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Impact of Race, Ethnicity, Primary Language and Insurance on Reconstruction after Mastectomy for Patients with Breast Cancer at an Urban, Academic Safety-Net Hospital
Brendin Beaulieu-Jones1, Ann Fefferman2, Grant Shewmaker1, Tina Zhang3, Daniel S. Roh1, Nilton Medina1, Andrea Merrill1, Naomi Ko3, Michael R. Cassidy1
1Surgery, Boston Medical Center, Boston, Massachusetts, United States, 2Boston University Medical School, Boston, Massachusetts, United States, 3Medicine, Boston Medical Center, Boston, Massachusetts, United States

Objective: Marked disparities in the frequency, timing and approach to breast reconstruction after mastectomy have been observed in national cohorts and single-institution studies based on race, ethnicity, insurance status and preferred language. However, relatively little has been published regarding the performance of safety-net hospitals to deliver equitable care in this important domain of breast cancer treatment. In this study, we investigate the impact of race, ethnicity, insurance and language on the frequency and timing of reconstruction after mastectomy among women with breast cancer.

Design: Single-institution, retrospective cohort

Setting: Urban, academic safety-net hospital in Boston, Massachusetts

Patients: 109 women who underwent unilateral or bilateral mastectomy for stage 1-3 breast cancer (2009-2014)

Intervention: Age, race, ethnicity, insurance status, primary language

Main outcome measure: Frequency, timing (immediate vs delayed) and approach (autologous vs implant-based) to breast reconstruction; reasons for not performing breast reconstruction after mastectomy were also analyzed

Results: 520 women with stage 1-3 invasive breast cancer were diagnosed and treated at our institution during the study period. Median age was 58.5 years, 56.1% were non-white, 31.7% were non-English-speaking, 16.4% were Hispanic, and 50.1% were Medicaid/uninsured. 109 patients (21.0%) underwent mastectomy during their index surgical resection. 52.3% (N=57) did not complete breast reconstruction. Reasons for not performing breast reconstruction included: patient preference (N=17), contraindication to immediate reconstruction (i.e., adjuvant radiation) and no scheduled or patient-initiated follow-up for consideration of delayed reconstruction (N=9), prohibitive risk or contraindication (i.e., active smoking, morbid obesity, significant medical comorbidities) for any reconstruction (N=8), and progression of disease, prohibiting reconstruction (N=7). Immediate and delayed breast reconstruction were completed in 36.7% and 11.0% of patients, respectively. Rate of any reconstruction varied by age group (<50 years 65.9% versus ≥50 years 35.4%, p=0.002), but not race, ethnicity, insurance status or language.

Conclusions: At our academic safety-net hospital, rate of breast reconstruction after mastectomy did not vary by race, ethnicity, insurance status or primary language. We observed comparable rates of reconstruction at or above national estimates and did not observe disparities in breast reconstruction. Additional strategies are needed to ensure patients are counseled regarding reconstruction and appropriately afforded the opportunity to pursue delayed reconstruction, as indicated. Further research is needed to understand the role of reconstruction in breast cancer care, and how best to effectively educate patients of all backgrounds and advance their informed preferences.
Impact of Race, Ethnicity, Insurance & Primary Language on Rate of Reconstruction

N (%)
N (%)
N (%)
N (%)
Primary Language
N (%)
<50 years≥50 yearsBlackWhiteHispanicNon-HispanicPrivatePublicEnglishNon-English
No Reconstruction15 (34.1)42 (64.6)29 (63.0)22 (44.0)3 (37.5)54 (53.5)16 (50.0)41 (53.3)41 (53.3)16 (50.0)
Any Reconstruction29 (65.9)23 (35.4)*17 (37.0)28 (56.0)5 (62.5)47 (46.5)16 (50.0)36 (46.8)36 (46.8)16 (50.0)

Rate of breast construction was evaluated in 109 females who underwent mastectomy for breast cancer (2009-2014). Breast reconstruction rates include either immediate or delayed reconstruction. *Chi-square test: P=0.002
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