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ScienceDirect journal homepage: www.JournalofSurgicalResearch.com

Racial disparities in the type of postmastectomy reconstruction chosen Anaeze C. Offodile II, MD,a,1 Thomas C. Tsai, MD, MPH,b,c,1 Julia B. Wenger, MPH,d and Lifei Guo, MD, PhDa,* a

Department of Plastic Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts c Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts d Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts b

article info

abstract

Article history:

Background: Racial disparities remain for women undergoing immediate breast recon-

Received 20 October 2014

struction (IBR) after mastectomy. Understanding patterns of racial disparities in IBR utili-

Received in revised form

zation may present opportunities to tailor policies aimed at optimizing care across racial

11 December 2014

groups. The aim of this study was to determine if racial disparities exist for types of IBR

Accepted 8 January 2015

chosen.

Available online 13 January 2015

Methods: A national, retrospective cohort study used the 2005e2011 American College of Surgeons National Surgical Quality Improvement Program database. Multivariable logistic

Keywords:

regression models were created to detect the odds by race for receiving each subtype of IBR

Racial disparities

after mastectomydprosthetic, pedicled-transfer autologous tissue, or free-transfer autol-

Immediate breast reconstruction

ogous tissue. Secondary outcome was trends in IBR rates over time.

Health policy

Results: There were 44,597 women identified in the data set who underwent mastectomy.

Mastectomy

Thirty-seven percent of women (N ¼ 16, 642) were noted to undergo IBR after mastectomy.

Race

Prosthetic reconstruction (84.4%, n ¼ 37, 640) was the most common form of IBR compared

Breast cancer

with pedicled-autologous reconstruction (15.4%, n ¼ 6868) and free transfer autologous reconstruction (4.9%, n ¼ 2185), P < 0.001. In multivariate analysis, minorities had lower odds of undergoing IBR compared with whites (odds ratio [OR] 0.37 and 95% confidence interval [CI] 0.33e0.42 for Asians, OR 0.57 and 95% CI 0.52e0.61 for blacks, and OR 0.64 and 95% CI 0.58e0.71 for Hispanics, all P < 0.001). Compared with whites, Hispanics (OR 0.70, 95% CI 0.58e0.83) and blacks (OR 0.53, 95% CI 0.46e0.60) were less likely to use prosthetic reconstruction and more likely to use free-transfer autologous reconstruction (OR 1.66, 95% CI 1.26e2.18 for Hispanics, OR 2.13, 95% CI 1.73e2.63 for blacks), all P < 0.001. Racial disparities persisted from 2005e2011; as minority patients were less likely to undergo IBR than whites (P < 0.001). Conclusions: Utilization of IBR may be a sensitive measure of disparities in access to highquality care and underlying cultures. Strategies aimed at reducing racial disparities in IBR should be tailored to specific patterns of disparities among Asian, black, and Hispanic women. ª 2015 Elsevier Inc. All rights reserved.

* Corresponding author. Department of Plastic Surgery, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805. Tel.: þ1 781 744 5760; fax: þ1 781 744 1052. E-mail address: [email protected] (L. Guo). 1 Denotes authors with equal contribution. 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.01.013

j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 5 ( 2 0 1 5 ) 3 6 8 e3 7 6

1.

Introduction

Breast cancer is the second most common malignancy among American women, and approximately 232,670 women are expected to be diagnosed with invasive breast cancer in 2014 alone [1]. Although breast-conserving therapy with lumpectomy and radiation is more prevalent, mastectomy remains a common treatment modality, with 38.4% of women undergoing total mastectomy for the treatment of early breast cancer [2]. For those women who undergo total mastectomy, immediate breast reconstruction (IBR) is associated with considerable cosmetic and psychosocial benefits [3]. Higher levels of postoperative satisfaction and quality of life have been convincingly shown among IBR patients [4e6]. IBR has also translated into minimal risk of delaying treatment or disrupting cancer surveillance [7]. Accordingly, the availability of IBR may represent access to high-quality comprehensive breast cancer treatment. Despite its established benefits, only 25%e40% of women who develop breast cancer eventually seek out IBR after total mastectomy [8,9]. Currently available IBR modalities range in complexity and include prosthetics-based reconstruction (tissue expander and/or implant) and autologous tissue transfer (ATR). ATR can be further divided into two broad categories as follows: pedicled-autologous reconstruction (e.g., Transverse Rectus Abdominis flap) and free-flap autologous reconstruction (e.g., Deep Inferior Epigastric Perforator flap). Over the past two decades, evidence has emerged that significant racial disparities persist in the rates of IBR among women with breast cancer treated with mastectomy [3,10e15]. However, there is very limited information on how these disparities impact patterns of IBR utilization. This poorly studied area may actually provide an opportunity to understand inequalities in our health care system. This is because disparities in the way IBR is used may be a reflection of access issues, such as seeking care at comprehensive cancer centers or availability of specialty breast reconstructive surgeons. To our knowledge, this is the first study to investigate racial disparities, if any, in type of IBR received using a contemporary, validated national database. We sought to answer two very important questions. First, are there racial disparities with respect to the subtype of IBR received after mastectomy? Second, given the increased attention to reducing disparities in cancer care, have the racial disparities in receipt of IBR subtype, if any, changed over time?

