Disparities in Nipple Sparing Mastectomy: Lessons learned from 1,202 Mastectomies within a Single Health System
Tanvee Singh, Jenna Bekeny, BA.
Georgetown University School of Medicine, Washington, DC, USA.
BACKGROUND: Nipple sparing mastectomies (NSM) offer superior aesthetic and patient-reported outcomes afforded by retention of the nipple areolar complex (NAC). Disparities in reconstructive care are pervasive and have been well documented for breast cancer patients. Yet, no study to date has specifically evaluated the disparities that exist with regard to mastectomy type, specifically, NSM. The objective of this study is to examine multilevel - patient, disease, provider, hospital system - factors related to the inequitable distribution of NSM to certain patient subgroups. METHODS: Patients undergoing mastectomy for breast cancer between 2014 to 2018 across 10 hospitals in a single healthcare system were retrospectively reviewed. Our cohort includes patients treated at academic, urban, community, and rural hospitals. Demographic information included race, insurance type, location of hospital, median income by zip code, and disease characteristics. Patients were categorized by mastectomy type - NSM or other (OM). Provider level and systems level variables, such as hospital of operation and insurance status, were determined. Bivariate analysis was used to identify variables for inclusion in a backward multivariable model. RESULTS: A cohort of 1,202 mastectomy patients was identified, with 388 receiving NSM. The average age was 55.8 years (NSM: 48.8, OM: 59.1, p<0.001). 39.8% of white patients (n=242) and 20.0% of African American patients (n=88) received NSM (p<0.001). 36.9% of patients with commercial insurance (n=363), 14.1% with Medicaid (n=13), and 9.2% with Medicare (n=10) received NSM (p<0.001). 41.4% (n=359) of patients treated at academic centers and 6.9% (n=21) of patients treated at community centers received NSM (p<0.001). In the NSM group, 93.8% of surgeons were female (n=364), while 83.2% were female in the OM group (n=677) (p=<0.001). Race congruence between patient and provider was present in 55.4% of NSM cases, but only 42.0% of OM cases (p=<0.001). In the multivariate model, male surgeons were related to decreased odds of NSM (89.0%, CI 0.033-0.37), and age, mastectomy weight, income by Zip code, insurance, cancer stage, reconstruction performed, hospital and hospital type were significantly related to disparities in NSM. CONCLUSIONS: This study utilizes a large multi-institutional database to highlight the critical disparities in NSM that exist at the patient, disease, provider, and system levels. Our analyses indicate that patient’s access to resources, and specific qualities of the provider and hospital system contribute to this disparity. These findings provide an impetus for multilevel interventions to close the gap and ensure that all patients have equitable access to NSM.
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