Abstract
INTRODUCTION:
Disparities in access to reconstructive surgery after breast cancer have been reported. We aim to evaluate demographic and socioeconomic factors influencing type of autologous breast reconstruction in Florida.
METHODS:
We queried the Florida Inpatient Discharge Dataset to evaluate disparities in type of autologous breast reconstructive surgery between January 1, 2013, and September 30, 2017. Patients 18 years of age or older were included. Women younger than 65 years old on Medicare were excluded. Patients were categorized into three groups according to type of autologous reconstruction: latissimus dorsi pedicled flap (pedicled flap), free flap, or pedicled flap with implant (combined flap). Demographic and socioeconomic variables were evaluated. 𝜒2 and Mann–Whitney tests were used to estimate statistical significance. A multivariate logistic regression was performed to find independent associations.
RESULTS:
Our results showed higher odds of reconstruction with free flap in Hispanic patients (odds ratio (OR), 1.66; 95% CI, 1.32–2.09; P < 0.0001) and patients with comorbidities (OR, 1.45; 95% CI, 1.23–1.71; P < 0.0001). However, patients treated in Central and South Florida were less likely to undergo free flap than combined and pedicled flap reconstructions compared with those treated in North Florida (P < 0.05). Patients insured by Medicaid and Medicare were less likely to undergo free flap than combined or pedicled flap reconstruction compared to patients with private insurance (P < 0.05).
CONCLUSIONS:
Our study identified that race, region, insurance, and comorbidity are factors associated with type of autologous breast reconstruction in Florida.
Introduction
Breast reconstruction is a surgical procedure that has decreased psychological stress and improved quality of life of breast cancer survivors [1,2]. Two types of breast reconstruction are continuously offered to patients with breast cancer: autologous versus implant reconstruction. Although implant reconstruction is the most frequent procedure, women who undergo autologous reconstruction have reported higher rates of satisfaction [3].
Autologous breast reconstruction has been suggested to have several advantages compared to implants. While implant reconstruction carries major disadvantages, including capsular contracture and risk of device failure, autologous reconstruction provides volume and reconstruction of skin defect without the risk of rejection inherent to use of exogenous material. However, autologous reconstruction does have disadvantages, such as donor site morbidity and a longer, more complex procedure [4].
While latissimus dorsi pedicled flap (pedicled flap) and abdomen, gluteal, or thigh-based free flaps are the most commonly used types of autologous reconstruction, the combination of pedicled flap and implant (combined flap) has also been reported [5,6]. This combined flap procedure is better suited and indicated for immediate reconstruction in patients undergoing salvage mastectomy for failed breast reconstruction therapy [5] or delayed breast reconstructions after mastectomy and radiation therapy, especially when the deformity involves the lower half of the breast [6].
Although autologous breast reconstruction is the preferred procedure after mastectomy due to its benefits, the decision to perform a specific type of reconstruction is determined based on patient condition and disease characteristics [7]. However, health disparities have also been reported to influence the decision [8–11]. In this context, demographic and socioeconomic factors including race, income, and insurance have been identified to predict breast reconstruction [10,12,13]. In addition, a previous analysis of disparities in access to breast reconstruction identified that patients treated in facilities specialized in integrated cancer and academic/research programs were more likely to undergo breast reconstruction compared with those in community cancer programs [11]. In our previous study, we have found that health disparities remain when accessing to the type of breast reconstruction in Florida [14]. We observed that African American and Hispanic or Latino patients were less likely to undergo implant breast reconstruction when compared to Caucasians [14]. Understanding whether these factors determine the type of autologous breast reconstruction performed may help to identify inequity in the health care system and suggest possible causes that support the creation of solutions to decrease disparities. In this study, we aim to evaluate demographic and socioeconomic factors influencing type of autologous breast reconstruction in Florida.
Methods
Data source
We analyzed the Florida Inpatient Discharge Dataset, which consists of the administrative deidentified patient data from all acute care hospitals in the state of Florida, from January 1, 2013, to September 30, 2017.
