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Original Investigation |

Access to Breast Reconstruction After Mastectomy and Patient Perspectives on Reconstruction Decision Making ONLINE FIRST

Monica Morrow, MD1; Yun Li, PhD2; Amy K. Alderman, MD3; Reshma Jagsi, MD, DPhil4; Ann S. Hamilton, PhD5; John J. Graff, PhD6; Sarah T. Hawley, PhD7,8,9; Steven J. Katz, MD, MPH10
[+] Author Affiliations
1Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
2School of Public Health, University of Michigan, Ann Arbor
3The Swan Center for Plastic Surgery, Alpharetta, Georgia
4Department of Radiation Oncology, University of Michigan, Ann Arbor
5Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles
6Department of Radiation Oncology, Robert Wood Johnson Medical School, New Brunswick, New Jersey
7Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
8Medical School, University of Michigan, Ann Arbor
9School of Public Health, University of Michigan, Ann Arbor
10Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
JAMA Surg. Published online August 20, 2014. doi:10.1001/jamasurg.2014.548
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Importance  Most women undergoing mastectomy for breast cancer do not undergo breast reconstruction.

Objective  To examine correlates of breast reconstruction after mastectomy and to determine if a significant unmet need for reconstruction exists.

Design, Setting, and Participants  We used Surveillance, Epidemiology, and End Results registries from Los Angeles, California, and Detroit, Michigan, for rapid case ascertainment to identify a sample of women aged 20 to 79 years diagnosed as having ductal carcinoma in situ or stages I to III invasive breast cancer. Black and Latina women were oversampled to ensure adequate representation of racial/ethnic minorities. Eligible participants were able to complete a survey in English or Spanish. Of 3252 women sent the initial survey a median of 9 months after diagnosis, 2290 completed it. Those who remained disease free were surveyed 4 years later to determine the frequency of immediate and delayed reconstruction and patient attitudes toward the procedure; 1536 completed the follow-up survey. The 485 who remained disease free at follow-up underwent analysis.

Exposures  Disease-free survival of breast cancer.

Main Outcomes and Measures  Breast reconstruction at any time after mastectomy and patient satisfaction with different aspects of the reconstruction decision-making process.

Results  Response rates in the initial and follow-up surveys were 73.1% and 67.7%, respectively (overall, 49.4%). Of 485 patients reporting mastectomy at the initial survey and remaining disease free, 24.8% underwent immediate and 16.8% underwent delayed reconstruction (total, 41.6%). Factors significantly associated with not undergoing reconstruction were black race (adjusted odds ratio [AOR], 2.16 [95% CI, 1.11-4.20]; P = .004), lower educational level (AOR, 4.49 [95% CI, 2.31-8.72]; P < .001), increased age (AOR in 10-year increments, 2.53 [95% CI, 1.77-3.61]; P < .001), major comorbidity (AOR, 2.27 [95% CI, 1.01-5.11]; P = .048), and chemotherapy (AOR, 1.82 [95% CI, 0.99-3.31]; P = .05). Only 13.3% of women were dissatisfied with the reconstruction decision-making process, but dissatisfaction was higher among nonwhite patients in the sample (AOR, 2.87 [95% CI, 1.27-6.51]; P = .03). The most common patient-reported reasons for not having reconstruction were the desire to avoid additional surgery (48.5%) and the belief that it was not important (33.8%), but 36.3% expressed fear of implants. Reasons for avoiding reconstruction and systems barriers to care varied by race; barriers were more common among nonwhite participants. Residual demand for reconstruction at 4 years was low, with only 30 of 263 who did not undergo reconstruction still considering the procedure.

Conclusions and Relevance  Reconstruction rates largely reflect patient demand; most patients are satisfied with the decision-making process about reconstruction. Specific approaches are needed to address lingering patient-level and system factors with a negative effect on reconstruction among minority women.

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SEER indicates Surveillance, Epidemiology, and End Results registry of the National Cancer Institute.

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