Disparities in postmastectomy breast reconstruction

In a new study examining disparities in postmastectomy breast reconstruction, researchers at Brigham and Women's Hospital (BWH) and Dana-Farber Cancer Institute (DFCI) in Boston, Mass., concluded that lack of patient-provider discussion may contribute to socioeconomic, age and race-related inconsistencies in the use of breast reconstruction after mastectomy.

However, the study also found that reconstruction was more likely to occur after the surgeon discussed options with the patient, suggesting that efforts are required to increase and improve these conversations. The full study appears in the April issue of the Journal of the American College of Surgeons.

Breast reconstructive surgery is an expensive elective procedure, but for many women it is a vital component of surgical care for breast cancer. The choice to have breast reconstruction is a complex decision that is influenced by access to care, patient preference and the provider's interaction with the patient.

“Patient preferences should be respected, but an informative discussion of reconstruction is required to help patients understand and weigh the risks and benefits of this procedure,” said Caprice C. Greenberg, MD, Instructor of Surgery in the Center for Surgery and Public Health at BWH and the Center for Outcomes and Policy Research at DFCI. “We learned that physicians need to improve communications with patients and whenever possible, universally address the issue of reconstruction with all women undergoing a mastectomy, regardless of age, race or socioeconomic status.”

Using the National Initiative on Cancer Care Quality database, researchers evaluated 626 patients who underwent mastectomy for breast cancer. The data had been collected in a study commissioned by the American Society of Clinical Oncology (ASCO) and undertaken by researchers at the Rand Corporation and the Harvard School of Public Health. Researchers reviewed data collected via survey and chart review approximately four years after diagnosis of breast cancer. Of these patients, 253 (40.4 percent) received breast reconstruction, and 249 (39.8 percent) had medical records documenting the occurrence of a discussion about this option.

“The data from the NICCQ study are continuing to reveal important opportunities to improve cancer care,” said ASCO President Nancy Davidson, MD, professor of oncology and breast cancer research chair at the Sidney Kimmel Cancer Center at Johns Hopkins University in Baltimore. “As oncologists, we need to be sure that we are thoroughly communicating with patients about all of their options for care.”

Approximately 70 percent of patients who had a documented discussion about breast reconstruction with their provider underwent the procedure. However, researchers found that increasing age and lower levels of education were associated with lower rates of a documented discussion. Hispanic patients, patients born outside the United States and those whose primary language was not English were less likely to actually receive reconstruction once the procedure was discussed

Based on these results, the study authors suggest that physicians should systematically address the issue of reconstruction with all patients undergoing mastectomy, including why she is or is not a candidate. They also recommend optimizing physician-patient discussions by using interpreters and appropriate educational materials to ensure an informative conversation regardless of primary language, ethnicity, or education level.

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