Racial/Ethnic Barriers to Breast Reconstruction After Mastectomy for Breast Cancer
In a study reported in JAMA Surgery, Morrow et al found that breast reconstruction after mastectomy for breast cancer largely reflects patient demand, with the majority of women being satisfied with the decision-making process. However, black women were significantly less likely to have reconstruction, and black and Latina women were significantly more likely to be dissatisfied with the decision process.
Study Details
The study included analysis of Surveillance, Epidemiology, and End Results (SEER) registries from Los Angeles and Detroit to identify a sample of women aged 20 to 79 years diagnosed between June 2005 and February 2007 with ductal carcinoma in situ or stage I to III invasive breast cancer. Black and Latina women were oversampled to ensure adequate representation of racial/ethnic minorities. Participants had to be able to complete a survey in English or Spanish.
A total of 3,252 women were sent an initial survey at a median of 9 months after diagnosis, with 2,290 completing it. Of these, 1,536 who remained disease-free completed a follow-up survey at 4 years, including 485 who had undergone mastectomy.
Compared with respondents, nonrespondents to the follow-up survey were more likely to be black (35.2% vs 26.7%, P < .001) or Latina (17.2% vs 13.3%, P = .002), to have stage II or III cancer (54.9% vs 37.8%, P < .001), and to have undergone mastectomy (37.5% vs 30.8%, P < .001).
Factors Associated With No Reconstruction
Of the 485 patients reporting mastectomy at the initial survey and remaining disease free at follow-up, 24.8% underwent immediate and 16.8% delayed reconstruction (total = 41.6%). Factors significantly associated with not undergoing reconstruction were black race (adjusted odds ratio [AOR] = 2.16, P = .004), lower educational level (AOR = 4.49, P < .001), increased age (AOR = 2.53, P < .001, for 10-year increments), major comorbidity (AOR = 2.27, P = .048), and chemotherapy (AOR = 1.82, P = .05).
Patient and Systems Factors
Overall, 13.3% of women expressed dissatisfaction with the reconstruction decision process; dissatisfaction was higher among black (OR = 2.87) and Latina patients (OR = 2.03, P = .03 for trend) vs nonblack, non-Latina patients, but did not differ according to income or education levels.
The most common patient factors cited for not having reconstruction were the desire to avoid additional surgery (48.5%; 70.0% among nonblack, non-Latina women, 39.7% among black women, and 34.1% among Latina women, P < .001), fear of implants (36.3%; no difference among groups), and the belief that it was not important (33.8%; 42.4%, 21.6%, and 31.3%, P = .04). Significant differences were also observed among racial/ethnic groups for the reasons of concern about possible complications (27.9%, 20.4%, and 43.8%, P = .02) and inability to take time off from work or family (8.9%, 9.5%, and 24.7%, P = .02. Among systems factors reported for not having reconstruction, there were differences among groups in citing no insurance coverage (2.2%, 23.7%, and 18.6%, P = .001) and surgeons not taking insurance (2.8%, 16.8%, and 8.5%, P = .09).
Delayed Reconstruction
Among patients having delayed reconstruction, the most common reasons for delay were focus of attention on treating the cancer (68.7%), need for chemotherapy (50.7%), and need for radiotherapy (26.3%). However, 14.3% reported not knowing that reconstruction was an option and 10.3% reported having no insurance coverage as a barrier.
Residual demand for reconstruction at 4 years was low, with only 30 (11.4%) of 263 who did not undergo reconstruction still considering the procedure.
The investigators concluded: “Reconstruction rates largely reflect patient demand; most patients are satisfied with the decision-making process about reconstruction. Specific approaches are needed to address lingering patient-level and system factors with a negative effect on reconstruction among minority women.”
Monica Morrow, MD, of Memorial Sloan Kettering Cancer Center, is the corresponding author for the JAMA Surgery article.
The study was supported by grants and awards from the National Cancer Institute, American Cancer Society, and California Department of Public Health. The authors reported no conflicts of interest.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
