Insurance Type, Race, and Distance to Clinic Primary Barriers for Breast Reconstruction Surgery

Private insurance coverage and living closer to a plastic surgeon’s office encouraged women who had a mastectomy to undergo breast reconstruction, according to a new study by researchers at the University of North Carolina Lineberger Comprehensive Cancer Center.

Breast reconstruction following a mastectomy can boost a woman’s quality of life by influencing her self-esteem, body image, and sexuality. Despite these benefits, women often face socioeconomic and demographic barriers to such services. To better understand the correlation between density of plastic surgeons and health insurance with the rate of breast reconstruction surgery in North Carolina, researchers at the University of North Carolina at Chapel Hill conducted retrospective analysis of data from the Integrated Cancer Information and Surveillance System, which links the North Carolina Central Cancer Registry to beneficiaries in Medicare, Medicaid, and private insurance plans across the state.

“We know that breast cancer affects not only the physical wellbeing of the patient, but also her psychosocial wellbeing, and we know that breast reconstruction can help address those issues,” said first author of the study Michelle Roughton, MD, assistant professor of surgery and program director for the UNC School of Medicine Section of Plastic and Reconstructive Surgery.

After applying inclusion and exclusion criteria to more than 27,638 cases diagnosed between 2003 and 2006, the final cohort included 5381 patients. Exclusion criteria included inflammatory disease, death or autopsy, distant metastatic disease, multiple breast cancers, no mastectomy, mastectomy performed 6 months after diagnosis, and patients who were simultaneously enrolled in Medicaid, Medicare, and private insurance.

The analysis found that 20% of women in the cohort being studied underwent postmastectomy breast reconstruction. Receipt of reconstruction was significantly associated with distance to the breast reconstructive surgeon: 10 miles or less seemed conducive to undergoing the operation; women living between 10 and 20 miles from a surgeon had 22% lower odds of a breast reconstruction (odds ratio [OR], 0.78; 95% CI, 0.63 to 0.96), while those living more than 20 miles from a surgeon had 27% lower odds (OR, 0.73; 95% CI, 0.57 to 0.93) compared with women who lived within a 10-mile radius.

Insurance was another looming factor. Women enrolled in Medicare (OR, 0.58; 95% CI, 0.45 to 0.74) or Medicaid (OR, 0.24; 95% CI, 0.19 to 0.32) had lower odds of undergoing reconstruction compared with those who paid for private insurance coverage. A racial bias was also observed, with white women more likely to choose the reconstruction option.

“As doctors working for the state’s flagship cancer hospital, we aim to provide breast reconstruction to every woman who desires it despite distance and payer,” Roughton said, sharing that telemedicine and digital communications such as e-mail and text messaging was being used at their cancer hospital, at least for the initial consultations.

Reference

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(2):203e-211e. doi: 10.1097/PRS.0000000000002343.