2.

Methods

2.1.

Data

We used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) participant use file for 2005e2011 to identify all female patients who underwent IBR after mastectomy. The ACS-NSQIP database is a validated, multi-institutional prospective registry that, based on peer-controlled systematic methods, collects high-quality clinical information on surgical patients [16].

2.2.

369

Patient selection

We identified patients who underwent a total or complete breast extirpation for cancer between January 1, 2005 and December 31, 2011 based on primary, concurrent, or other Current Procedural Terminology (CPT) codes: 19180, 19182, 19200, 19220, 19240, and 19303e19307. Partial mastectomies were not examined as they do not routinely require reconstruction. Male patients were excluded from the study as well as patients with missing race information and those of American Indian and/or Alaskan Native descent due to insufficient sample size (329 total patients of whom only 30 underwent IBR). Female patients who then underwent IBR were identified by the presence of one of the following concurrent CPT codes in addition to a primary total mastectomy CPT code: 19340 (implant insertion), 19357 (tissue expander), 19364 (free tissue transfer), 19361 (Latissimus dorsi flap), 19367 (TRAM flap-single pedicle), 19368 (pedicled TRAM flap with super charging), and 19369 (TRAM flap-bipedicled). For the purposes of statistical analysis, the following IBR groupings were created: prosthetic (19340, 19357), pedicled-autologous tissue (19361, 19367, 19368, and 19369), and free flapautologous tissue (19364). Latissimus dorsi flap with or without implant was classified under pedicled-autologous to simplify the analysis. In the rare instances in which a patient underwent bilateral IBR of different types, each IBR type was handled separately in the analysis.

2.3.

Outcome variable

The primary outcome variable of interest was the type of IBR chosen; prosthetic, pedicled-transfer autologous tissue, or free-transfer autologous tissue. For secondary subgroup analyses, the outcome was trend in IBR subtype utilization over time.

2.4.

Predictor and covariates

Race was the primary independent variable for the study. For statistical analysis, we grouped patients into one of the following four categories as captured in the NSQIP database: white, black, Asian, and Hispanic and/or Latino. For all analyses, white patients served as the reference group. Based on univariate analyses, a set of statistically significant and clinically relevant patient co-morbidities and baseline characteristics from the NSQIP database were included for risk adjustment. These include age, body mass index (BMI), current smoking status (defined in the ACSNSQIP database as smoking within the year before admission for surgery), radiotherapy 90 d, chemotherapy 30 d, disseminated cancer, function status, history of diabetes, history of chronic obstructive pulmonary disease, history of congestive heart failure, history of myocardial infarction, history of angina, history of peripheral vascular disease, acute renal failure postoperation, history of transient ischemic attack, history of cerebrovascular accident and/or stroke, resident participation, and the American Society of Anesthesiologists (ASA) class.

370 2.5.

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Statistical analysis

Baseline characteristics are presented for all IBR patients and also according to race. Characteristics by race were compared with the use of one-way analysis of variance tests or chisquare tests and are presented as means  standard deviations or numbers and percentages. For rates of IBR utilization, rates are presented as percentages and were compared with chi-square tests between races. Two sets of analyses were carried out to elucidate the impact of race on patterns of IBR utilization. First, we investigated the association between race and receiving any type of IBR and then second, for those who underwent IBR, the impact of race on the type of IBR received. To do this, we investigated the predictive value of race for receiving any IBR compared with not receiving IBR in unadjusted logistic regression analyses. To test for the independent effect of race on receiving IBR, we then used multivariable logistic regression models that additionally controlled for patient co-morbidities, characteristics, and demographics in the entire mastectomy cohort.

