Disparities in Access to Postmastectomy Breast Reconstruction: Does Living in a Specific ZIP Code Determine the Patient’s Reconstructive Journey?

Abstract

Background Postmastectomy breast reconstruction (BR) has been shown to provide long-term quality of life and psychosocial benefits. Despite the policies initiated to improve access to BR, its delivery continues to be inequitable, suggesting that barriers to access have not been fully identified and/or addressed. The purpose of this study was to assess the influence of geographic location, socioeconomic status, and race in access to immediate BR (IBR). Methods An institutional review board–approved observational study was conducted. All patients who underwent breast cancer surgery from 2014 to 2019 were queried from our institutional Breast Cancer Registry. A geographical analysis was conducted using demographic characteristics and patient’s ZIP codes. Euclidean distance from patient home ZIP code to UPMC Magee Women's Hospital was calculated, and χ2, Student t test, Mann-Whitney, and Kruskal-Wallis tests was used to evaluate differences between groups, as appropriate. Statistical significance was set at P < 0.05. Results Overall, 5835 patients underwent breast cancer surgery. A total of 56.7% underwent lumpectomy or segmental mastectomy, and 43.3% underwent modified, total, or radical mastectomy. From the latter group, 33.5% patients pursued BR at the time of mastectomy: 28.6% autologous, 48.1% implant-based, 19.4% a combination of autologous and implant-based, and 3.9% unspecified reconstruction. Rates of IBR varied among races: White or European (34.1%), Black or African American (27.7%), and other races (17.8%), P = 0.022. However, no difference was found between type of BR among races (P = 0.38). Moreover, patients who underwent IBR were significantly younger than those who did not pursue reconstruction (P < 0.0001). Patients who underwent reconstruction resided in ZIP codes that had approximately US $2000 more annual income, a higher percentage of White population (8% vs 11% non-White) and lower percentage of Black or African American population (1.8% vs 2.9%) than the patients who did not undergo reconstruction. Conclusions While the use of postmastectomy BR has been steadily rising in the United States, racial and socioeconomic status disparities persist. Further efforts are needed to reduce this gap and expand the benefits of IBR to the entire population without distinction.

Disparities in Breast Reconstruction

“…3). This is consistent with recently published reports that cite Black women have significantly lower reconstruction rates (35% vs 49%) when compared with White women, and when reconstruction is pursued it is more commonly autologous reconstruction (13% vs 7%) 18–20 . The type of reconstruction treatment chosen may reflect patient preferences, attitudes toward reconstruction, cultural beliefs, and bias among providers.…”

“…This is consistent with recently published reports that cite Black women have significantly lower reconstruction rates (35% vs 49%) when compared with White women, and when reconstruction is pursued it is more commonly autologous reconstruction (13% vs 7%). [18][19][20] The type of reconstruction treatment chosen may reflect patient preferences, attitudes toward reconstruction, cultural beliefs, and bias among providers. Although implant-based reconstruction was found to be the most common overall treatment option in our patient population, several studies have shown that autologous reconstruction has preferred outcomes.…”