Nationally, approximately 5.6-42% of women undergoing mastectomy receive immediate or early- delayed BR17-20
. BR has been shown to have a significant positive psychosocial impact on patients1-4
with overall good to excellent patient satisfaction3, 21-22
. Appropriately, the Women’s Health and Cancer Rights Act of 1998 requires all medical insurers providing mastectomy coverage to also cover all stages of reconstruction of the affected breast and reconstruction of the contralateral breast to provide a symmetrical appearance23
. Because post-mastectomy BR has become an expected component of quality cancer care, because residents of rural areas have demonstrated health care disparities relative to their urban-dwelling counterparts for other health indicators, and because rural residents have been shown to more likely undergo mastectomy for the primary treatment of their BCa, we hypothesized that patients from more rural areas would be less likely to receive post-mastectomy BR than their urban counterparts.
In agreement with our stated hypothesis, patients from rural and near-metro areas were less likely to receive post-mastectomy BR relative to their urban-dwelling counterparts, even after controlling for known patient, tumor, and treatment-specific factors. The reason for the observed rural-urban disparity in usage of BR is unclear, but is likely multifactorial. In addition to demonstrating the BR disparities among rural, near-metro, and urban counties, the present study validates previously reported predictors of lower likelihood of BR including age24
, ethnicity18, 25
, removal of the contralateral breast2
, tumor factors predictive of local recurrence including T stage2, 26-27
, and tumor grade28
. The only factors associated with an increased likelihood of BR in our study included performance of a bilateral mastectomy procedure, ILC histology, and T4 tumors. Patients undergoing bilateral mastectomy for prophylactic reasons may be more motivated to undergo BR to obtain chest wall symmetry and simultaneously reduce their risk of contralateral breast cancer. Similarly, ILC more often is bilateral than IDC and these patients may therefore more likely choose or require bilateral mastectomy for treatment of their breast cancer. It seems counterintuitive that T4 tumors would be more associated with BR than smaller tumors. However, T4 tumors may necessitate more radical resections of the chest wall, which may require subsequent reconstruction for wound closure. These procedures may therefore be coded as BR procedures.
Why should rural patients receive lower rates of BR than urban patients? One possibility is that rural and near-metro areas may have fewer plastic surgeons. To investigate this possibility, we researched the number of plastic surgeons within each county using the American Society of Plastic Surgery database. Those counties identified as “rural” had no plastic surgeons serving their areas. The counties identified as near-metro had a total of 20 plastic surgeons serving their areas. Urban counties, however, had 25 plastic surgeons servicing their areas. This would indicate that the supply of plastic surgeons in rural and near-metro areas may contribute to the lower rate of BR seen in these populations.
Patients from rural or near-metro areas may attempt to alleviate this plastic surgeons supply problem by traveling to an area where a plastic surgeon is available. Travel itself, however, may be an issue. Research has investigated the role of distance to travel for care as a predictor of compliance and receipt of obstetric, medical, and cancer care29-35
. Athas et al., in their analysis of New Mexican women undergoing care for BCa, found an inverse relationship between travel distance and receipt of post lumpectomy radiation therapy36
. Nair et al. evaluated the effect of travel distance on bilateral breast reduction utilization among symptomatic women living near Edinburgh, Scotland. The Scottish health care system is socialized and provides free health care to all permanent residents, and breast reduction is fully covered for eligible women. They found that the likelihood of uptake of breast reduction surgery decreased with both travel time and distance traveled to the operative hospital. In this study, satellite plastic surgery clinics that assessed women preoperatively and that were strategically located within rural communities had a strong positive effect on qualified, symptomatic women receiving breast reduction37
. Difficulty in attaining plastic surgeon consultation and travel barriers may negatively influence surgeon-patient discussions of and patient decisions about BR.
Finding a plastic surgeon, either locally or via distant travel, does not guarantee access to BR. Surgeon preference is cited as an important predictor of BCa treatment38-40
. Higher BR rates are seen in patients who have pre-mastectomy discussions of BR with their cancer surgeon41-42
and plastic surgeon43
. Surgeons most likely to refer patients for BR are more likely women (OR 2.3, p=0.03), with high volume breast practices (OR 4.1, p=0.01), in cancer centers (OR 2.4, p=0.01)44
. Surgeons least likely to refer patients for BR may believe that their patients have more barriers (cost, plastic surgeon availability) and lower desire for BR44
. Although these studies were accomplished in exclusively urban areas, these findings raise the question of whether or not similar referral patterns and biases exist among surgeons practicing in rural areas. It is possible that rural surgeons may be less likely to have discussions regarding BR with their patients and be less likely to recommend BR. These biases could contribute to the BR rate disparities seen in the current study and should be a point of future research.
