Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States

Abstract

Purpose: Concerns exist regarding breast cancer patients' access to breast reconstruction, which provides important psychosocial benefits.

Patients and methods: Using the MarketScan database, a claims-based data set of US patients with employment-based insurance, we identified 20,560 women undergoing mastectomy for breast cancer from 1998 to 2007. We evaluated time trends using the Cochran-Armitage test and correlated reconstruction use with plastic-surgery workforce density and other treatments using multivariable regression.

Results: Median age of our sample was 51 years. Reconstruction use increased from 46% in 1998 to 63% in 2007 (P < .001), with increased use of implants and decreased use of autologous techniques over time (P < .001). Receipt of bilateral mastectomy also increased: from 3% in 1998 to 18% in 2007 (P < .001). Patients receiving bilateral mastectomy were more likely to receive reconstruction (odds ratio [OR], 2.3; P < .001) and patients receiving radiation were less likely to receive reconstruction (OR, 0.44; P < .001). Rates of reconstruction receipt varied dramatically by geographic region, with associations with plastic surgeon density in each state and county-level income. Autologous techniques were more often used in patients who received both reconstruction and radiation (OR, 1.8; P < .001) and less frequently used in patients with capitated insurance (OR, 0.7; P < .001), patients undergoing bilateral mastectomy (OR, 0.5; P < .001), or patients in the highest income quartile (OR, 0.7; P = .006). Delayed reconstruction was performed in 21% of patients who underwent reconstruction.

Conclusion: Breast reconstruction has increased over time, but it has wide geographic variability. Receipt of other treatments correlates with the use of and approaches toward reconstruction. Further research and interventions are needed to ensure equitable access to this important component of multidisciplinary treatment of breast cancer.

Fig 1.

Time trends in the use of associated treatments in patients undergoing mastectomy for breast cancer, depicting the trends in rates of use of postmastectomy radiation therapy (RT), bilateral mastectomy, lymph node surgery, and breast reconstruction among the breast cancer patients in our sample from the MarketScan claims database.

Fig 2.

Time trends in the use of different breast reconstruction techniques, depicting the trends in rates of use of various techniques for breast reconstruction (autologous tissue alone, implant-based reconstruction alone, use of both autologous tissue and implants, placement of a tissue expander [TE] only, or other approaches) among the breast cancer patients in our sample from the MarketScan claims database.

Fig 3.

Adjusted receipt of reconstruction for each state in the United States, using final logistic model adjusted for all covariates except for density of plastic surgeons and county-level income. This heat map demonstrates the geographic variability in use of breast reconstruction among the breast cancer patients in our sample from the MarketScan claims database.

Fig A1.

Covariate distributions over time. Given the overall increase in the MarketScan cohort size over time, subsidiary analyses evaluated for stability of covariate distributions in the analytic cohort over time. Trends over time for region and income were statistically significant at P < .05, whereas distributions of age, employer relationship, and type of insurance were not. (A) Age at diagnosis; (B) region; (C) relationship to the employer; (D) type of insurance coverage; (E) county-level median income. HMO, health maintenance organization; PPO, preferred provider organization.

Fig A2.

Sample size and percent reconstruction by year, 1998 to 2007, demonstrating changes over time in the sample size of the cohort and also in the percent utilization of reconstruction. As the MarketScan data increased in scope and expanded to include health plan clients, the overall sample size increased substantially. However, the major rise in use of reconstruction occurred between 2003 and 2004, with utilization of reconstruction rising from 50% to 56%. During this time period, the sample size was relatively stable, with 2,309 patients in 2003 and 2,460 patients in 2004, an only 7% relative increase. In contrast, the sample size increased dramatically between 2005 and 2006, rising from 2,610 to 3,630 patients, a 39% increase. However, during this time interval, use of reconstruction was flat, at 58% in 2005 versus 57% in 2006. These observations suggest that the changes in the cohort size were not directly associated with changes in the observed reconstruction rate.

Fig A3.

Use of reconstruction over time by covariate strata. Percent use of reconstruction over time was evaluated by (A) age at diagnosis, (B) region, (C) relationship to the employer, (D) type of insurance coverage, and (E) county-level median household income (by quartile, from lowest to highest). There was a significant increase (P < .05) in use of reconstruction for all covariate-specific strata evaluated, with the exception of the West region. HMO, health maintenance organization; PPO, preferred provider organization.