The Impact of Race on Choice of Post-Mastectomy Reconstruction: Is There a Healthcare Disparity?

Background: Although the Institute of Medicine has declared equity to be one of the six key domains of health care quality, racial disparities continue to be a well-documented problem afflicting contemporary American healthcare. Since the breast represents a symbol of femininity for women, breast reconstruction is critical to mitigating the psychosocial and cultural stigma of a breast cancer diagnosis. However, whether different races have equitable access to breast reconstruction, after accounting for other pertinent confounders, remains unknown.

Methods: A retrospective cohort study was designed using N = 2,533 women who underwent first-time autologous or first-time implant-based breast reconstruction following mastectomy for breast cancer. The following were tabulated for each patient: age, smoking, diabetes, obesity, provider, race, pathologic stage, health insurance type, charge to patient, and socioeconomic status. Wilcoxon rank-sum and chi-squared tests were used to compare group medians and proportions, respectively. A backwards-stepwise multivariate logistic regression model was employed to identify independent predictors of type of breast reconstruction. Two-sided α = 0.05 indicated significance in all tests.

Results: Compared to those of Caucasian descent (n = 2,086), African-Americans (n = 349) were statistically-significantly more likely to be under-insured (p<0.01), face a lesser charge for reconstruction (p<0.01), smoke (p<0.01), have diabetes (p<0.01), suffer from obesity (p<0.01), live in a zip code with a lower median household income (p<0.01), and undergo autologous-based reconstruction (p=0.01). (Table 1). On initial multivariate analysis, African-American race (OR 2.21, p<0.01), charge to patient (OR 1.00, p<0.01), and provider (OR 0.96, p<0.01) were significantly associated with autologous-based reconstruction. After backwards-stepwise regression, only African-American race (OR 2.23, p<0.01), charge to patient (OR 1.00, p<0.01), and provider (OR 0.96, p<0.01) independently predicted type of breast reconstruction, while age (OR 1.02, p=0.06) and diabetes (OR 0.48, p=0.08) did not. (Table 2).

Conclusions: To our knowledge, this study is the first high-powered and rigorous analysis to demonstrate a racial disparity regarding breast reconstruction while accounting for other important confounders. African-American race remains the most clinically significant predictor of autologous-based breast reconstruction after mastectomy for breast cancer, even after controlling for age, obesity, pathologic stage, health insurance type, charge to patient, socioeconomic status, smoking, and diabetes. Future research is required to address whether this disparity stems from patient preferences or more profound sociocultural and economic forces including discrimination.