Disparities in Access to Postmastectomy Breast Reconstruction: Does Living in a Specific Zip Code Determine the Patient's Journey?
Samyd S. Bustos, MD1, Alejandro Munoz-Valencia MD3, Elizabeth Moroni, MD1, Nerone KO Douglas, MSc2, Steven Evans, MD3, Emilia Diego, MD3, Carolyn De La Cruz, MD1.
1Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 2University of Pittsburgh School of Medicine, Pittsburgh, PA, USA, 3Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Background: Postmastectomy breast reconstruction is considered an integral part of breast cancer treatment. It aims to surgically restore the breast mound, which has been shown to provide long-term quality-of-life and psychosocial benefits. Despite the policies initiated to improve access to breast reconstruction, its delivery continues to be inequitable, suggesting that barriers of access still persist and have not been fully identified or addressed. The purpose of this study is to assess the influence of zip codes, socioeconomic status, and race in access to breast reconstruction.
Methods: After approval by the Quality Review Committee, the UPMC Cancer Registry was queried and a list was obtained of all patients who underwent breast cancer surgery at the UPMC Magee-Womens Hospital from 2014 to 2019. A geographical analysis was conducted using demographic characteristics including zip codes and addresses. Quantitative data were analyzed using Chi-square, Student’s t-test, Mann Whitney and Kruskal Wallis tests, when appropriate, and a significance was set at p < 0.05. Euclidean distance from patient home zip code to Magee Hospital was calculated using ArcMap 10.7 software. Results: Overall, 5,835 patients underwent breast cancer surgery at UPMC Magee from 2014 to 2019. A total of 3,307 (56.7%) underwent lumpectomy or segmental mastectomy, and 2,528 (43.3%) underwent modified, total, or radical mastectomy. From the latter group, 846 patients (33.5%) pursued breast reconstruction: 242 (28.6%) autologous, 407 (48.1%) implant-based, 164 (19.4%) a combination of autologous and implant-based, and 33 (3.9%) were not specified. Rates of breast reconstruction varied among races: White or European (34.1%), Black or African American (27.7%), and other races (17.8%), p=0.022. However, no difference was found between type of breast reconstruction among races (p=0.38). Moreover, patients who underwent breast reconstruction were younger (52.6±10.4 years vs. 59.9±13.8 years, p<0.0001), came from zip codes that had approximately 2,000 USD more average income, and came from zip codes with a predominant White population (8% vs. 11% non-White population) and zip codes with lower percentage of Black or African American population (1.8% vs. 2.9%). Conclusion: While the use of postmastectomy breast reconstruction has been steadily rising in the United States, racial and socioeconomic disparities persist, limiting the expansion of access to certain populations. Further efforts are needed to reduce this gap in healthcare access across the board. Increasing culturally concordant educational materials, and advocacy and sociopolitical awareness within our surgical community could bring us closer to achieving equity in comprehensive breast cancer treatment.
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