A Claims-Based Study of Baseline Comorbidities as a Predictive Factor for Breast Reconstruction After Mastectomy in Geriatric Women
Hope Xu, BA, Jenny Lin, MD, MPH, Keith Sigel, MD, PhD, Peter J. Taub, MD.
Icahn School of Medicine at Mount Sinai, New York City, NY, USA.
Background: Since the Women’s Health and Cancer Rights Act in 1998 which mandated coverage for elective reconstructive surgeries following mastectomy, an abundance of literature has identified sociodemographic and tumor-related factors that influence rates of breast reconstruction. However, the relationship between successful reconstruction and baseline medical comorbidities has yet to be examined in detail in a large, national study population. The purpose of this study was to analyze specific comorbidities as a predictive factor for breast reconstruction in post-mastectomy women.
Methods: A longitudinal, retrospective cohort study was conducted using data from the Surveillance, Epidemiology and End Results registry linked to Medicare claims. A cohort of women age 66+ years with Medicare diagnosed with primary breast cancer between 2000-2011 who underwent mastectomy was identified. Mastectomy, breast reconstruction, and medical comorbidities as delineated by the Elixhauser Comorbidity Index were identified using ICD-9 and CPT billing codes between 2000-2014. Weighted Elixhauser scores were calculated to estimate the burden across thirty-one comorbidities. Univariate analyses and multivariate logistic regression models were fit to analyze for differences in breast reconstruction rates.
Results: Of the 192,465 women who met criteria, 63,696 (33.2%) underwent mastectomy. Of these, 4,962 women (7.80%) then underwent reconstruction before 2014. In univariate analyses, women who underwent reconstruction were more likely to be younger (median age 70.8 vs. 76.5 years, p<0.0001), white (8.28% vs. 4.61% for Blacks, 4.77% for Hispanics, 3.91% for Asians, p<0.0001), and have less comorbidity burden (mean weighted Elixhauser score 1.40 vs. 2.53, p<0.0001). In a predictive model including sociodemographic variables, tumor-related characteristics, and the thirty-one Elixhauser comorbidities, a baseline comorbidity of congestive heart failure (OR=0.70), peripheral vascular disorder (OR=0.79), uncomplicated hypertension (OR=0.82), other neurological disorders (OR=0.64), chronic pulmonary disease (OR=0.86), both uncomplicated and complicated diabetes (OR=0.65, 0.62), obesity (OR=0.69), fluid and electrolyte disorders (OR=0.75), and psychoses (OR=0.32) were associated with decreased odds of reconstruction. Hypothyroidism (OR=1.22) and depression (OR=1.19) were associated with increased odds of reconstruction.
Conclusions: Among older women diagnosed with primary breast cancer, successful reconstruction after mastectomy is associated with both specific, identifiable comorbidities and overall comorbidity burden. As the first of its kind, this predictive claims-based study based upon an established and extensive comorbidity index demonstrates the significance of precise medical characterization at baseline, which can both aid appropriate surgical candidate selection and inform counseling for pre-mastectomy geriatric patients considering reconstruction. 
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