Evaluating Disparities in Pathways to Breast Reconstruction

Sabrina M. Wang; Moreen W. Njoroge; Lily R. Mundy; Amanda R. Sergesketter; Bryanna Stukes; Ronnie L. Shammas; Hannah C. Langdell; Yisong Geng; Scott T. Hollenbeck

doi:10.1055/s-0043-1764486

Journal of Reconstructive Microsurgery, Table of Contents

J Reconstr Microsurg 2023; 39(09): 671-680
DOI: 10.1055/s-0043-1764486

Original Article

Evaluating Disparities in Pathways to Breast Reconstruction

Sabrina M. Wang

¹Duke University School of Medicine, Durham, North Carolina

,

Moreen W. Njoroge

¹Duke University School of Medicine, Durham, North Carolina

,

Lily R. Mundy

²Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland

³Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, Maryland

,

Amanda R. Sergesketter

⁴Division of Plastic, Oral, and Maxillofacial Surgery, Duke University, Durham, North Carolina

,

Bryanna Stukes

¹Duke University School of Medicine, Durham, North Carolina

,

Ronnie L. Shammas

⁴Division of Plastic, Oral, and Maxillofacial Surgery, Duke University, Durham, North Carolina

,

Hannah C. Langdell

⁴Division of Plastic, Oral, and Maxillofacial Surgery, Duke University, Durham, North Carolina

,

Yisong Geng

⁵Calc LLC, Wilton, Connecticut

,

Scott T. Hollenbeck

⁴Division of Plastic, Oral, and Maxillofacial Surgery, Duke University, Durham, North Carolina

› Author Affiliations

Abstract

Background Rates of postmastectomy breast reconstruction have been shown to vary by racial, ethnic, and socioeconomic factors. In this study, we evaluated disparities across pathways toward breast reconstruction.

Methods All women who underwent mastectomy for breast cancer at a single institution from 2017 to 2018 were reviewed. Rates of discussions about reconstruction with breast surgeons, plastic surgery referrals, plastic surgery consultations, and ultimate decisions to pursue reconstruction were compared by race/ethnicity.

Results A total of 218 patients were included, with the racial/ethnic demographic of 56% white, 28% Black, 1% American Indian/Native Alaskan, 4% Asian, and 4% Hispanic/Latina. The overall incidence of postmastectomy breast reconstruction was 48%, which varied by race (white: 58% vs. Black: 34%; p < 0.001). Plastic surgery was discussed by the breast surgeon with 68% of patients, and referrals were made in 62% of patients. While older age (p < 0.001) and nonprivate insurance (p < 0.05) were associated with lower rates of plastic surgery discussion and referral, it did not vary by race/ethnicity. The need for an interpreter was associated with lower rates of discussion (p < 0.05). After multivariate adjustment, a lower reconstruction rate was associated with the Black race (odds ratio [OR] = 0.33; p = 0.014) and body mass index (BMI) ≥ 35 (OR = 0.14; p < 0.001). Elevated BMI did not disproportionately lower breast reconstruction rates in Black versus white women (p = 0.27).

Conclusion Despite statistically equivalent rates of plastic surgery discussions and referrals, black women had lower breast reconstruction rates versus white women. Lower rates of breast reconstruction in Black women likely represent an amalgamation of barriers to care; further exploration within our community is warranted to better understand the racial disparity observed.

