Access to Breast Reconstruction and Patient Perspectives on Decision Making
Published Date:Oct 2014
Source:JAMA Surg. 149(10):1015-1021.
Carcinoma, Ductal, Breast
Health Services Accessibility
Pubmed Central ID:PMC4732701
Funding:K05CA111340/CA/NCI NIH HHS/United States
R01 CA088370/CA/NCI NIH HHS/United States
K05 CA111340/CA/NCI NIH HHS/United States
P30 CA008748/CA/NCI NIH HHS/United States
R01 CA139014/CA/NCI NIH HHS/United States
U58 DP000807/DP/NCCDPHP CDC HHS/United States
R01CA109696/CA/NCI NIH HHS/United States
N01PC54404/CA/NCI NIH HHS/United States
R21CA122467/CA/NCI NIH HHS/United States
N01PC35145/CA/NCI NIH HHS/United States
R21 CA122467/CA/NCI NIH HHS/United States
N01PC35139/CA/NCI NIH HHS/United States
R01 CA109696/CA/NCI NIH HHS/United States
Most women having mastectomy for breast cancer treatment do not have breast reconstruction.
To examine correlates of reconstruction and determine if there is a significant unmet need for reconstruction.
Los Angeles and Detroit SEER registries utilized rapid case ascertainment to identify a sample of women diagnosed with breast cancer. Subjects were surveyed a median of 9mos post-diagnosis initially; those remaining disease-free were surveyed again at 4yrs to determine the frequency of immediate and delayed reconstruction, and patient attitudes toward the procedure.
Two metropolitan area population-based SEER registries were used to identify subjects; Latina/Black women were oversampled to ensure adequate minority representation.
Women age 20-79 with DCIS and stage 1-3 invasive carcinoma diagnosed between 6/05-2/07 were eligible if they could complete a questionnaire in English or Spanish. Initial survey was sent to 3252 women. 2290 completed it. 1536 completed the follow-up survey. The 485 undergoing initial mastectomy and remaining disease-free at follow-up are this report’s subject.
Participants were surveyed a mean of 9mos and again at 50mos post-diagnosis. Latina and Black women were oversampled.
Response rates in the initial and follow-up surveys were 73% and 68%, respectively (overall, 50%). Of 485 patients reporting mastectomy at initial survey and remaining disease-free, 41.6% had reconstruction—24.8% immediate, 16.8% delayed. Factors significantly associated with not receiving reconstruction were Black race, lower education level, older age, major co-morbidity, and receipt of chemotherapy. Only 13% of women were dissatisfied with reconstruction decision making, but dissatisfaction was higher among non-whites in the sample(p=.032). The most common patient-reported reasons for not having reconstruction were the desire to avoid additional surgery and feeling that it was not important, but 36% expressed fear of implants. Reasons for avoiding reconstruction and systems barriers to care varied by race; barriers were more common among non-whites. Residual demand for reconstruction at 4yrs was low, with only 30/263 non-reconstructed respondents still considering the procedure.
Reconstruction rates largely reflect patient demand; most patients are satisfied with reconstruction decision making. Specific approaches are needed to address lingering patient-level and systems factors negatively impacting reconstruction use in minority women.
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