Advertisement

Perspectives of Wisconsin Providers on Factors Influencing Receipt of Post-Mastectomy Breast Reconstruction

      Abstract

      Background

      : The objective is to determine perspectives of general surgeons, plastic surgeons, and cancer navigators on factors contributing to breast cancer patients’ decision for post-mastectomy reconstruction, especially for women facing financial hardship.

      Methods

      : We mailed Wisconsin general and plastic surgeons who performed >5 breast cancer procedures annually a survey, including a postcard inviting cancer navigators to participate. Descriptive statistics summarize item responses. McNemar's chi-squared tests evaluated surgeons’ perspectives of factors influencing reconstruction for all women compared to women facing financial hardship.

      Results

      : Respondents include 70 general surgeons, 18 plastic surgeons, and 9 navigators. Respondents perceived preference-related factors as important, including “does not want more surgery” (85% reported it important overall and 77% for financial hardship women) and “reconstructed breast is not important to her” (77% vs. 61%). Surgeons perceived logistical factors were more important for women facing financial hardship, including “capacity to be away from work or home responsibilities for recovery” (30% reported important overall and 60% for financial hardship women), “concerned about out-of-pocket costs” (26% vs. 57%), and “frequent visits to complete reconstruction too burdensome” (27% vs. 49%).

      Conclusion

      : Our findings demonstrate Wisconsin surgeons and cancer navigators perceive logistical concerns influence reconstruction decisions for women facing financial hardship.

