Annals of Surgical Oncology

, Volume 20, Issue 2, pp 399–406

Racial Disparities in Immediate Breast Reconstruction After Mastectomy: Impact of State and Federal Health Policy Changes

  • Rachel L. Yang
  • Andrew S. Newman
  • Caroline E. Reinke
  • Ines C. Lin
  • Giorgos C. Karakousis
  • Brian J. Czerniecki
  • Liza C. Wu
  • Rachel R. Kelz
Healthcare Policy and Outcomes



Federal and Pennsylvania state policies instituted in the late 1990s were designed to improve access to postmastectomy breast reconstruction. We sought to evaluate the impact of these policy changes on access to care among racial minorities.


Mastectomy patients ≥18 years old were identified in the Pennsylvania Health Care Cost Containment Council inpatient database (1994–2004) and classified by immediate breast reconstruction (IBR) status. Rates of IBR were calculated by patient characteristics and year. Patients were stratified by race before (1994–1997) and after (2001–2004) policy changes, and relative odds of IBR were estimated by univariate and multivariate logistic regression analyses with adjustment for known confounders.


Overall rates of IBR were significantly higher in the time period after policy change compared to before policy change (18.5 vs. 32.7 %, p < 0.01). White, black, and Asian patients all saw a significant rise in rates of IBR. However, after adjustment for potential confounders, black patients, Asian patients, and those of mixed or other races all remained less likely to undergo IBR when compared to white patients after policy changes (odds ratio [OR] 0.66, 95 % confidence interval [CI] 0.55–0.80; OR 0.30, 95 % CI 0.18–0.49; OR 0.29, 95 % CI 0.16–0.51, respectively).


Rates of IBR increased across all racial groups after policy changes. However, not all races were affected equally, and thus disparities remained. Future studies are needed to investigate the role of other factors, including cultural preferences in utilization of IBR that might explain residual disparities.


