A Systematic Literature Review on Disparities in Postmastectomy Breast Reconstruction

PURPOSE: Eliminating healthcare disparities is a major priority as the United States population diversifies. Literature focusing on identifying disparities in postmastectomy breast reconstruction continues to expand. However, no study has assessed whether this research is progressing appropriately to promote tangible intervention in reducing disparities. The purpose of this study is to utilize a previously established public health framework for advancing health disparities research to evaluate the current state of breast reconstruction disparities research and provide literature-based recommendations for interventions.

METHODS: A systematic literature review was performed in accordance with the preferred reporting items for systematic reviews and meta-analysis (PRISMA) to identify studies evaluating disparities in postmastectomy breast reconstruction. Results were analyzed according to the Kilbourne model, which categorizes disparities research into one of three phases: detecting (identifies and measures disparities in vulnerable populations), understanding (establishes determinants of disparities at the individual/systemic level) and reducing (proposes and evaluates interventions for eliminating disparities).¹

RESULTS: Ninety-five studies were identified between 1979-2016, with 61(64.2%) published after 2010. Forty-nine (51.6%) articles were retrospective cohort or case-control studies (ASPS level III evidence). Fifty-eight (63.7%), 31 (34.1%) and two (2.2%) studies provided detecting-, understanding- and reducing-phase disparities research, respectively. Non-plastic and reconstructive surgery (PRS) journals accounted for 70.5% of all articles and for most higher phase research articles, publishing 83.9% and 100% of second and third phase studies, respectively. Disparity categories investigated included race/ethnicity, age, income, insurance status/type, geography, and education level. The most commonly investigated disparity categories were race/ethnicity and age (73.7% and 50.5% of studies, respectively). The most commonly measured outcome was percent of sub-population receiving reconstruction (63, 66.3%), followed by reconstruction type (14, 16.7%). Patient-, provider-, system, and research-level factors were identified as potential targets for interventions to reduce disparities.

CONCLUSION: Despite the expanding pool of research on postmastectomy breast reconstruction disparities, the majority of this research focuses on detecting disparities with inadequate progression to second (understanding) and third (reducing) phase studies. The PRS community should take increasing ownership of this issue and promote higher-phase disparities research, as over half of published research exists in non-PRS journals. Increasing research funding, availability of language- and culturally concordant educational materials, as well as advocacy and sociopolitical awareness within the plastic surgery community is necessary to advance research on postmastectomy breast reconstruction and ultimately, eliminating it.

References

1. Kilbourne AM, Switzer G, Hyman K, Crowley-Matoka M, Fine MJ. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health. 2006;96(12):2113-2121.