Keywords

breast reconstruction - disparities - breast cancer

Full Text

References

References
1 Kummerow KL, Du L, Penson DF, Shyr Y, Hooks MA. Nationwide trends in mastectomy for early-stage breast cancer. JAMA Surg 2015; 150 (01) 9-16
2 Agarwal S, Pappas L, Neumayer L, Kokeny K, Agarwal J. Effect of breast conservation therapy vs mastectomy on disease-specific survival for early-stage breast cancer. JAMA Surg 2014; 149 (03) 267-274
3 Cohen WA, Mundy LR, Ballard TNS. et al. The BREAST-Q in surgical research: a review of the literature 2009-2015. J Plast Reconstr Aesthet Surg 2016; 69 (02) 149-162
4 Al-Ghazal SK, Fallowfield L, Blamey RW. Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur J Cancer 2000; 36 (15) 1938-1943
5 Greenberg CC, Schneider EC, Lipsitz SR. et al. Do variations in provider discussions explain socioeconomic disparities in postmastectomy breast reconstruction?. J Am Coll Surg 2008; 206 (04) 605-615
6 Sergesketter AR, Thomas SM, Lane WO. et al. Decline in racial disparities in postmastectomy breast reconstruction: a surveillance, epidemiology, and end results analysis from 1998 to 2014. Plast Reconstr Surg 2019; 143 (06) 1560-1570
7 Connors SK, Goodman MS, Myckatyn T, Margenthaler J, Gehlert S. Racial disparities in breast reconstruction at a comprehensive cancer center. J Racial Ethn Health Disparities 2022; 9 (06) 2323-2333
8 Panchal H, Matros E. Current trends in postmastectomy breast reconstruction. Plast Reconstr Surg 2017; 140 (5S Advances in Breast Reconstruction): 7S-13S
9 Siotos C, Azizi A, Assam L. et al. Breast reconstruction for Medicaid beneficiaries: a systematic review of the current evidence. J Plast Surg Hand Surg 2020; 54 (02) 77-82
10 Alderman AK, McMahon Jr L, Wilkins EG. The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors. Plast Reconstr Surg 2003; 111 (02) 695-703 , discussion 704–705
11 Offodile II AC, Tsai TC, Wenger JB, Guo L. Racial disparities in the type of postmastectomy reconstruction chosen. J Surg Res 2015; 195 (01) 368-376
12 Alderman AK, Hawley ST, Janz NK. et al. Racial and ethnic disparities in the use of postmastectomy breast reconstruction: results from a population-based study. J Clin Oncol 2009; 27 (32) 5325-5330
13 Tseng JF, Kronowitz SJ, Sun CC. et al. The effect of ethnicity on immediate reconstruction rates after mastectomy for breast cancer. Cancer 2004; 101 (07) 1514-1523
14 Mahmoudi E, Lu Y, Metz AK, Momoh AO, Chung KC. Association of a policy mandating physician-patient communication with racial/ethnic disparities in postmastectomy breast reconstruction. JAMA Surg 2017; 152 (08) 775-783
15 Breast Cancer Statistics | How Common Is Breast Cancer?. Accessed March 26, 2022 at: https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html
16 Women's Health and Cancer Rights Act (WHCRA). | CMS. Accessed January 14, 2022 at: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/whcra_factsheet
17 Alderman AK, Hawley ST, Waljee J, Morrow M, Katz SJ. Correlates of referral practices of general surgeons to plastic surgeons for mastectomy reconstruction. Cancer 2007; 109 (09) 1715-1720
18 Oh DD, Flitcroft K, Brennan ME, Spillane AJ. Patterns and outcomes of breast reconstruction in older women---a systematic review of the literature. Eur J Surg Oncol 2016; 42 (05) 604-615
19 Sharma K, Grant D, Parikh R, Myckatyn T. Race and breast cancer reconstruction: is there a health care disparity?. Plast Reconstr Surg 2016; 138 (02) 354-361
20 Roughton MC, DiEgidio P, Zhou L, Stitzenberg K, Meyer AM. Distance to a plastic surgeon and type of insurance plan are independently predictive of postmastectomy breast reconstruction. Plast Reconstr Surg 2016; 138 (02) 203e-211e
21 Medicaid and CHIP Payment and Access Commission. . Medicaid expansion to the new adult group. Medicaid and CHIP Payment and Access Commission. Accessed December 5, 2021 at: https://www.macpac.gov/subtopic/medicaid-expansion/
22 Text - S.1192 - 114th Congress (2015–2016): Breast Cancer Patient Education Act of 2015 | Congress.gov | Library of Congress. Accessed April 14, 2022 at: https://www.congress.gov/bill/114th-congress/senate-bill/1192/text?format=txt