Race/ethnicity can influence rates of BR. Using the SEER registries from Detroit and Los Angeles, Alderman et al. showed that 40.9% of whites received BR while 33.5% of blacks received post mastectomy BR25
. Interestingly, assimilated Hispanics showed rates of BR of 41.2%, while un-assimilated Hispanics had BR rates of only 13.5%. The authors further showed that non-white women were less likely than white women to see a plastic surgeon before initial surgery but were more likely to desire information regarding BR. Our data confirm the role of race/ethnicity on use of BR; black and Hispanic women had a 45% and 33% decreased likelihood, respectively, of receiving BR relative to white women. Even with the incorporation of race/ethnicity into several multivariate analyses, rural areas continued to show lower rates of BR relative to urban areas.
and insurance status20
may also influence receipt of BR. Christian et al. demonstrated a 42% rate of BR within 8 National Comprehensive Cancer Network Centers—a rate significantly higher than previously reported in population-based studies45
--and found that patients with Medicare/ Medicaid were significantly less likely to receive BR than those with managed care insurance. Even among a fully insured patient population, insurance status represents an important barrier to health care, and there are others17
. A major reason patients express for not undergoing BR is a desire for no further surgery27, 38
. Unfortunately, our SEER data do not allow us to comment on individual patient income, insurance status, or preferences.
Nevada county was the only geographic area to demonstrate an association with a higher likelihood of BR as compared to Sacramento county (OR 2.25, 95% CI 1.46-3.48, P<0.001). Sixty miles from the city of Sacramento, California and 88 miles from the city of Reno, Nevada, median household income in Nevada County was $52,700 (2000, 3rd
highest among the counties examined-data not shown46
) as compared to a median household income of $50,700 for Sacramento County. The percentage of persons living under the poverty line in the county was 8.1% (3rd
lowest among the counties examined). In contrast, residents in Butte County demonstrated the lowest likelihood of receiving BR (OR 0.24, 95% CI 0.12-0.49, p<0.001). Median household income was $41,000, and nearly 20% of the county lived below the poverty line. Residents of Amador County had the 2nd
lowest likelihood of receiving BR (OR 0.36, 95% CI 0.14-0.90, p=0.03). Median household income of the county was $51,200 (4th
highest) with 9.2% of the county populace living below the poverty line. These findings suggest that socioeconomic status is not the only population variable affecting delivery of post-mastectomy BR.
Limitations of this study include the fact that SEER codes only treatment received during the “first course” of therapy. We may have underestimated the number of patients receiving BR. It was unknown if 50.7% of patients in our series received BR. Furthermore, we determined that 18% of patients received post-mastectomy radiation therapy, presumably due to locally advanced disease. It is plausible, then, that those patients receiving late or delayed reconstruction due to intervening chest wall radiation therapy are not included in our analysis47
. SEER also does not abstract medical comorbidities. It is possible that women with BCa from rural areas had a higher prevalence of significant relative contraindications to breast reconstruction such as smoking and diabetes. We also recognize that there is likely geographic clustering at the county and local level. Population based analyses such as these are not meant to be generalizeable at the individual level.
The decision to undergo BR is a personal decision. Those who decide to undergo BR report excellent rates of satisfaction and may receive psychological and social benefits from their decision. So, too, may women who make the informed choice not to perform BR. It is important to note, that patients may choose not to have BR because they do not feel it is necessary for their physical or emotional well-being48
Our findings generate a number of questions. In addition to the complex interaction between ethnicity and socioeconomic characteristics such as income, educational level, and employment status there likely exists an interaction between the rural- urban continuum and these factors. Even after controlling for previously investigated prognostic factors for BR, differences in BR rates among the counties studied existed.
Differences in use of BR detected at a population level should guide future studies and interventions to increase rates of BR at the local level. Findings from the current study suggest differences in the utilization of BR in rural and urban settings in Northern California. Further studies are needed to evaluate the causes of these disparities and identify potential areas of improvement with a goal of providing patient- centered BCa care.