Ethnic Disparities Persist in Post-Mastectomy Breast Reconstructive Surgery Rates

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(ChemotherapyAdvisor) – Ethnic disparities persist in post-mastectomy breast reconstruction surgery rates despite mandated insurance coverage for this procedure under the 1998 federal Women's Health and Cancer Rights Act and harmonizing changes to state Medicaid policies, according to a Pennsylvania study published in the Annals of Surgical Oncology.

“Despite policy changes that entitle all breast cancer patients in the United States to insurance coverage of reconstruction after mastectomy, utilization rates remain low, especially among racial minorities,” reported senior author Rachel R. Kelz, MD, MSCE, of the Department of Surgery at the Hospital of the University of Pennsylvania in Philadelphia, and coauthors. “Rates of IBR increased across all racial groups after policy changes. However, not all races were affected equally, and thus disparities remained.” 

The researchers used immediate breast reconstruction (IBR) status data for 1994 to 2004 from the Pennsylvania Health Care Cost Containment Council inpatient database to assess IBR rates stratified by ethnicity, prior to (1994-1997) and after (2001-2004) adoption of the new policies.

The team found that 15,472 (75% of mastectomy patients older than age 17 years) did not receive reconstruction surgery and that 5,157 women (25%) did.

Overall IBR rates across all ethnicities were significantly higher after policy changes (18.5% vs. 32.7%; P<0.01), the authors reported. But in multivariate analyses, African-American patients (OR 0.66 [95 % CI: 0.55–0.80]), Asian patients (OR 0.30 [95 % CI: 0.18–0.49]), and patients “of mixed or other races” (OR 0.29 [95 % CI 0.16–0.51]) were less likely than Caucasian patients to undergo IBR, after policy changes were adopted, the team reported. The overall IBR OR among non-Caucasian women compared to Caucasians was 0.56 (95 % CI 0.48–0.67).

“Both before and after the policy changes, rates of IBR were lower among patients who were nonwhite, of older age, had a higher comorbidity index, and a lower estimated household income,” the authors reported.

Among women of all ethnicities, higher income was associated with higher likelihood of undergoing IBR. Changes to state law ensuring Medicaid coverage of post-mastectomy breast reconstruction “should have eliminated disparities” based on income, the authors noted.

“Unfortunately, the dissemination of information regarding these policies may have variable penetrance related to socioeconomic status,” they suggested. Particularly among Asian women, language barriers may partly explain the disparities, the authors wrote.


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