EDITORIAL
Disparities in Immediate Breast Reconstruction after Mastectomy: Time for a Change
B
reast cancer treatment has evolved tremendously, as has the emphasis on restoration to pretreatment quality of life. Legislation has recognized this need and in 1998, passed the Women’s Health and Cancer Rights Act (WHRCA), which ensures that women who have insurance coverage for a mastectomy will also have insurance coverage for breast reconstruction and lymphedema care (1). With the passage of this law came an increase in the utilization of postmastectomy reconstruction. Yang et al. demonstrated that between 2000 and 2009, rates of immediate breast reconstruction increased over 4-fold in Medicaid patients and over 2-fold in Medicare and privately insured patients (2). This law spoke volumes to the survivorship population about the importance of quality of life following mastectomy. However, not everyone received that message. Despite the passage of this law, rates of reconstruction were not equalized among varying groups. Disparities continued to plague breast cancer treatment in this country and in 2006, a large population based analysis using the Surveillance, Epidemiology, and End Results (SEER) data-base showed that the WHRCA did not significantly increase the use of reconstruction or reduce disparities in reconstruction rates across geographic location or racial groups (3). Previous studies have investigated the disparity that persists in specific regions. Kruper et al. identified that age, race, type of insurance, and type of hospital all were significant factors in determining the use of reconstruction in Southern California (4). Tseng et al. showed that proximity to an urban center had an effect on reconstruction rates in northern California (5). Alderman et al. investigated racial differences in reconstruction rates as well as variables that may affect these differences (6). Her group showed that Address correspondence and reprint requests to: Grant W. Carlson, Emory University School of Medicine, Winship Cancer Institute, 1365B Clifton Road, Atlanta, GA 30322, USA, or e-mail: [email protected]. DOI: 10.1111/tbj.12280 © 2014 Wiley Periodicals, Inc., 1075-122X/14 The Breast Journal, Volume 20 Number 4, 2014 337–338
limited information about reconstruction procedures and decreased access to plastic surgeons might play a role in the lower reconstruction rates in these populations. The deduction from these studies is that much like we have seen in breast cancer screening and treatment, the etiology accounting for the disparities in reconstruction is multifactorial. In this issue of The Breast Journal, Wexelman et al. from St. Luke’s-Roosevelt Hospital in New York report on disparities in immediate breast reconstruction performed based on the Nationwide Inpatient Sample data-base from over 1000 hospitals in 42 states (7). This is the largest analysis of disparities in reconstruction rates among race, socioeconomic class, and geographic location to date. The study included all women who underwent a unilateral mastectomy or bilateral mastectomies in 2008. Women considered to have immediate breast reconstruction (IBR) were those who underwent reconstruction during the same hospitalization. The three groups compared were those who received no reconstruction, tissue expanders, and pedicled or free flap reconstruction. The objectives were to identify patient characteristics associated with immediate breast reconstruction as well as to differentiate patient characteristics associated with each type of reconstruction. A total of 14,764 patients were identified, 9,441 (63.9%) of which had no reconstruction, 3,526 (23.9%) had tissue expander (TE) placement, and 1,797 (12.2%) had flap reconstruction, attesting to the comprehensiveness of this analysis. The nonreconstructed group was older, had more comorbidities, was more likely to be covered by Medicare or Medicaid and had a higher proportion of women from the two lowest median income zip codes. There were also a higher proportion of Black and Hispanic women in the no reconstruction group. Women from major cities were more likely to receive IBR than women in other cities but still the majority of the women in these cities did not receive IBR. When comparing the two types of reconstruction analyzed, TE was more often performed
338 • editorial