      Clinical Practice Points

      : Rates of post-mastectomy breast reconstruction have increased over the past decade. However, disparities in the receipt of reconstruction still exist, especially for socioeconomically disadvantaged women. In order to understand these disparities, one must first understand the upstream factors affecting the ultimate decision for reconstruction. Clinical stakeholders, play major roles in the decision-making process of patients contemplating breast surgery. We examined the perspectives of general surgeons, plastic surgeons, and cancer navigators in the state of Wisconsin on factors that contribute to whether or not breast cancer patients considering mastectomy subsequently undergo breast reconstruction, specifically focusing on women who are socioeconomically disadvantaged. Our study demonstrated that surgeons perceive preference-related factors as important determinants, including “does not want more surgery” (85% reported it important overall and 77% for financial hardship women) and “reconstructed breast is not important to her” (77% vs. 61%). Importantly, surgeons perceived logistical factors were more important for women facing financial hardship, including “capacity to be away from work or home responsibilities for recovery” (30% reported important overall and 60% for financial hardship women), “concerned about out-of-pocket costs” (26% vs. 57%), and “frequent visits to complete reconstruction too burdensome” (27% vs. 49%). Our respondents identified potential opportunities to reduce disparities, including improving processes for referral or facilitating the peri-operative care for patients who must travel for reconstruction, improving patient education about reconstruction options when they meet with a general/breast surgeon (i.e. educational videos), and educating surgeons acceptable delays between diagnosis and surgery to allow for coordination of reconstruction.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Clinical Breast Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Wilkins EG
        • Cederna PS
        • Lowery JC
        • et al.
        Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study.
        Plastic and reconstructive surgery. 2000; 106 (1014-25; discussion 26-7)
        • Atisha D
        • Alderman AK
        • Lowery JC
        • Kuhn LE
        • Davis J
        • Wilkins EG.
        Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study.
        Annals of surgery. 2008; 247: 1019-1028
        • Eltahir Y
        • Werners LL
        • Dreise MM
        • et al.
        Quality-of-life outcomes between mastectomy alone and breast reconstruction: comparison of patient-reported BREAST-Q and other health-related quality-of-life measures.
        Plastic and reconstructive surgery. 2013; 132 (201e-9e)
        • Elder EE
        • Brandberg Y
        • Bjorklund T
        • et al.
        Quality of life and patient satisfaction in breast cancer patients after immediate breast reconstruction: a prospective study.
        Breast. 2005; 14: 201-208
        • Women's Health and Cancer Rights Act (WHCRA)
        HR 4328,: 105th Cong.
        1998
        • Schumacher JR
        • Taylor LJ
        • Tucholka JL
        • et al.
        Socioeconomic Factors Associated with Post-Mastectomy Immediate Reconstruction in a Contemporary Cohort of Breast Cancer Survivors.
        Annals of surgical oncology. 2017; (in press)
        • Jagsi R
        • Jiang J
        • Momoh AO
        • et al.
        Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States.
        Journal of clinical oncology: official journal of the American Society of Clinical Oncology. 2014; 32: 919-926
        • Sisco M
        • Du H
        • Warner JP
        • Howard MA
        • Winchester DP
        • Yao K.
        Have we expanded the equitable delivery of postmastectomy breast reconstruction in the new millennium? Evidence from the national cancer data base.
        Journal of the American College of Surgeons. 2012; 215 (discussion 66): 658-666
        • Yang RL
        • Newman AS
        • Lin IC
        • et al.
        Trends in immediate breast reconstruction across insurance groups after enactment of breast cancer legislation.
        Cancer. 2013; 119: 2462-2468
        • Christian CK
        • Niland J
        • Edge SB
        • et al.
        A multi-institutional analysis of the socioeconomic determinants of breast reconstruction: a study of the National Comprehensive Cancer Network.
        Annals of surgery. 2006; 243: 241-249
        • Agarwal S
        • Pappas L
        • Neumayer L
        • Agarwal J.
        An analysis of immediate postmastectomy breast reconstruction frequency using the surveillance, epidemiology, and end results database.
        The breast journal. 2011; 17: 352-358
        • Wexelman B
        • Schwartz JA
        • Lee D
        • Estabrook A
        • Ma AM.
        Socioeconomic and geographic differences in immediate reconstruction after mastectomy in the United States.
        The breast journal. 2014; 20: 339-346
        • Yang RL
        • Newman AS
        • Reinke CE
        • et al.
        Racial disparities in immediate breast reconstruction after mastectomy: impact of state and federal health policy changes.
        Annals of surgical oncology. 2013; 20: 399-406
        • Alderman AK
        • Hawley ST
        • Janz NK
        • et al.
        Racial and ethnic disparities in the use of postmastectomy breast reconstruction: results from a population- based study.
        Journal of clinical oncology: official journal of the American Society of Clinical Oncology. 2009; 27: 5325-5330
        • Hershman DL
        • Richards CA
        • Kalinsky K
        • et al.
        Influence of health insurance, hospital factors and physician volume on receipt of immediate post-mastectomy reconstruction in women with invasive and non-invasive breast cancer.
        Breast cancer research and treatment. 2012; 136: 535-545
        • Kruper L
        • Holt A
        • Xu XX
        • et al.
        Disparities in reconstruction rates after mastectomy: patterns of care and factors associated with the use of breast reconstruction in Southern California.
        Annals of surgical oncology. 2011; 18: 2158-2165
        • Offodile AC
        • Tsai TC
        • Wenger JB
        • Guo L.
        Racial disparities in the type of postmastectomy reconstruction chosen.
        The Journal of surgical research. 2015; 195 (2nd): 368-376
        • Reuben BC
        • Manwaring J
        • Neumayer LA.
        Recent trends and predictors in immediate breast reconstruction after mastectomy in the United States.
        American journal of surgery. 2009; 198: 237-243
        • Roughton MC
        • DiEgidio P
        • Zhou L
        • Stitzenberg K
        • Meyer AM.
        Distance to a Plastic Surgeon and Type of Insurance Plan Are Independently Predictive of Postmastectomy Breast Reconstruction.
        Plastic and reconstructive surgery. 2016; 138 (203e-11e)
        • Shippee TP
        • Kozhimannil KB
        • Rowan K
        • Virnig BA.
        Health insurance coverage and racial disparities in breast reconstruction after mastectomy. Women's health issues: official publication of the Jacobs Institute of Women's.
        Health. 2014; 24: e261-e269
        • Tseng JF
        • Kronowitz SJ
        • Sun CC
        • et al.
        The effect of ethnicity on immediate reconstruction rates after mastectomy for breast cancer.
        Cancer. 2004; 101: 1514-1523
        • Kilbourne AM
        • Switzer G
        • Hyman K
        • Crowley-Matoka M
        • Fine MJ.
        Advancing health disparities research within the health care system: a conceptual framework.
        American journal of public health. 2006; 96: 2113-2121
        • Preminger BA
        • Trencheva K
        • Chang CS
        • et al.
        Improving access to care: breast surgeons, the gatekeepers to breast reconstruction.
        Journal of the American College of Surgeons. 2012; 214: 270-276
        • Battaglia TA
        • Darnell JS
        • Ko N
        • et al.
        The impact of patient navigation on the delivery of diagnostic breast cancer care in the National Patient Navigation Research Program: a prospective meta-analysis.
        Breast cancer research and treatment. 2016; 158: 523-534
      1. Wisconsin Hospital Association. (Accessed May 22, 2017, at http://www.wha.org/.

