Abstract C08: Multilevel determinants of disparities in breast reconstruction: A systematic review
Authors: Khushalani Jaya S. 
Published: May 2016

Context and Objectives: Breast reconstruction has been shown to yield important psycho-social and quality of life benefits for patients with breast cancer who have undergone mastectomy. However, a number of studies have demonstrated significant disparities in access to breast reconstruction. The Women's Health and Cancer Rights Act, which mandated insurance coverage of post mastectomy breast reconstruction in 1999 sought to improve access and reduce disparities but disparities continue to persist in spite of legislative action. Previous studies have established the presence of racial, income, insurance and geographic variation in breast reconstruction. However, no systematic review of these multiple disparities has been conducted. This study has two aims: 1) To conduct a quantitative assessment of the magnitude of multiple disparities in breast reconstruction and 2) To conduct a qualitative and quantitative assessment of multi-level determinants of these disparities.

Methods: 43 relevant articles published from 1999 to 2015 were obtained through electronic database searches (PubMed) and manual searches of reference lists. English-language studies from United States were included if study objectives included examination of non-clinical patient level, provider level, institution level or geographic level determinants of Breast Reconstruction surgery after Mastectomy. Both qualitative and quantitative studies were included. Data were extracted and rated for study quality by one reviewer.

Findings: Reconstruction rates varied from 6% to 53% in the studies reviewed based on the population assessed and the data used. Implants were more likely to be performed than autologous reconstruction. African Americans and Hispanics, patients with Medicare and Medicaid and patients residing in areas with median income in the lowest quartile were less likely to receive reconstructions. A consistent association was seen between increasing patient age and decreasing likelihood of reconstruction. Another significant and consistent association was between African American race and autologous versus implant reconstruction.

Conclusions: Socioeconomic disparities in breast reconstruction remain pervasive in spite of legislation such as the Women's Health and Cancer Rights Act (WHCRA) and the Affordable Care Act, with substantial variation by racial or ethnic subgroup, median income of area of residence and payer. Factors explaining these disparities include variation in access to early diagnosis (later stage patients are less likely to get reconstruction), access to information regarding reconstruction (due to language barriers or provider bias) and in access to providers and institutions with high volumes of reconstruction. Other non-clinical patient level factors that influence reconstruction include patient preferences (religious preferences, body image perception, importance of feeling whole again, etc.), marital status, education, employment status, etc. Plastic surgeon characteristics include age and years in practice. Institutional characteristics include setting, teaching status, region, affiliation with an oncology group or national cancer centers, presence of residents, etc. Future reviews should focus on identifying interventions to successfully reduce these disparities in breast reconstruction.

New Contribution: Although there have been two systematic reviews which look at socioeconomic and other determinants of breast reconstruction, neither of them focus only on United States nor do they include sufficient number of studies conducted after the Affordable Care Act in order to determine its impact on socioeconomic disparities. Additionally, neither of the two studies look at multi-level determinants of breast reconstruction and the type of reconstruction nor do they rate the quality of the studies included in the review. Thus, this review will address these gaps and make a significant and new contribution to literature.

Citation Format: Jaya S. Khushalani. Multilevel determinants of disparities in breast reconstruction: A systematic review. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C08.