BACKGROUND: Although breast reconstruction is associated with multiple benefits, several barriers have been described including age, stage of disease or economic status. In an US study conducted in low-income patients, 37% have completed breast reconstructive surgery (BRS) (Maly, Cancer 2009). In universal healthcare systems however, little is known about the effect of these factors: in Canada (NS), the rate of BRS remains lower than in the USA (3.8%) without any influence of household income (Barnsley, Can J Surg 2008). We decided to evaluate barriers to BRS in an area (Seine-Saint-Denis, SSD) with an estimated population of 1.4 billion, which is among the poorest in France. Median household income is 68% lower than in Paris (+68%), a gap growing with time. In SSD, cancer is the leading cause of premature mortality. Yet, the area has no more than one academic cancer center.
PATIENTS AND METHODS: Oncologie 93 is a non-profit organization whose aim is to provide supportive care, health education and counseling to cancer patients treated in various cancer centers in SSD. A phone survey was conducted using semi-structured interviews. All pts completed their chemotherapy 1 year ago. Vulnerability was evaluated using a 11-item standardized score (EPICES) previously investigated by French Health Examination Centers. Strictly speaking this score was aimed at measuring “precarity”, a concept referring to a social condition assumed to face worsening. This score is more strongly related to health status than the administrative classification of poverty (Sass, Sante Publique 2006). Vulnerability was defined by a score ≥30 and considered as severe when ≥40.
RESULTS: Among 99 pts screened over a 10 months period, 42 underwent a mastectomy. Mean age was 54 but only 27% stayed professionally active, 30% were retired. A majority (60%) had a partner. The EPICES score was ≥30 in 45% of pts, and ≥40 in 35%, ie 2.5 fold higher than average. One year after therapy, only 5 pts (12%) had BRS but 17 (46%) of the remaining 37 pts were considering BRS. Only 3 of them (8%) already got an appointment with a plastic surgeon. Other patients (n = 19) were still undecided (51%). Main reasons invoked were: fear of a new surgical procedure (n = 10, 27%) or feeling unprepared to BRS (n = 9, 24%). Five patients (13%) considered BRS as “useless”: 4 of them were ≥65 and age was the main factor in their choice. Vulnerability was not correlated with the decisions about BRS, neither was marital status. Of note, for all patients but one financial difficulties were not regarded as a critical issue and all pts were aware that BRS can be reimbursed by the public health insurance; none of them, however, knew that extra fees were the rule when BRS is performed outside of public hospitals.
CONCLUSIONS: In an universal healthcare system, only a minority of low-income or vulnerable patients choose BRS. Although BRS funding is usually not regarded as a problem, numerous barriers to BRS still exist, mainly related to irrational grounds or wrong beliefs. Whether these barriers can be overcome by improved patient-doctor communication or better information remains an issue.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD08-03.
