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The Equity Gap in Prophylactic Mastectomy: Utilization Declines Fivefold with Increasing Social Vulnerability
Emma Lascar
*, Neil Parikh, Sheuli Chowdhury, Sahil Sharma, Patricia Fuentes, Peter J. Taub, Peter W. Henderson
Division of Plastic and Maxillofacial Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
Purpose: Prophylactic mastectomy reduces breast cancer risk by up to 95% in high-risk patients, yet access remains inequitable. While disparities by race and insurance status have been described, composite community-level social vulnerability has not been evaluated as a predictor of utilization. This study evaluated the association between CDC Social Vulnerability Index (SVI) and prophylactic mastectomy rates in a breast reconstruction cohort.
Methods: A retrospective analysis of 1,059 reconstruction patients at a single academic institution (2019-2023) was performed. SVI was assigned by ZIP code and stratified into quartiles (Q1 = lowest, Q4 = highest vulnerability). Chi-square analysis compared utilization across quartiles; logistic regression adjusted for age, BMI, race, and insurance status. Findings were cross-validated using the Area Deprivation Index (ADI), an independent measure of neighborhood disadvantage.
Results: Mastectomy utilization declined significantly with increasing vulnerability (Q1=10.2%, Q2=5.7%, Q3=3.0%, Q4=1.9%; p=0.0001). Patients in Q1 were more than five times as likely to undergo prophylactic mastectomy as those in Q4. Higher SVI was associated with decreased utilization on univariate (OR=0.086; p<0.001) and remained an multivariate analysis (OR=0.20; p=0.008). Insurance type explained only 13% of the effect; all four SVI subdomains were independently associated with reduced utilization (p<0.005). ADI cross-validation confirmed a similar inverse association (Q1=7.4% vs. Q4=3.4%; p=0.017).
Conclusions: Prophylactic mastectomy utilization is independently inversely associated with social vulnerability, suggesting that barriers to risk-reducing care extend beyond race and insurance inequities. Structural factors, including access to genetic counseling, health literacy, and care navigation, likely contribute. Surgeons and healthcare systems should prioritize equitable access to genetic risk assessment and prophylactic counseling in socially vulnerable communities.
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