        • Dykema J
        • Jones NR
        • Piche T
        • Stevenson J.
        Surveying clinicians by web: current issues in design and administration.
        Evaluation & the health professions. 2013; 36: 352-381
        • VanGeest JB
        • Johnson TP
        • Welch VL.
        Methodologies for improving response rates in surveys of physicians: a systematic review.
        Evaluation & the health professions. 2007; 30: 303-321
        • Edwards P
        • Roberts I
        • Clarke M
        • et al.
        Increasing response rates to postal questionnaires: systematic review.
        BMJ. 2002; 324: 1183
        • Dykema J
        • Stevenson J
        • Day B
        • Sellers SL
        • Bonham VL.
        Effects of incentives and prenotification on response rates and costs in a national web survey of physicians.
        Evaluation & the health professions. 2011; 34: 434-447
        • Reinisch JF
        • Yu DC
        • Li WY.
        Getting a Valid Survey Response From 662 Plastic Surgeons in the 21st Century.
        Ann Plast Surg. 2016; 76: 3-5
      2. Wisconsin Well Woman Medicaid. (Accessed May 22, 2017, at https://www.dhs.wisconsin.gov/medicaid/publications/p10065.htm.)

        • Alderman AK
        • Atisha D
        • Streu R
        • et al.
        Patterns and correlates of postmastectomy breast reconstruction by U.S. Plastic surgeons: results from a national survey.
        Plastic and reconstructive surgery. 2011; 127: 1796-1803
        • Alderman AK
        • Hawley ST
        • Waljee J
        • Morrow M
        • Katz SJ.
        Correlates of referral practices of general surgeons to plastic surgeons for mastectomy reconstruction.
        Cancer. 2007; 109: 1715-1720
        • Alderman AK
        • Hawley ST
        • Waljee J
        • Mujahid M
        • Morrow M
        • Katz SJ.
        Understanding the impact of breast reconstruction on the surgical decision-making process for breast cancer.
        Cancer. 2008; 112: 489-494
      3. Emmi-educate. (Accessed 3/19, 2022, at https://www.wolterskluwer.com/en/solutions/emmi/emmi-educate.)

      4. Health Dialog. (Accessed March 19, 2022, at https://www.healthdialog.com/.)

      5. Option Grid decision aids. (Accessed March 19, 2022, at http://www.optiongrid.org/.)

      6. Healthwise. (Accessed March 19, 2022, at https://www.healthwise.net/ohridecisionaid/Content/StdDocument.aspx?DOCHWID=tb1934 .)

        • Tjoe JA
        • Heslin K
        • Perez Moreno AC
        • Thomas S
        • Kram JJF
        Factors Associated With Breast Cancer Surgery Delay Within a Coordinated Multihospital Community Health System: When Does Surgical Delay Impact Outcome?.
        Clin Breast Cancer. 2022; 22: e91-e100
        • Mateo AM
        • Mazor AM
        • Obeid E
        • et al.
        Time to Surgery and the Impact of Delay in the Non-Neoadjuvant Setting on Triple-Negative Breast Cancers and Other Phenotypes.
        Annals of surgical oncology. 2020; 27: 1679-1692
        • Prakash I
        • Thomas SM
        • Greenup RA
        • et al.
        Time to surgery among women treated with neoadjuvant systemic therapy and upfront surgery for breast cancer.
        Breast cancer research and treatment. 2021; 186: 535-550
      7. Commonwealth Fund Scorecard on State Health System Performance for Low-Income Populations, 2013. 2013.

      8. The Wisconsin Health Care Landscape. 2015. (Accessed May 16, 2017, at http://kff.org/health-reform/fact-sheet/the-wisconsin-health-care-landscape/.)

        • Schumacher JR
        • Stankowski-Drengler TJ
        • Tucholka JL
        • et al.
        Utility of health services regions in examining socioeconomic disparities in receipt of breast reconstruction.
        The breast journal. 2020; 26: 1895-1897
        • Morrow M
        • Li Y
        • Alderman AK
        • et al.
        Access to breast reconstruction after mastectomy and patient perspectives on reconstruction decision making.
        JAMA surgery. 2014; 149: 1015-1021