Differences in rates of immediate breast reconstruction in Canada and the United States: what can we learn?

On the cusp of full implementation of the Affordable Care Act, there is great interest in the influence of this legislation on cancer care in the United States. Proponents of health care reform rightly note that markedly increasing the number of insured adults should result in increased access to cancer screening, preventive services, and treatment with downstream improvements in cancer mortality and patient outcomes. Yet concern exists regarding potential for this legislation to exert unintended consequences, particularly through causing changes in payer mix and health care reimbursement. An interesting perspective on the impact of health care payment system on cancer care comes from Zhong et al, who evaluated breast cancer care within the single-payer Canadian health care system, where insurance status is not a barrier to accessing care. Specifically, Zhong et al evaluated patterns of immediate breast reconstruction (ie, reconstruction performed at the same time as mastectomy) for patients undergoing mastectomy to either treat breast cancer or prevent future breast cancer. Availability of breast reconstruction is an important component of multidisciplinary breast cancer care, given that reconstruction improves psychosocial quality-of-life outcomes such as body image. However, because breast reconstruction is inherently complex, is expensive, and does not influence classic cancer outcomes such as recurrence or survival, breast reconstruction may not be routinely available to patients in health care settings where scarce resources force rationing of care. Therefore, availability of breast reconstruction is an interesting marker of quality, one that may indicate a well-resourced medical system that can afford not simply to cure cancer but also to intervene to repair the physical and psychological damage done by cancer treatment. Zhong et al report that, among women residing in Ontario, Canada, undergoing mastectomy, the percentage of women undergoing immediate breast reconstruction increased from 8.9% in 2002 to 16.0% in 2011. This increase was driven exclusively by an increase in immediate breast reconstruction for women undergoing mastectomy for prophylactic risk reduction or to treat in situ disease; use of immediate breast reconstruction for women with invasive cancer did not change. In multivariable analysis, factors associated with higher odds of immediate reconstruction included higher neighborhood-level income and the patient not being an immigrant. These findings suggest that even within the Canadian system, where lack of insurance is not a barrier to care, sociodemographic factors still influence patterns of cancer care. This description of immediate breast reconstruction patterns in the Canadian health care system is particularly salient when viewed in comparison with patterns from similar, recently reported studies on women in the United States. For example, Jagsi et al recently reported trends in breast reconstruction for women in the United States with private insurance who underwent mastectomy to treat invasive breast cancer. From 1998 through 2007, the rate of immediate breast reconstruction in such women increased from 34.4% to 50% (P .001). In contrast, Zhong et al report that, for women with invasive breast cancer in Ontario, the rate of immediate breast reconstruction was only 7.1% and did not increase between 2002 and 2011 (P .5). These findings reveal a stark difference between Canada and the United States in the use of immediate breast reconstruction for invasive breast cancer. Potential explanations for this difference include both patient and structural factors. From a patient perspective, it should be noted that the mean age in the study by Zhong et al was 60.6 years, whereas the median age in the study by Jagsi et al was 52 years. Given that older women are less likely to have breast reconstruction, the difference in immediate reconstruction rates between the two populations would be attenuated, although not eliminated, if rates were age-standardized. Another patient factor could be cultural differences between Canada and the United States leading to different preferences for immediate breast reconstruction. However, much of the research suggesting a quality-of-life benefit from breast reconstruction was conducted outside the United States, so it is unlikely that the benefits of breast reconstruction and related preferences regarding this procedure would differ substantially between the United States and other countries. Another relevant patient factor is location of residence, particularly whether metropolitan or rural. Given that patients in rural areas typically must travel farther for care, it may be more difficult to coordinate the multiple provider visits needed to facilitate breast reconstruction for rural patients. However, only 16.6% of the population in the study by Zhong et al resided in rural areas, similar to the proportion of the US population that resides in rural areas (approximately 19%). Thus, it is unlikely that differences in the distribution of metropolitan versus rural residence could JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 32 NUMBER 20 JULY 1