Annals of Surgical Oncology

, Volume 26, Issue 1, pp 62–70 | Cite as

Regional Market Competition and the Use of Immediate Breast Reconstruction After Mastectomy

  • Jason D. WrightEmail author
  • Ling Chen
  • Melissa Accordino
  • Bret Taback
  • Cande V. Ananth
  • Alfred I. Neugut
  • Dawn L. Hershman
Reconstructive Oncology



Prior work has shown that the competitiveness of the market in which hospitals operate is associated with use of surgical procedures. This study examined the association between regional market competition and use of breast reconstruction for women with breast cancer and ductal carcinoma in situ undergoing mastectomy.


Women who underwent mastectomy from 2010 to 2011 recorded in the National Inpatient Sample were selected. The competitive market environment for each hospital in which patients were treated was estimated using the Herfindahl–Hirschman Index. Multivariable models were developed to examine the association between regional market competition and breast reconstruction, with adjustment for other clinical, demographic, and structural variables.


Immediate breast reconstruction was performed for 9902 (45%) of 22,011 women. The rate of immediate breast reconstruction was 34.5% at hospitals in non-competitive markets, 49% at hospitals in moderately competitive markets, and 56.4% at hospitals in highly competitive markets (P < 0.0001). In a multivariable model, women in moderately competitive markets were 24% (risk ratio [RR] 1.24; 95% confidence interval [CI] 1.10–1.41) more likely to undergo immediate breast reconstruction than women in noncompetitive markets, whereas those in competitive markets were 25% (RR 1.25; 95% CI 1.11–1.41) more likely to have reconstruction. Later year of treatment, higher census tract income level, and residence in an urban area were associated with an increased likelihood of reconstruction (P < 0.05 for all). In contrast, older age, non-white race, and non-commercial insurance were associated with a lower likelihood of reconstruction (P < 0.05 for all).


Patients who undergo mastectomy at hospitals in competitive markets are more likely to undergo immediate breast reconstruction.



Dr. Jason D. Wright (NCI R01CA169121-01A1) is a recipient of a grant from the National Cancer Institute. Dr. Dawn L. Hershman is the recipient of grants from the Breast Cancer Research Foundation, the Conquer Cancer Foundation, and the Susan Komen Foundation.


Dr. Jason D. Wright has served as a consultant for Tesaro and Clovis Oncology. Dr. Neugut has served as a consultant to Pfizer, Teva, Eisai, Otsuka, and United Biosource Corporation. He is on the medical advisory board of EHE, International. No other authors have any conflicts of interest or disclosures.

Supplementary material

10434_2018_6825_MOESM1_ESM.docx (28 kb)
Supplementary material 1 (DOCX 28 kb)