  1. 1.
    National Cancer Institute. SEER stat fact sheets: breast. Accessed 14 Jan 2012.
  2. 2.
    Stevens LA, McGrath MH, Druss RG, Kister SJ, Gump FE, Forde KA. The psychological impact of immediate breast reconstruction for women with early breast cancer. Plast Reconstr Surg. 1984;73:619–28.PubMedCrossRefGoogle Scholar
  3. 3.
    Schain WS. Breast reconstruction. Update of psychosocial and pragmatic concerns. Cancer. 1991;68:1170–5.PubMedCrossRefGoogle Scholar
  4. 4.
    Downes KJ, Glatt BS, Kanchwala SK, et al. Skin-sparing mastectomy and immediate reconstruction is an acceptable treatment option for patients with high-risk breast carcinoma. Cancer. 2005;103:906–13.PubMedCrossRefGoogle Scholar
  5. 5.
    Polednak AP. Geographic variation in postmastectomy breast reconstruction rates. Plast Reconstr Surg. 2000;106:298–301.PubMedCrossRefGoogle Scholar
  6. 6.
    DeSantis C, Siegel R, Bandi P, Jemal A. Breast cancer statistics, 2011. CA Cancer J Clin. 2011;61:408–18.CrossRefGoogle Scholar
  7. 7.
    Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Accessed 15 July 2011.
  8. 8.
    Wilkins EG, Alderman AK. Breast reconstruction practices in North America: current trends and future priorities. Semin Plast Surg. 2004;18:149–55.PubMedCrossRefGoogle Scholar
  9. 9.
    Pennsylvania Breast Cancer Coalition. Legislative victories. Accessed 2 Nov 2011.
  10. 10.
    Morrow M, Mujahid M, Lantz PM, et al. Correlates of breast reconstruction: results from a population-based study. Cancer. 2005;104:2340–6.PubMedCrossRefGoogle Scholar
  11. 11.
    Alderman AK, McMahon L Jr, Wilkins EG. The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors. Plast Reconstr Surg. 2003;111:695–703.PubMedCrossRefGoogle Scholar
  12. 12.
    Pennsylvania Health Care Cost Containment Council. PHC4 FYI—PHC4 “Special Requests”: a valuable investment. Accessed 20 Dec 2011.
  13. 13.
    Pennsylvania Health Care Cost Containment Council. Pennsylvania uniform claims and billing form reporting manual. Accessed 10 Dec 2011.
  14. 14.
    Southern DA, Quan H, Ghali WA. Comparison of the Elixhauser and Charlson/Deyo methods of comorbidity measurement in administrative data. Med Care. 2004;42:355–60.PubMedCrossRefGoogle Scholar
  15. 15.
    Clegg LX, Li FP, Hankey BF, Chu K, Edwards BK. Cancer survival among U.S. whites and minorities: a SEER (Surveillance, Epidemiology, and End Results) Program population-based study. Arch Intern Med. 2002;162:1985–93.PubMedCrossRefGoogle Scholar
  16. 16.
    Eley JW, Hill HA, Chen VW, et al. Racial differences in survival from breast cancer: results of the National Cancer Institute Black/White Cancer Survival Study. JAMA. 1994;272:947–54.PubMedCrossRefGoogle Scholar
  17. 17.
    Ragland KE, Selvin S, Merrill DW. Black–white differences in stage-specific cancer survival: analysis of seven selected sites. Am J Epidemiol. 1991;133:672–82.PubMedGoogle Scholar
  18. 18.
    Bassett MT, Krieger N. Social class and black–white differences in breast cancer survival. Am J Public Health. 1986;76:1400–3.PubMedCrossRefGoogle Scholar
  19. 19.
    Dayal HH, Power RN, Chiu C. Race and socio-economic status in survival from breast cancer. J Chronic Dis. 1982;35:675–83.PubMedCrossRefGoogle Scholar
  20. 20.
    U.S. Department of Health and Human Services, Office of Minority Health. Asian American/Pacific Islander profile. Accessed 7 Feb 2012.
  21. 21.
    Finlayson CA, MacDermott TA, Arya J. Can specific preoperative counseling increase the likelihood a woman will choose postmastectomy breast reconstruction? Am J Surg. 2001;182:649–53.PubMedCrossRefGoogle Scholar
  22. 22.
    Katipamula R, Degnim AC, Hoskin T, et al. Trends in mastectomy rates at the Mayo Clinic Rochester: effect of surgical year and preoperative magnetic resonance imaging. J Clin Oncol. 2009;27:4082–8.PubMedCrossRefGoogle Scholar
  23. 23.
    McGuire KP, Santillan AA, Kaur P, et al. Are mastectomies on the rise? A 13-year trend analysis of the selection of mastectomy versus breast conservation therapy in 5865 patients. Ann Surg Oncol. 2009;16:2682–90.PubMedCrossRefGoogle Scholar
  24. 24.
    Bagley FH. The role of magnetic resonance imaging mammography in the surgical management of the index breast cancer. Arch Surg. 2004;139:380–3.PubMedCrossRefGoogle Scholar
  25. 25.
    Bilimoria KY, Cambic A, Hansen NM, Bethke KP. Evaluating the impact of preoperative breast magnetic resonance imaging on the surgical management of newly diagnosed breast cancers. Arch Surg. 2007;142:441–7.PubMedCrossRefGoogle Scholar
  26. 26.
    Chan A, Pintilie M, Vallis K, Girourd C, Goss P. Breast cancer in women < or =35 years: review of 1002 cases from a single institution. Ann Oncol. 2000;11:1255–62.PubMedCrossRefGoogle Scholar
  27. 27.
    Champaneria MC, Wong WW, Hill ME, Gupta SC. The evolution of breast reconstruction: a historical perspective. World J Surg. 2012;36:730–42.PubMedCrossRefGoogle Scholar
  28. 28.
    Fancher TT, Palesty JA, Thomas R, et al. A woman’s influence to choose mastectomy as treatment for breast cancer. J Surg Res. 2009;153:128–31.PubMedCrossRefGoogle Scholar
  29. 29.
    Bian J, Krontiras H, Allison J. Outpatient mastectomy and breast reconstructive surgery. Ann Surg Oncol. 2008;15:1032–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Guyomard V, Leinster S, Wilkinson M. Systematic review of studies of patients’ satisfaction with breast reconstruction after mastectomy. Breast. 2007;16:547–67.PubMedCrossRefGoogle Scholar
  31. 31.
    Malmgren JA, Parikh J, Atwood MK, Kaplan HG. Impact of mammography detection on the course of breast cancer in women aged 40–49 years. Radiology. 2012;262:797–806.PubMedCrossRefGoogle Scholar
  32. 32.
    Selber JC, Kurichi JE, Vega SJ, Sonnad SS, Serletti JM. Risk factors and complications in free TRAM flap breast reconstruction. Ann Plast Surg. 2006;56:492–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Mehrara BJ, Santoro TD, Arcilla E, Watson JP, Shaw WW, Da Lio AL. Complications after microvascular breast reconstruction: experience with 1195 flaps. Plast Reconstr Surg. 2006;118:1100–1.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2012

Authors and Affiliations

  • Rachel L. Yang
    • 1
  • Andrew S. Newman
    • 1
  • Caroline E. Reinke
    • 1
  • Ines C. Lin
    • 1
  • Giorgos C. Karakousis
    • 1
  • Brian J. Czerniecki
    • 1
  • Liza C. Wu
    • 1
  • Rachel R. Kelz
    • 1
  1. 1.Department of SurgeryHospital of the University of PennsylvaniaPhiladelphiaUSA

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