in Medicare patients, White women, and in those in the highest median income bracket. No difference was seen in the mid-level income bracket. Black women were more likely to have flaps performed. This analysis also separated reconstruction rates by state. The authors gave many reasons to explain the disparities they identified. Age and the presence of comorbidities impact whether or not a patient can safely undergo immediate reconstruction. It is possible, as the authors point out, that these patients may have undergone delayed reconstruction but those rates were not looked at in this study. The authors also hypothesized that women in lower income brackets may have more demands on their time and so may not have been able to afford the time needed for recovery from reconstruction. Disparities based on geographic location may be explained by access to plastic surgeons who perform reconstructive surgery and specifically, the microsurgery necessary to perform flap reconstruction. When looking at the types of reconstruction performed, the authors state that the differences may be due to the comorbidities in Medicare patients (necessitating TE over flaps) and also in preference patterns among different races. There are confounding factors related to race that may place a role in the difference in type of reconstruction performed, such as comorbidities and type of oncologic surgery performed. African–Americans females are more likely to have a higher BMI than their counterparts (8), which may influence the higher rate of unilateral mastectomy and autologous reconstruction. Additionally, work out of Memorial Sloan-Kettering Cancer Center (9) showed a trend in increasing contralateral and bilateral prophylactic mastectomies, especially in young patients, those of Caucasian and Hispanic race and those with private insurance. These patients typically have implant-based reconstruction. It would be interesting to learn the details of the patients’ cancer diagnoses in this data base to see if this had a role in the type of reconstruction they received. The limitations of this study identified by the authors provide a great launch pad for further analyses. The authors state they did not have access to tumor characteristics. Historically, stage at presentation is linked to race as well as socioeconomic status and may account for some of the discrepancy seen in the reconstruction rates, since more advanced stages may need treatment that preclude IBR, i.e., radiation. As the authors point out, information such as rates of delayed reconstruction, tumor characteristics, and the
decision-making process would add to our understanding of the disparities seen in this population. Wexelman and colleagues have added to the growing body of literature on the influence of socioeconomic status, race, insurance status, and geographic location on reconstruction rates in the USA. While the passage of the Women’s Health Care Right Act has increased the availability of reconstruction to a diverse population, a disparity still exists. The authors have confirmed that while factors contributing to disparities in breast cancer detection and treatment also affect reconstruction rates, increasing education, and access to plastic surgeons to perform reconstruction is of paramount importance in addressing the gap. Veronica C. Jones, MD Grant W. Carlson, MD Emory University School of Medicine Winship Cancer Institute 1365B Clifton Road Atlanta GA 30322, USA REFERENCES 1. The Women’s Health and Cancer Rights Act. Available at: http://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-InsuranceProtections/whcra_factsheet.html 2. Yang RL, Newman AS, Lin IC, et al. Trends in immediate breast reconstruction acorss insurance groups after enactment of breast cancer legislation. Cancer 2013;119(13):2462–8. 3. Alderman A, Wei Y, Birkmeyer J. Use of Breast Reconstruction After Mastectomy Following the Women’s Health and Cancer Rights Act. JAMA 2006;295(4):387–8. 4. Kruper L, Holt A, Xu XX, et al. Disparities in reconstruction rates after mastectomy: patterns of care and factors associated with the use of breast reconstruction in Southern California. Ann Surg Oncol 2011;18(8):2158–65. 5. Tesng WH, Stevenson TR, Canter RJ, et al. Sacramento area breast cancer epidemiology study: use of postmastectomy breast reconstruction along the rural-to-urban continuum. Plast Reconstr Surg 2010;126(6):1815–24. 6. Alderman A, Hawley S, Janz N, 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– 30. 7. Wexelman B, Schwartz A, Lee D., Estabrook A, Ma A. Socioeconomic and Geographic Differences in Immediate Reconstruction after Mastectomy in the United States. Breast J 2014; 20(4):339–46. 8. Flegal K, Carroll M, Kit B, Ogden C. Prevalence of Obesity and Trends in the Distribution of Body Mass Index among US Adults, 1999-2010. JAMA 2012;307(5):491–7. 9. Cemal Y, Albornoz CR, Disa JJ, et al. A paradigm shift in U.S. breast reconstruction: Part 2. The influence of changing mastectomy patterns on reconstructive rate and method. Plast Reconstr Surg 2013;131(3):320e–6e.