Female patients 18 years of age or older, diagnosed with breast cancer, who underwent breast reconstruction using a combined, free, or pedicled flap were included. Women under the age of 65 on Medicare were excluded.
Dependent variables
The dependent variable for the analysis was whether the patient had a combined, free, or pedicled flap reconstruction. The surgical procedures were defined by ICD-9 and ICD-10 codes.
Independent variables
Covariates included in the analysis were the following patient characteristics: age, race/ethnicity, region, insurance payer type, and comorbidities. Race was categorized as white, African American, and Hispanic or Latino. Insurance payer type comprised Medicare (including Medicare Managed Care Patient), Medicaid (including Medicaid Managed Care Patient), commercial (private), or other (including self-pay or non-payment). Patient regional locations were based upon the seven regions of the Florida Department of Transportation, and indications of rurality were defined by the Florida Department of Health [15]. In addition, patient regions were grouped into North, South, and Central to allow an acceptable statistical power for the multivariable models. The Elixhauser Score was used to categorize presence of patient comorbidities [16].
Analysis
Descriptive analysis was conducted to obtain the frequency and percentage or median and range. Pearson 𝜒2 and Kruskal–Wallis tests compared categorical and continuous variables, respectively. A multivariable logistic regression was used to show strength of the association of each patient characteristic in performing a combined, free, or pedicled flap for breast reconstruction. All tests of significance were 2-sided, and P values were reported. The level of statistical significance was set at 𝛼 less than 0.05. Analyses were preformed using SAS, version 9.4 (SAS Institute Inc).
Results
A total of 3,177 patients underwent postmastectomy breast reconstruction, with most patients receiving free flap (1,636 [51.5%]). Significant differences were found between all groups (Table 1). The mean (range) age of the cohort was 54 (20–93) years. A total of 2,016 (65.6%) patients were white, 457 (14.9%) were black, and 602 (19.6%) were Hispanic. Most of the patients lived in South Florida (1,420 [46.0%]) and had private insurance (2,201 [69.3%]). At least one or more comorbidities were found in 1,511 (47.6%) patients evaluated with the Elixhauser Score.
Surgical population descriptive statistics for breast cancer patients
Surgical population descriptive statistics for breast cancer patients
Statistical tests of difference: 1 Kruskal Wallis, 2 Chi-Square. Statistics reported: Continuous variables were summarized with the median (range).
After performing multivariate analysis, we found that age, race, patient region, insurance payer, and comorbidities were factors associated with the type of flap received in breast reconstruction (Table 2). Older patients had lower odds of undergoing combined (OR, 0.82; 95% CI, 0.71–0.95; P = 0.0075) or free flap reconstructions (OR, 0.78; 95% CI, 0.67–0.91; P = 0.0015) compared with pedicled flaps. Hispanic patients had higher odds of undergoing free flap compared to combined (OR, 1.66; 95% CI, 1.32–2.09; P < 0.0001) and pedicle flap (OR, 1.41; 95% CI, 1.02–1.95; P = 0.0358). Moreover, patients treated in Central and South Florida were less likely to undergo free flap than combined and pedicled flap reconstructions compared with those treated in North Florida (P < 0.05). Interestingly, patients with Medicare or Medicaid had significantly lower odds than those with private insurance of undergoing free flap reconstruction compared with combined and pedicle flap (P < 0.005). Regarding comorbidities, we observed that patients with comorbidities were more likely to undergo a free flap reconstruction compared with combined (OR, 1.45; 95% CI, 1.23–1.71; P < 0.0001) or pedicled flap reconstruction (OR, 3.27; 95% CI, 2.55–4.18; P < 0.0001). Furthermore, patients with comorbidities had higher odds of undergoing combined flap reconstruction compared with pedicled flap (OR, 2.45; 95% CI, 1.90–3.15; P < 0.0001).
Multivariate logistic regression models between surgical groups
CI: Confidence Interval, OR: Odds Ratio.
