Variation in the Utilization of Reconstruction Following Mastectomy in Elderly Women

Background. Regardless of their age, women who choose to undergo postmastectomy reconstruction report improved quality of life as a result. However, actual use of reconstruction decreases with increasing age. Whereas this may reflect patient preference and clinical factors, it may also represent age-based disparity. Methods. Women aged 65 years or older who underwent mastectomy for DCIS/stage I/II breast cancer (2000–2005) were identified in the SEER-Medicare database. Overall and institutional rates of reconstruction were calculated. Characteristics of hospitals with higher and lower rates of reconstruction were compared. Pseudo-R statistics utilizing a patient-level logistic regression model estimated the relative contribution of institution and patient characteristics. Results. A total of 19,234 patients at 716 institutions were examined. Overall, 6 % of elderly patients received reconstruction after mastectomy. Institutional rates ranged from zero to [40 %. Whereas 53 % of institutions performed no reconstruction on elderly patients, 5.6 % performed reconstructions on more than 20 %. Although patient characteristics (%DR = 70 %), and especially age (%DR = 34 %), were the primary determinants of reconstruction, institutional characteristics also explained some of the variation (%DR = 16 %). This suggests that in addition to appropriate factors, including clinical characteristics and patient preferences, the use of reconstruction among older women also is influenced by the institution at which they receive care. Conclusions. Variation in the likelihood of reconstruction by institution and the association with structural characteristics suggests unequal access to this critical component of breast cancer care. Increased awareness of a potential age disparity is an important first step to improve access for elderly women who are candidates and desire reconstruction. Following the treatment of early-stage breast cancer with mastectomy, women who opt for reconstructive surgery may experience better quality of life without adverse oncologic outcomes. The Women’s Health and Cancer Rights Act (WHCRA) passed in 1999 mandates insurance coverage of breast reconstruction after mastectomy for breast cancer. Yet, studies have found persistent differences in rates of reconstruction according to patient-related factors, including age, race, socioeconomic status (SES), and insurance status, as well as institutional characteristics, such as urban hospital location, academic institution affiliation, or National Cancer Institute (NCI) cancer center designation. Although this may represent appropriate variation based on patient preferences, this also may represent unequal access to care. Reported reconstruction rates after mastectomy are 15–42 %. On subgroup analysis, these studies show that reconstruction rates for elderly patients are 4.1–14 %, suggesting that decision making about reconstruction in elderly patients differs from that in younger patients. Whereas elderly women who opt for reconstruction report improved quality of life without increased complications, Society of Surgical Oncology 2012 First Received: 8 August 2012; Published Online: 22 December 2012 H. In, MD, MBA, MPH e-mail: Haejin.In@uchospitals.edu Ann Surg Oncol (2013) 20:1872–1879 DOI 10.1245/s10434-012-2821-5