23 Scarpato KR, Kappa SF, Goggins KM. et al. The impact of health literacy on surgical outcomes following radical cystectomy. J Health Commun 2016; 21 ( sup (Suppl. 02) 99-104
24 Frisell A, Lagergren J, Halle M, de Boniface J. Influence of socioeconomic status on immediate breast reconstruction rate, patient information and involvement in surgical decision-making. BJS Open 2020; 4 (02) 232-240
25 Portelli Tremont JN, Downs-Canner S, Maduekwe U. Delving deeper into disparity: the impact of health literacy on the surgical care of breast cancer patients. Am J Surg 2020; 220 (04) 806-810
26 Hall WJ, Chapman MV, Lee KM. et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health 2015; 105 (12) e60-e76
27 Familusi O, Rios-Diaz AJ, Tilahun ED. et al. Post-mastectomy breast reconstruction: reducing the disparity through educational outreach to the underserved. Support Care Cancer 2021; 29 (02) 1055-1063
28 Hoffman RL, Bryant B, Allen SR, Lee MK, Aarons CB, Kelz RR. Using community outreach to explore health-related beliefs and improve surgeon-patient engagement. J Surg Res 2016; 206 (02) 411-417
29 Enewold LR, McGlynn KA, Zahm SH. et al. Breast reconstruction after mastectomy among Department of Defense beneficiaries by race. Cancer 2014; 120 (19) 3033-3039
30 Wang MM, Warnack E, Joseph K-A. Breast reconstruction in an underserved population: a retrospective study. Ann Surg Oncol 2019; 26 (03) 821-826
31 Llaneras J, Klapp JM, Boyd JB. et al. Post-mastectomy patients in an urban safety-net hospital: how do safety-net hospital breast reconstruction rates compare to national breast reconstruction rates?. Am Surg 2023; 89 (04) 902-906
32 Morrow M, Li Y, Alderman AK. et al. Access to breast reconstruction after mastectomy and patient perspectives on reconstruction decision making. JAMA Surg 2014; 149 (10) 1015-1021
33 Suite DH, La Bril R, Primm A, Harrison-Ross P. Beyond misdiagnosis, misunderstanding and mistrust: relevance of the historical perspective in the medical and mental health treatment of people of color. J Natl Med Assoc 2007; 99 (08) 879-885
34 Scheirer MA, Santos SLZ, Tagai EK. et al. Dimensions of sustainability for a health communication intervention in African American churches: a multi-methods study. Implement Sci 2017; 12 (01) 43
35 Hurd TC, Muti P, Erwin DO, Womack S. An evaluation of the integration of non-traditional learning tools into a community based breast and cervical cancer education program: the Witness Project of Buffalo. BMC Cancer 2003; 3: 18
36 Fischer JP, Nelson JA, Kovach SJ, Serletti JM, Wu LC, Kanchwala S. Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets. J Am Coll Surg 2013; 217 (04) 656-664
37 Panayi AC, Agha RA, Sieber BA, Orgill DP. Impact of obesity on outcomes in breast reconstruction: a systematic review and meta-analysis. J Reconstr Microsurg 2018; 34 (05) 363-375
38 Rahman M, Berenson AB. Accuracy of current body mass index obesity classification for white, black, and Hispanic reproductive-age women. Obstet Gynecol 2010; 115 (05) 982-988
39 Tomiyama AJ, Hunger JM, Nguyen-Cuu J, Wells C. Misclassification of cardiometabolic health when using body mass index categories in NHANES 2005-2012. Int J Obes 2016; 40 (05) 883-886
40 Kamel GN, Nash D, Jacobson J. et al. Patient-reported satisfaction and quality of life in postmastectomy radiated patients: a comparison between delayed and delayed immediate autologous breast reconstruction in a predominantly minority patient population. J Reconstr Microsurg 2019; 35 (06) 445-451
41 Blankensteijn LL, Sparenberg S, Crystal DT, Ibrahim AMS, Lee BT, Lin SJ. Racial disparities in outcomes of reconstructive breast surgery: an analysis of 51,362 patients from the ACS-NSQIP. J Reconstr Microsurg 2020; 36 (08) 592-599
42 U.S. Census Bureau QuickFacts. . United States. Accessed March 1, 2022 at: https://www.census.gov/quickfacts/fact/table/US/RHI725219

Supplementary Material

Supplementary Material