  1. 1.
    Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. 2000;106:1014–25; discussion 1026–1027.Google Scholar
  2. 2.
    Atisha D, Alderman AK, Lowery JC, Kuhn LE, Davis J, Wilkins EG. Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study. Ann Surg. 2008;247:1019–28.CrossRefGoogle Scholar
  3. 3.
    Rowland JH, Desmond KA, Meyerowitz BE, Belin TR, Wyatt GE, Ganz PA. Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst. 2000;92:1422–9.CrossRefGoogle Scholar
  4. 4.
    Al-Ghazal SK, Sully L, Fallowfield L, Blamey RW. The psychological impact of immediate rather than delayed breast reconstruction. Eur J Surg Oncol. 2000;26:17–9.CrossRefGoogle Scholar
  5. 5.
    Malin JL, Schneider EC, Epstein AM, Adams J, Emanuel EJ, Kahn KL. Results of the National Initiative for Cancer Care Quality: how can we improve the quality of cancer care in the United States? J Clin Oncol. 2006;24:626–34.CrossRefGoogle Scholar
  6. 6.
    Ilonzo N, Tsang A, Tsantes S, Estabrook A, Thu Ma AM. Breast reconstruction after mastectomy: a ten-year analysis of trends and immediate postoperative outcomes. Breast. 2017;32:7–12.CrossRefGoogle Scholar
  7. 7.
    Jagsi R, Jiang J, Momoh AO, et al. Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States. J Clin Oncol. 2014;32:919–26.CrossRefGoogle Scholar
  8. 8.
    8. Hershman DL, Richards CA, Kalinsky K, et al. Influence of health insurance, hospital factors, and physician volume on receipt of immediate post-mastectomy reconstruction in women with invasive and non-invasive breast cancer. Breast Cancer Res Treat. 2012;136:535–45.CrossRefGoogle Scholar
  9. 9.
    Wright JD, Tergas AI, Hou JY, et al. Effect of regional hospital competition and hospital financial status on the use of robotic-assisted surgery. JAMA Surg. 2016 151:612–620.CrossRefGoogle Scholar
  10. 10.
    Dor A, Koroukian S, Xu F, Stulberg J, Delaney C, Cooper G. Pricing of surgeries for colon cancer: patient severity and market factors. Cancer. 2012;118:5741–8.CrossRefGoogle Scholar
  11. 11.
    Sethi RK, Henry AJ, Hevelone ND, Lipsitz SR, Belkin M, Nguyen LL. Impact of hospital market competition on endovascular aneurysm repair adoption and outcomes. J Vasc Surg. 2013;58:596–606.CrossRefGoogle Scholar
  12. 12.
    Richards CA, Rundle AG, Wright JD, Hershman DL. Association between hospital financial distress and immediate breast reconstruction surgery after mastectomy among women with ductal carcinoma in situ. JAMA Surg. 2017 153:344–351.CrossRefGoogle Scholar
  13. 13.
    Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP), 2007–2009. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved 26 January 2014 at
  14. 14.
    HCUP Hospital Market Structure Files. Retrieved 5 January 2015 at
  15. 15.
    Wong HS, Zhan, C., Mutter, R. Do different measures of hospital competion matter in empirical investigations of hospital behavior? Rev Industr Organ. 2005;26:61–87.Google Scholar
  16. 16.
    Federal Trade Commission; Department of Justice. Horizonal Merger Guidelines. 8 April 2015 at
  17. 17.
    Baker LC, Bundorf MK, Royalty AB, Levin Z. Physician practice competition and prices paid by private insurers for office visits. JAMA. 2014;312:1653–62.CrossRefGoogle Scholar
  18. 18.
    Cutler DM, Scott Morton F. Hospitals, market share, and consolidation. JAMA. 2013;310:1964–70.CrossRefGoogle Scholar
  19. 19.
    Aggarwal A, Lewis D, Mason M, Purushotham A, Sullivan R, van der Meulen J. Effect of patient choice and hospital competition on service configuration and technology adoption within cancer surgery: a national, population-based study. Lancet Oncol. 2017;18:1445–53.CrossRefGoogle Scholar
  20. 20.
    Cerullo M, Chen SY, Dillhoff M, Schmidt C, Canner JK, Pawlik TM. Association of Hospital Market Concentration With Costs of Complex Hepatopancreaticobiliary Surgery. JAMA Surg. 2017;152:e172158.CrossRefGoogle Scholar
  21. 21.
    Haley DR, Zhao M, Spaulding A, Hamadi H, Xu J, Yeomans K. The influence of hospital market competition on patient mortality and total performance score. Health Care Manage Frederick. 2016;35:266–76.Google Scholar
  22. 22.
    Glick DB, Wroblewski K, Apfelbaum S, Dauber B, Woo J, Tung A. The relationship between competition and quality in procedural cardiac care. Anesth Analg. 2015;120:220–9.CrossRefGoogle Scholar
  23. 23.
    Maeda JL, LoSasso AT. Effect of market competition on hospital performance for heart failure. Am J Manage Care. 2011;17:816–22.Google Scholar
  24. 24.
    Chang DC, Shiozawa A, Nguyen LL, et al. Cost of inpatient care and its association with hospital competition. J Am Coll Surg. 2011;212:12–9.CrossRefGoogle Scholar
  25. 25.
    Robinson JC, Luft HS. The impact of hospital market structure on patient volume, average length of stay, and the cost of care. J Health Econ. 1985;4:333–56.CrossRefGoogle Scholar
  26. 26.
    Robinson JC, Luft HS. Competition and the cost of hospital care, 1972 to 1982. JAMA. 1987;257:3241–5.CrossRefGoogle Scholar
  27. 27.
    Yang RL, Newman AS, Lin IC, et al. Trends in immediate breast reconstruction across insurance groups after enactment of breast cancer legislation. Cancer. 2013;119:2462–8.CrossRefGoogle Scholar
  28. 28.
    Kruper L, Xu X, Henderson K, Bernstein L. Disparities in reconstruction rates after mastectomy for ductal carcinoma in situ (DCIS): patterns of care and factors associated with the use of breast reconstruction for DCIS compared with invasive cancer. Ann Surg Oncol. 2011;18:3210–9.CrossRefGoogle Scholar
  29. 29.
    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; discussion 704–705.Google Scholar
  30. 30.
    Xie Y, Tang Y, Wehby GL. Federal health coverage mandates and health care utilization: the case of the Women’s Health and Cancer Rights Act and use of breast reconstruction surgery. J Womens Health Larchmt. 2015;24:655–62.CrossRefGoogle Scholar
  31. 31.
    Fu R, Baser, O, Kurlansky, P, Means, J, Rohde, C. Abstract 31: The Impact of the 2010 NY State Breast Cancer Provider Discussion Law on Breast Reconstruction Rates: An Analysis of 42,137 Patients From the NY SPARCS Database. Plast Reconstr Surg Glob Open. 2017;5(4 Suppl):25.CrossRefGoogle Scholar
  32. 32.
    Bauder AR, Gross CP, Killelea BK, Butler PD, Kovach SJ, Fox JP. The relationship between geographic access to plastic surgeons and breast reconstruction rates among women undergoing mastectomy for cancer. Ann Plast Surg. 2017;78:324–9.CrossRefGoogle Scholar
  33. 33.
    Butler PD, Familusi O, Serletti JM, Fox JP. Influence of race, insurance status, and geographic access to plastic surgeons on immediate breast reconstruction rates. Am J Surg. 2017 215:987–994.CrossRefGoogle Scholar
  34. 34.
    Bauder AR, Sarik JR, Butler PD, et al. Geographic variation in access to plastic surgeons. Ann Plast Surg. 2016;76:238–43.CrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2018

Authors and Affiliations

  • Jason D. Wright
    • 1
    • 2
    • 3
    Email author
  • Ling Chen
    • 1
  • Melissa Accordino
    • 1
    • 2
    • 3
  • Bret Taback
    • 1
  • Cande V. Ananth
    • 4
  • Alfred I. Neugut
    • 1
    • 2
    • 3
    • 4
  • Dawn L. Hershman
    • 1
    • 2
    • 3
    • 4
  1. 1.Division of Gynecologic Oncology, Department of Obstetrics and GynecologyColumbia University College of Physicians and SurgeonsNew YorkUSA
  2. 2.Herbert Irving Comprehensive Cancer CenterColumbia University College of Physicians and SurgeonsNew YorkUSA
  3. 3.New York Presbyterian HospitalNew YorkUSA
  4. 4.Mailman School of Public HealthColumbia UniversityNew YorkUSA

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