This is among the first studies to describe minority patients' experience with postmastectomy breast reconstruction with sufficient representation of Latina patients with breast cancer to examine this group by level of acculturation. We found that Latinas with less acculturation, and African Americans, were much less likely than whites to receive breast reconstruction after mastectomy (immediate or early delayed). Yet the receipt of reconstruction for highly acculturated Latinas was similar to that of whites. In addition, older women, those with Medicaid or no health insurance, and those requiring chemotherapy or radiation therapy were also less likely to receive reconstruction as compared with their counterparts.
Our results suggest that the low use of reconstruction for less acculturated Latinas and African Americans was not explained by lower demand for the procedure. Minority patients were the least likely to report that reconstruction was not important, were the most likely to desire more information about reconstruction, and were the least likely to be satisfied with their surgical treatment decision. It seems that minority patients were confronted with several informational barriers that may have limited their opportunities for reconstruction. Both African American and less acculturated Latinas had significantly less counseling from the general surgeon regarding the types and timing options for breast reconstruction. This is consistent with our prior research that found that only one third of patients with breast cancer reported having a discussion with their general surgeon about the option of breast reconstruction.22
Minority patients were also less likely to be counseled about these options from a plastic surgeon, and they expressed the greatest desire for more information about breast reconstruction as compared with their counterparts. These results suggest that there is substantial unmet need for information regarding reconstruction options among minorities. It is likely that the information barriers reported by less acculturated Latinas in our sample were compounded by language barriers and lower levels of educational attainment, which may contribute to lower health literacy and poorer comprehension of complex medical information.
Financial barriers also appeared to limit options for reconstruction, especially for less acculturated Latinas. Women with Medicaid or no insurance—which mostly comprised less acculturated Latinas—were significantly less likely to receive reconstruction as compared with those with private insurance or Medicare. Furthermore, less acculturated Latinas expressed the most concern regarding the financial costs of reconstruction. These financial barriers may account for the limited access minority women had to a preoperative consultation with a plastic surgeon and to reconstructive surgery, as many plastic surgeons have reported limiting their breast reconstructive practice because of poor third-party reimbursement.23
This study has some limitations. These results are limited to two metropolitan areas, Detroit and Los Angeles, and may not reflect national trends in breast cancer care. In particular, Latinas in the Los Angeles metropolitan area who are primarily of Mexican origin may not be representative of other Latina groups in the United States. However, the large racially and ethnically diverse population-based patient samples and the high response rate suggest that we have a sample that is well representative of patients with breast cancer in these racial/ethnic groups. Our study only addresses reconstruction at or near the time of the mastectomy and does not reflect practice patterns and decisions for delayed breast reconstruction. In addition, other factors may influence use of breast reconstruction that were unavailable to us, such as general surgeons' attitudes toward reconstruction and plastic surgeons' availability to perform these cases. The study was necessarily retrospective in design. Patients' recall of their encounters with clinicians may change over time. However, the survey was completed within 9 months of diagnosis on average and prior work has suggested this timeframe is adequate to produce good recall of treatment experiences. A small proportion of respondents (13%) indicated that they had help completing the questionnaire, possibly as a result of lower levels of literacy, which may contribute to less accurate responses.
Our findings have important implications for patient care and policy. Physicians, patients, and women's health advocates have devoted considerable energy toward ensuring women's access to postmastectomy breast reconstruction through the Women's Health and Cancer Rights Act. We found that racial/ethnic variations in the use of this procedure persist, despite interest in the procedure across all racial/ethnic groups. In our study, less acculturated Latinas faced the greatest barriers to both information about and receipt of postmastectomy reconstruction, indicating substantial unmet need for the procedure in this racial/ethnic subgroup.
Efforts must be directed at reducing the informational and financial barriers faced by minority women who may be candidates for breast reconstruction. One approach is to develop and deploy decision tools that the surgeon could use to educate both patients and families about the risks and benefits of surgery. Decision tools have been associated with improved decisional quality for breast cancer care24
; however, most existing decision support tools do not include information about reconstruction. Most tools are directed at higher literacy levels and are not available in different languages.24
As well, research has shown that Latinas, especially those who are less acculturated, may rely heavily on family in breast cancer treatment decision making.25,26
Thus it is important that tools are accessible and understandable by those involved in supporting the patients' decision making. Provision of professional translational services and/or decision-making and educational materials appropriate for patients and families of different literacy levels and languages may improve the quality of breast reconstruction decision making.
However, interventions will not fully address the gaps in information needs reported by minority women if they have limited access to plastic surgeons. A prior study showed that many surgeons who treat patients with breast cancer reported that few of their patients receive consultations with plastic surgeons before surgery.27
This suggests that more multidisciplinary approaches to treatment decision making may be another mechanism to improve access to care. Finally, financial access to breast reconstruction remains an important barrier for those uninsured or underinsured. Charity organizations such as the Susan G. Komen for the Cure Foundation have provided support through community grants that cover breast cancer-related treatment, including reconstruction, for medically underserved populations.28
Taken together, these initiatives may improve the access of patients with breast cancer to reconstruction and potentially impact longer-term outcomes such as quality of life.