Disparities in Immediate Breast Reconstruction after Mastectomy: Time for a Change
B
reast cancer treatment has evolved tremendously, as has the emphasis on restoration to pretreatment quality of life. Legislation has recognized this need and in 1998, passed the Women’s Health and Cancer Rights Act (WHRCA), which ensures that women who have insurance coverage for a mastectomy will also have insurance coverage for breast reconstruction and lymphedema care (1). With the passage of this law came an increase in the utilization of postmastectomy reconstruction. Yang et al. demonstrated that between 2000 and 2009, rates of immediate breast reconstruction increased over 4-fold in Medicaid patients and over 2-fold in Medicare and privately insured patients (2). This law spoke volumes to the survivorship population about the importance of quality of life following mastectomy. However, not everyone received that message. Despite the passage of this law, rates of reconstruction were not equalized among varying groups. Disparities continued to plague breast cancer treatment in this country and in 2006, a large population based analysis using the Surveillance, Epidemiology, and End Results (SEER) data-base showed that the WHRCA did not significantly increase the use of reconstruction or reduce disparities in reconstruction rates across geographic location or racial groups (3). Previous studies have investigated the disparity that persists in specific regions. Kruper et al. identified that age, race, type of insurance, and type of hospital all were significant factors in determining the use of reconstruction in Southern California (4). Tseng et al. showed that proximity to an urban center had an effect on reconstruction rates in northern California (5). Alderman et al. investigated racial differences in reconstruction rates as well as variables that may affect these differences (6). Her group showed that Address correspondence and reprint requests to: Grant W. Carlson, Emory University School of Medicine, Winship Cancer Institute, 1365B Clifton Road, Atlanta, GA 30322, USA, or e-mail: [email protected]. DOI: 10.1111/tbj.12280 © 2014 Wiley Periodicals, Inc., 1075-122X/14 The Breast Journal, Volume 20 Number 4, 2014 337–338
limited information about reconstruction procedures and decreased access to plastic surgeons might play a role in the lower reconstruction rates in these populations. The deduction from these studies is that much like we have seen in breast cancer screening and treatment, the etiology accounting for the disparities in reconstruction is multifactorial. In this issue of The Breast Journal, Wexelman et al. from St. Luke’s-Roosevelt Hospital in New York report on disparities in immediate breast reconstruction performed based on the Nationwide Inpatient Sample data-base from over 1000 hospitals in 42 states (7). This is the largest analysis of disparities in reconstruction rates among race, socioeconomic class, and geographic location to date. The study included all women who underwent a unilateral mastectomy or bilateral mastectomies in 2008. Women considered to have immediate breast reconstruction (IBR) were those who underwent reconstruction during the same hospitalization. The three groups compared were those who received no reconstruction, tissue expanders, and pedicled or free flap reconstruction. The objectives were to identify patient characteristics associated with immediate breast reconstruction as well as to differentiate patient characteristics associated with each type of reconstruction. A total of 14,764 patients were identified, 9,441 (63.9%) of which had no reconstruction, 3,526 (23.9%) had tissue expander (TE) placement, and 1,797 (12.2%) had flap reconstruction, attesting to the comprehensiveness of this analysis. The nonreconstructed group was older, had more comorbidities, was more likely to be covered by Medicare or Medicaid and had a higher proportion of women from the two lowest median income zip codes. There were also a higher proportion of Black and Hispanic women in the no reconstruction group. Women from major cities were more likely to receive IBR than women in other cities but still the majority of the women in these cities did not receive IBR. When comparing the two types of reconstruction analyzed, TE was more often performed
338 • editorial