To elucidate the impact of race on patterns of IBR utilization, we first limited the analyses and risk adjustment to only those patients who underwent IBR. This is because to pursue the analysis of IBR subtype, the patients had to have undergone IBR in the first place. Using separate models for each of the types of IBR (prosthetic, pedicled-transfer autologous, and free transfer autologous) as the dependant variable, we assessed the bivariate impact of race for each type of IBR. We then developed three separate multivariable logistic regression models controlling for patient factors to predict the independent impact of race on receiving either prosthetic, pedicled-transfer autologous, or free transfer autologous reconstruction. Finally, we analyzed if racial disparities had diminished over the period of our study from 2005e2011. For each year, we assessed the odds of using an IBR subtype, adjusting for patient co-morbidities and clinical characteristics, and for each race with an additional term for race by survey year interaction. White female patients undergoing IBR during each survey year served as the reference group. P value for trend was

Table 1 e Baseline characteristics of patients undergoing IBR. Characteristics N Age BMI Operation year 2005 2006 2007 2008 2009 2010 2011 Current smokers Radiotherapy 90 d Chemotherapy 30 d Disseminated cancer Functional status Independent Partially dependent Totally dependent History of diabetes History of COPD History of CHF History of MI History of angina History of PVD Acute renal failure postoperation History of TIA History of CVA/stroke Resident participation ASA class No disturbance Mild disturbance Severe disturbance Life threatening

IBR patients

Asian

Black

Hispanic

White

16,642 51.1  10.4 27.1  6.4

578 48.4  9.5 24.2  4.7

1317 50.6  10.5 30.6  7.9

874 49.3  10.5 28.3  6.2

13,873 51.4  10.4 26.8  6.2

275 919 1910 2560 3375 3557 4046 2155 59 682 135

(1.7) (5.5) (11.5) (15.4) (20.3) (21.4) (24.3) (13.0) (0.4) (4.1) (0.8)

6 16 59 84 99 137 177 23 1 17 3

(1.0) (2.8) (10.2) (14.5) (17.1) (23.7) (30.6) (4.0) (0.2) (2.9) (0.5)

16,605 31 4 795 122 3 2 12 15 2 76 90 9550

(99.8) (0.2) (0.1) (4.8) (0.7) (0.1) (0.1) (0.1) (0.1) (0.1) (0.5) (0.5) (57.4)

578 (100.0) 0 (0.0) 0 (0.0) 29 (5.0) 2 (0.4) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.2) 0 (0.0) 288 (49.8)

1597 11,785 3198 43

(9.6) (70.8) (19.2) (0.3)

71 440 66 1

(12.3) (76.1) (11.4) (0.2)

22 80 128 167 257 305 358 210 3 57 17

(1.7) (6.1) (9.7) (12.7) (19.5) (23.2) (27.2) (16.0) (0.2) (4.3) (1.3)

1312 (99.6) 5 (0.4) 0 (0.0) 129 (9.8) 8 (0.6) 2 (0.2) 0 (0.0) 0 (0.0) 1 (0.1) 0 (0.0) 11 (0.8) 19 (1.4) 800 (60.7) 68 824 414 10

(5.2) (62.6) (31.4) (0.8)

5 50 83 106 187 213 230 90 2 52 11

(0.6) (5.7) (9.5) (12.1) (21.4) (24.4) (26.3) (10.3) (0.2) (6.0) (1.3)

871 (99.7) 2 (0.2) 0 (0.0) 67 (7.7) 4 (0.5) 0 (0.0) 0 (0.0) 2 (0.2) 0 (0.0) 0 (0.0) 3 (0.3) 4 (0.5) 417 (47.7) 73 645 154 2

(8.4) (73.8) (17.6) (0.2)

242 773 1640 2203 2832 2902 3281 1832 53 556 104

(1.7) (5.6) (11.8) (15.9) (20.4) (20.9) (23.7) (13.2) (0.4) (4.0) (0.8)

13,844 (99.8) 24 (0.2) 4 (0.1) 570 (4.1) 108 (0.8) 1 (0.1) 2 (0.1) 10 (0.1) 14 (0.1) 2 (0.1) 61 (0.4) 67 (0.5) 8045 (58.0) 1385 9876 2564 30

P value

Racial disparities in the type of postmastectomy reconstruction chosen.

Racial disparities remain for women undergoing immediate breast reconstruction (IBR) after mastectomy. Understanding patterns of racial disparities in...
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