Do variations in provider discussions explain socioeconomic disparities in postmastectomy breast reconstruction?

Abstract

Background: The use of postmastectomy reconstruction varies with socioeconomic status, but the etiology of these variations is not understood. We investigated whether these differences reflect variations in the rate or qualitative aspects of the provider's discussion of reconstruction as an option.

Study design: Data were collected through chart review and patient survey for stages I to III breast cancer patients during the National Initiative on Cancer Care Quality. Multivariable logistic regression was used to identify predictors of reconstruction and discussion of reconstruction as an option. Predictors of not receiving reconstruction despite a documented discussion were also determined.

Results: There were 253 of 626 patients who received reconstruction (40.4%). Younger, more educated Caucasian women who were not overweight or receiving postmastectomy radiation were more likely to receive reconstruction. Patients who were younger, more educated, and not receiving postmastectomy radiation were more likely to have a documented discussion of reconstruction. If a discussion was documented, patients who were older, Hispanic, not born in the US, and received postmastectomy radiation were less likely to receive reconstruction. The greatest predictor of reconstruction was medical record documentation of a discussion about reconstruction.

Conclusions: We observed disparities in the likelihood of reconstruction that were at least partially explained by differences in the likelihood that reconstruction was discussed. But there were also differences in the likelihood of reconstruction based on age, race, and radiation once discussions occurred. Efforts to increase and improve discussions about reconstruction may decrease disparities for this procedure.

Figure 1. Schema depicting the factors that potentially contribute to whether a patient receives reconstruction following mastectomy

Patients cannot meaningfully participate in decision-making without an informative discussion of reconstruction as an option. Once mastectomy is considered as a surgical option, reconstruction should be discussed. This discussion may or many not take place based on clinical factors; however, the may also omit the discussion due to bias based on non-clinical factors. Once the discussion is initiated, there are a number of factors that determine whether a decision is made to proceed with the mastectomy with or without reconstruction. These relate to clinical factors, patient preferences, provider preferences and how these are communicated to the patient. The provider may present incomplete data about probabilities for outcomes with as compared to without reconstruction. Patient-provider communication could be limited because of non-clinical factors (e.g., limited visit time, limited English proficiency, etc.). The factors in italics represent potential target areas to decrease disparities.