in Medicare patients, White women, and in those in the highest median income bracket. No difference was seen in the mid-level income bracket. Black women were more likely to have flaps performed. This analysis also separated reconstruction rates by state. The authors gave many reasons to explain the disparities they identified. Age and the presence of comorbidities impact whether or not a patient can safely undergo immediate reconstruction. It is possible, as the authors point out, that these patients may have undergone delayed reconstruction but those rates were not looked at in this study. The authors also hypothesized that women in lower income brackets may have more demands on their time and so may not have been able to afford the time needed for recovery from reconstruction. Disparities based on geographic location may be explained by access to plastic surgeons who perform reconstructive surgery and specifically, the microsurgery necessary to perform flap reconstruction. When looking at the types of reconstruction performed, the authors state that the differences may be due to the comorbidities in Medicare patients (necessitating TE over flaps) and also in preference patterns among different races. There are confounding factors related to race that may place a role in the difference in type of reconstruction performed, such as comorbidities and type of oncologic surgery performed. African–Americans females are more likely to have a higher BMI than their counterparts (8), which may influence the higher rate of unilateral mastectomy and autologous reconstruction. Additionally, work out of Memorial Sloan-Kettering Cancer Center (9) showed a trend in increasing contralateral and bilateral prophylactic mastectomies, especially in young patients, those of Caucasian and Hispanic race and those with private insurance. These patients typically have implant-based reconstruction. It would be interesting to learn the details of the patients’ cancer diagnoses in this data base to see if this had a role in the type of reconstruction they received. The limitations of this study identified by the authors provide a great launch pad for further analyses. The authors state they did not have access to tumor characteristics. Historically, stage at presentation is linked to race as well as socioeconomic status and may account for some of the discrepancy seen in the reconstruction rates, since more advanced stages may need treatment that preclude IBR, i.e., radiation. As the authors point out, information such as rates of delayed reconstruction, tumor characteristics, and the
decision-making process would add to our understanding of the disparities seen in this population. Wexelman and colleagues have added to the growing body of literature on the influence of socioeconomic status, race, insurance status, and geographic location on reconstruction rates in the USA. While the passage of the Women’s Health Care Right Act has increased the availability of reconstruction to a diverse population, a disparity still exists. The authors have confirmed that while factors contributing to disparities in breast cancer detection and treatment also affect reconstruction rates, increasing education, and access to plastic surgeons to perform reconstruction is of paramount importance in addressing the gap. Veronica C. Jones, MD Grant W. Carlson, MD Emory University School of Medicine Winship Cancer Institute 1365B Clifton Road Atlanta GA 30322, USA REFERENCES 1. The Women’s Health and Cancer Rights Act. Available at: http://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-InsuranceProtections/whcra_factsheet.html 2. Yang RL, Newman AS, Lin IC, et al. Trends in immediate breast reconstruction acorss insurance groups after enactment of breast cancer legislation. Cancer 2013;119(13):2462–8. 3. Alderman A, Wei Y, Birkmeyer J. Use of Breast Reconstruction After Mastectomy Following the Women’s Health and Cancer Rights Act. JAMA 2006;295(4):387–8. 4. Kruper L, Holt A, Xu XX, et al. Disparities in reconstruction rates after mastectomy: patterns of care and factors associated with the use of breast reconstruction in Southern California. Ann Surg Oncol 2011;18(8):2158–65. 5. Tesng WH, Stevenson TR, Canter RJ, et al. Sacramento area breast cancer epidemiology study: use of postmastectomy breast reconstruction along the rural-to-urban continuum. Plast Reconstr Surg 2010;126(6):1815–24. 6. Alderman A, Hawley S, Janz N, 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– 30. 7. Wexelman B, Schwartz A, Lee D., Estabrook A, Ma A. Socioeconomic and Geographic Differences in Immediate Reconstruction after Mastectomy in the United States. Breast J 2014; 20(4):339–46. 8. Flegal K, Carroll M, Kit B, Ogden C. Prevalence of Obesity and Trends in the Distribution of Body Mass Index among US Adults, 1999-2010. JAMA 2012;307(5):491–7. 9. Cemal Y, Albornoz CR, Disa JJ, et al. A paradigm shift in U.S. breast reconstruction: Part 2. The influence of changing mastectomy patterns on reconstructive rate and method. Plast Reconstr Surg 2013;131(3):320e–6e.