Disparities in access to autologous breast reconstruction in the US have been reported before [10,17–19]. However, none of these studies were conducted in populations with a high number of Hispanic patients, such as in the state of Florida. In our previous study, we observed that minorities were more likely to undergo an autologous breast reconstruction compared with implant breast reconstruction [14]. We decided to evaluate whether disparities in demographic and socioeconomic factors, such as age, race, region, type of insurance, and presence of comorbidities, exist in the type of autologous breast reconstruction patients with breast cancer undergo in Florida.
For certain patient subsets, autologous breast reconstruction is the preferred method [20]; however, minimal consensus has been established regarding the preference to perform a specific type of autologous breast reconstruction. Among the options for free flap, transverse rectus abdominis musculocutaneous and deep inferior epigastric artery perforator free flaps are considered good options for autologous breast reconstruction [21]. Pedicled flaps are also an effective alternative when performing breast reconstruction surgery due ease of harvesting, though when required higher volumes of breast reconstruction are required or the breast has been previously irradiated, a combined flap may be considered [5,6,22]. The final decision of the type of recontruction should be patient-centered based on clinical evaluation.
Interestingly, we found that certain demographic and socioeconomic factors determined the type of autologous reconstruction received by patients with breast cancer in Florida. In our study, free flap breast reconstruction was more likely to be performed in Hispanic patients, those treated in North Florida, those with private insurance, and those with comorbidities compared with pedicled and combined flaps. The differences by region may be explained by the differences in income. In our previous study, we have reported that patients with an estimated income >$63,000 were found to be more likely to undergo breast reconstruction than patients with income less than $38,000 [10]. Regarding race, our results are consistent with Offodile et al., [18] who observed that Hispanic patients had lower odds of undergoing breast reconstruction compared to white patients. When comparing the type of reconstruction, they found that Hispanic patients were less likely to receive implant-based reconstruction and more likely to undergo free flap reconstruction [18]. These findings may have been related to patient preference, lack of insurance coverage, socioeconomic factors, language, and cultural preferences [17,18,23,24]. Medicare and Medicaid are the two government programs that provide health coverage in the USA. Medicare provides coverage for patients who are 65 or more years old and those with any disability independently of the age, while Medicaid provides health coverage for individuals with low income. Our findings aligned with Chouairi’s study [25]. It has been reported that patients with Medicare and Medicaid are more likely to receive an expander or implant instead of an autologous reconstruction [25]. This may be related with the higher costs that are needed to perform an autologous reconstruction compared with implant-based reconstruction [26]. Regarding the presence of comorbidities, Black et al. [27]. compared abdominally-based free flap and pedicled flap with immediate fat transfer. While they found that pedicled flap reconstruction had a shorter operation time and length of hospital stay compared with abdominally-based free flap, they did not find a difference in adverse effects between the two groups [27]. Therefore, they suggested that pedicled flap reconstruction could be offered to patients with comorbidities who require a shorter operation time.
Our study has some limitations. The fidelity of the information may be compromised by errors in the collection of data inherent to database analysis. Also, the Florida Inpatient Discharge Dataset registers every outpatient visit as a different case, which may affect the number of cases. In addition, we would have liked to evaluate how the clinical history of the patients such as BMI, breast cancer stage, and therapy received influenced the type of reconstruction, but it was not possible to extract the necessary data from the database. Despite these limitations, this study is of value given that it identifies disparities in the type of reconstruction undergone by patients with breast cancer in Florida.
Conclusion
Our study found disparities in race, region, insurance, and comorbidity influence regarding type of autologous breast reconstruction undergone by patients with breast cancer in the state of Florida. Further studies that evaluate the origin of these disparities will allow us to better understand this association.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Institutional Review Board: 18-008576) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
Financial disclosure statement
This study was supported in part by the Mayo Clinic Center for Individualized Medicine and the Mayo Clinic Center for Regenerative Medicine, and by the Plastic Surgery Foundation.
Conflict of interest
All authors report no conflict of interests in this study.