Sociodemographic and Clinical Variables Impacting Procedure Choice in Breast Reconstruction

Purpose: Many options are available to women seeking post-mastectomy breast reconstruction. To promote patient-centered care tailored to women’s individual needs and preferences, it is important to understand the impact of socio-demographic factors on patients’ procedure choices.  In this study, we analyzed the effects of these variables on reconstructive procedure choices following mastectomy.

Methods: Women undergoing post-mastectomy breast reconstruction were recruited as part of the NCI-funded Mastectomy Reconstruction Outcomes Consortium (MROC) Study, a prospective cohort study including 10 centers across the U.S. and Canada. In the current analysis, the effects of multiple socio-demographic and clinical variables on procedure choice were evaluated.  Procedure types were grouped into two cohorts: tissue expander-implant/direct-to-implant and abdominally-based flap reconstructions. Due to the small number of prophylactic mastectomies/reconstructions, this analysis was limited to women undergoing reconstruction following mastectomies for breast cancer.  Adjusted odds ratios (OR) of abdominally-based flaps were calculated from logistic regression with patient socio-demographic and clinical factors as the independent variables and adjusting for within-site correlation.

Results:  There were 2,203 women included in this analysis, with 1,557 receiving implant-based and 646 undergoing autologous tissue procedures.  Compared with women <40 years of age, women 40 to 49 years (OR=1.9, p<0.01) and 50 to 59 years (OR=2.0, p<0.01) were significantly more likely to undergo an abdominally-based flap. Women working or attending school full-time were more likely to receive an autologous procedure than those working part-time or volunteering (OR=1.6, p<0.01). Patients undergoing unilateral or delayed procedures were more likely to receive an abdominal flap compared to those undergoing bilateral or immediate procedures, respectively (OR=1.8, p<0.001; OR=11.4, p<0.001, respectively). Those with BMIs of ≥25 were significantly more likely to undergo autologous reconstruction than women with BMIs <25. Race, ethnicity, income, and education did not have significant effects on procedure type. 

Conclusions: The results of this multi-center, prospective cohort study indicate that patient age, employment status, laterality, timing, and BMI each have significant independent effects on the reconstructive options chosen.  At the same time, race, ethnicity, income, and education were not predictive of procedure type, suggesting no apparent inequity in procedure types in women undergoing breast reconstruction.  As our health care system moves to a patient-centered model, it is important for surgeons to recognize the impact of these factors on women’s choices in reconstruction.