Lower SES Survivors Less Likely to Receive Reconstruction Post Mastectomy

A new study indicates there are persistent socioeconomic disparities in the rates of women who receive breast reconstruction surgery after undergoing a mastectomy to treat their breast cancer.

Post mastectomy reconstruction is widely recognized as “a critical component of comprehensive, high-quality breast cancer care,” as it can improve women’s quality of life after breast cancer treatment, according to the study published in Annals of Surgical Oncology.

Despite policies meant to encourage plastic surgery consultations and provide insurance coverage of reconstruction, the surgery is not universal among all breast cancer survivors after a mastectomy. While some cases of skipped reconstruction are due to patient preference or clinical characteristics, the study authors hypothesized that socioeconomic status (SES) may also play a role in who receives reconstruction after a mastectomy.

Using the National Cancer Database, researchers identified nearly 300,000 women who had their stage 0 or 1 breast cancer treated with mastectomy between 2004 and 2013. The database included information on immediate breast reconstruction, as well as sociodemographic factors (eg, race, education, insurance, median household income, and urban/rural location) and clinical characteristics.

Across the entire study period, the cohort-wide rate of reconstruction was 40%; it had risen from 27% in 2004 to 48% in 2013. Women were most likely to receive reconstruction if they were white, had private insurance, and lived in areas with high rates of high school education (64.2% of these women received reconstruction).

In contrast, patients with Medicaid who lived in areas with the lowest high school graduation rates were least likely to undergo reconstruction. The odds of reconstruction for these patients were 45.7% for white women and 42.4% for black women. The researchers also determined that the gap in reconstruction across SES strata persisted across the study period, even though the absolute rate of reconstruction increased over time for all groups.

“Although the increases in the rate of immediate breast reconstruction observed in our study are promising, the ongoing disparities in the receipt of reconstruction for socioeconomically disadvantaged patients is significant,” the study authors wrote.

Based on theories of behavior change, the researchers suggested that these disparities arise from differences in patients’ capability, motivation, and opportunity to undergo reconstruction. For instance, patients without the education needed to ask their providers about reconstruction options would lack the capability, while patients who could not afford to take time off from work would not have the opportunity to receive this beneficial surgery.

Considering this complex interplay of factors, interventions to reduce the socioeconomic disparities in reconstruction must address the patient-level, provider-level, and systemic causes.

“Understanding how socioeconomic factors influence receipt of immediate reconstruction and determining which are modifiable critical next steps towards identifying interventions that will improve the quality of breast cancer surgical care for disadvantaged populations,” the authors concluded.