, City of Hope National Medical Center, Duarte, CA, USA.
Annals of Surgical Oncology (Impact Factor: 3.93). 02/2011; 18(8):2158-65. DOI: 10.1245/s10434-011-1580-z
Source: PubMed


Many factors influence whether breast cancer patients undergo reconstruction after mastectomy. We sought to determine the patterns of care and variables associated with the use of breast reconstruction in Southern California.
Postmastectomy reconstruction rates were determined from the California Office of Statewide Health Planning and Development (OSHPD) inpatient database from 2003 to 2007. International Classification of Disease-9 codes were used to identify patients undergoing reconstruction after mastectomy. Changes in reconstruction rates were examined by calendar year, age, race, type of insurance, and type of hospital using a chi-square test. Univariate and multivariate odds ratios (OR) with 95% confidence intervals (95% CI) were estimated for relative odds of immediate reconstruction versus mastectomy only.
In multivariate analysis, calendar year, age, race, type of insurance, and type of hospital were statistically significantly associated with use of reconstruction. The proportion of patients undergoing reconstruction rose from 24.8% in 2003 to 29.2% in 2007. Patients with private insurance were 10 times more likely to undergo reconstruction than patients with Medi-Cal insurance (OR 9.95, 95% CI 8.46-11.70). African American patients were less likely (OR 0.58, 95% CI 0.46-0.73) and Asian patients one-third as likely (OR 0.37, 95% CI 0.29-0.47) to undergo reconstruction as Caucasians patients Most reconstructive procedures were performed at teaching hospitals and designated cancer centers.
Although the rate of postmastectomy reconstruction is increasing, only a minority of patients undergo reconstruction. Age, race, type of insurance, and type of hospital appear to be significant factors limiting the use of reconstruction.

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Available from: Lei Duan, Oct 28, 2015
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    • "Denmark is ethnically relatively homogenous, and the number of women with a non-Danish ethnic background in our cohort was small (2%). In contrast to most other studies [26] [29] [43], we found this group to be more likely to receive reconstruction than women with a Danish ethnic background. It should be noted here that the definition of ethnicity is based on citizenship, and in the present study, non-Danish ethnicity thus constitutes a culturally heterogeneous group. "
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    ABSTRACT: We collected registry- and questionnaire-based data on socio-economic and health status, tumor- and treatment-related variables, and explored associations with receipt of reconstruction and information about treatment options in a nationwide cohort of Danish women, treated for primary breast cancer. A total of 594 women were available for analysis, 240 (40%) of these received reconstruction. Multivariate analyses showed that receipt of reconstruction was associated with 1) younger age at time of primary surgery (<36 years: OR = 10.04, [3.80-26.50], p < 0.001 and 36-49 years: OR = 2.48, [1.73-3.56], p < 0.001, compared to 50-60 year olds), 2) having received radiotherapy (OR = 0.57, [0.40-0.81], p = 0.002), 3) high income (Second quartile: OR = 1.74, [1.05-2.90], p = 0.033 and fourth quartile: OR = 2.18, [1.31-3.62], p = 0.003, compared with the lowest income quartile), and 4) ethnicity other than Danish (OR = 6.32, [1.58-25.36], p = 0.009). Health-related factors at the time of primary surgery (physical functioning, body mass index, smoking, use of alcohol, and comorbidity) were not associated with reconstruction. Odds of having received information about the option of reconstruction decreased by 8% per year of age in the multivariate analysis (OR = 0.92, [0.87-0.97], p = 0.003). In conclusion, younger age and not having been treated with radiotherapy was independently associated with reconstruction. In addition, higher income was also found to be associated with reconstruction despite free and equal access to reconstruction and healthcare in Denmark. Healthrelated factors were not associated with the use of reconstruction following mastectomy. Our findings underscore the need for physicians to ensure optimal level of information and accessibility to reconstruction for all women regardless of age, treatment, and socio-economic status. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Full-text · Article · Jun 2015 · Breast (Edinburgh, Scotland)
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    • "). The reasons underlying this disparity are not clear, although the disparity may relate to other factors shown to decrease the likelihood of breast reconstruction, such as marital status, rural residence, comorbidities, insurance , surgeon volume, hospital volume, hospital size, (Hershman et al. 2012) teaching hospital status, and cancer center designation (Kruper et al. 2011a). "
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    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.
    Full-text · Article · Aug 2014 · SpringerPlus
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    • "The rate is 32.1% at Institut Curie, a national cancer institute in Paris. Other studies have shown that reconstruction rates tend to be higher in specialized cancer-treatment centers (Kruper et al. 2011; Jeevan et al. 2010; Hvilsom et al. 2011; Morrow et al. 2001), and our study supports this finding, with a reconstruction rate well above the national average. "
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    ABSTRACT: Background The aims of the study were to investigate the factors associated with not having breast reconstruction following mastectomy and to assess patient satisfaction with information on reconstruction. Patients and methods We analysed a historical cohort of 1937 consecutive patients who underwent mastectomy at Institut Curie between January 2004 and February 2007. Their sociodemographic and clinicobiological characteristics were recorded in a prospective database. A questionnaire was sent to 10% of nonreconstructed patients. Results The proportion of patients with invasive cancer was 82.7%. The rate of nonreconstruction in patients with in situ and invasive cancer was 34.6% and 74.9%, respectively. On multivariate analysis, only employment outside the home was associated with reconstruction in patients with in situ cancer (p < 0.001). In patients with invasive cancer, employment status (p < 0.001) and smoking (p = 0.045) were associated with reconstruction, while age > 50, ASA score >1, radiotherapy (p < 0.0001) and metastatic status (p = 0.018) were associated with nonreconstruction. For 80% of questionnaire responders, nonreconstruction was a personal choice, mainly for the following reasons: refusal of further surgery, acceptance of body asymmetry, risk of complications and advanced age. Information on reconstruction was entirely unsatisfactory or inadequate for 62% of patients. Conclusion Better understanding the factors that influence decision of nonreconstruction can help us adapt the information to serve the patient’s personal needs.
    Full-text · Article · Jul 2013 · SpringerPlus
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