Disparities in Breast Reconstruction Access Persist Despite Advocacy Efforts

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Because most reconstructive surgeons are not trained in communicating complex risk information, some women may choose to have the procedure done without fully understanding the risks.
Because most reconstructive surgeons are not trained in communicating complex risk information, some women may choose to have the procedure done without fully understanding the risks.

It has been 20 years since researchers found evidence indicating that the likelihood of breast reconstruction after a breast cancer diagnosis depends a great deal on a woman's race, location, health insurance plan, income, and more.1 Yet, variations in breast reconstruction for patients with breast cancer persist today, according to 2 viewpoint articles published in JAMA Surgery.2,3

All women who want breast reconstruction after having a mastectomy should be able to have the procedure, but many women are not aware of their options. For some, breast reconstruction may not be the safest or most effective treatment.4 "The safety of immediate breast reconstruction… is somewhat unclear, with risks of a major complication or unplanned surgery exceeding those of other major elective procedures," wrote Clara Nan-hi Lee, MD, MPP. “The effectiveness of breast reconstruction to produce outcomes that are important to patients also remains unclear.”3

In addition, the procedure may not align with a woman's personal preferences, but she may undergo it anyway. Because most reconstructive surgeons are not trained in communicating complex risk information, some women may choose to have the procedure done without fully understanding the risks.3

Still, all women should be given equal opportunity to access these important procedures.

“Moving forward, we propose a realignment of priorities associated with practice variations in breast reconstruction. In addition to addressing access, surgeons need to improve the safety of breast reconstruction, demonstrate its effectiveness, and implement shared decision-making interventions,” wrote Dr Lee.3 “We should move toward a more nuanced conversation about breast reconstruction access — one that reflects the ideal of the right reconstructive procedure for the right patient at the right time. Only then will we be able to maximize the odds of both a good outcome and appropriate choice for breast cancer patients undergoing mastectomy.”

References

  1. Polednak AP. Geographic variation in postmastectomy breast reconstruction rates. Plast Reconstr Surg 2000;106(2):298-301.
  2. Berlin NL, Wilkins EG, Alderman AK. Addressing continued disparities in access to breast reconstruction on the 20th Anniversary of the Women's Health and Cancer Rights Act [published online May 2, 2018]. JAMA Surg. doi:10.1001/jamasurg.2018.0387
  3. Offodile AC, Lee CN. Future directions for breast reconstruction on the 20th anniversary of the Women's Health and Cancer Rights Act [published online May 2, 2018]. JAMA Surg. doi:10.1001/jamasurg.2018.0397
  4. Fischer JP, Fox JP, Nelson JA, Kovach SJ, Serletti JM. A longitudinal assessment of outcomes and healthcare resource utilization after immediate breast reconstruction-comparing implant- and autologous-based breast reconstruction. Ann Surg. 2015;262(4):692-699.

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