Barriers of Access to Breast Reconstruction

A Systematic Review

Helene Retrouvey, M.D.C.M.; Ogi Solaja, M.D.; Anna R. Gagliardi, Ph.D.; Fiona Webster, Ph.D.; Toni Zhong, M.D., M.H.S.

Disclosures

Plast Reconstr Surg. 2019;143(3):465e-476e. 

In This Article

Abstract and Introduction

Abstract

Background: The purpose of this systematic review was to comprehensively summarize barriers of access to breast reconstruction and evaluate access using the Penchansky and Thomas conceptual framework based on the six dimensions of access to care.

Methods: The authors performed a systematic review that focused on (1) breast reconstruction, (2) barriers, and (3) breast cancer. Eight databases (i.e., EMBASE, MEDLINE, PsycINFO, CINHAL, ePub MEDLINE, ProQuest, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials) were searched. English peer-reviewed articles published between 1996 and 2016 were included.

Results: The authors' search retrieved 4282 unique articles. Two independent reviewers screened texts, selecting 99 articles for inclusion. All studies were observational and qualitative in nature. The availability of breast reconstruction was highest in teaching hospitals, private hospitals, and national cancer institutions. Accessibility affected access, with lower likelihood of breast reconstruction in rural geographic locations. Affordability also impacted access; high costs of the procedure or poor reimbursement by insurance companies negatively influenced access to breast reconstruction. Acceptability of the procedure was not universal, with unfavorable physician attitudes toward breast reconstruction and specific patient and tumor characteristics correlating with lower rates of breast reconstruction. Lastly, lack of patient awareness of breast reconstruction reduced the receipt of breast reconstruction.

Conclusions: Using the access-to-care framework by Penchansky and Thomas, the authors found that barriers to breast reconstruction existed in all six domains and interplayed at many levels. The authors' systematic review analyzed this complex relationship and suggested multiprong interventions aimed at targeting breast reconstruction barriers, with the goal of promoting equitable access to breast reconstruction for all breast cancer patients.

Introduction

The main treatment of breast cancer remains surgical intervention, specifically, breast-conserving surgery or mastectomy.[1,2] Mastectomy can negatively impact a woman's self-esteem and sexual health, and may lead to body image concerns, with detriment to her quality of life.[3,4] Breast reconstruction can be performed after mastectomy to surgically restore the shape of the breast and may provide long-term psychosocial and quality-of-life benefits.[5–15]

Despite its benefits, breast reconstruction often fails to be consistently integrated as part of the treatment of breast cancer patients.[9,16–22] Several countries have noted low rates of breast reconstruction, and have initiated programs and/or policies to improve access to breast reconstruction.[7,18,22–27] In the United States, the Women's Health and Cancer Rights Act of 1998 and the Breast Cancer Patient Education Act of 2015 are two examples of policies aimed at improving access to breast reconstruction.[7,23,28,29] Despite these initiatives, the delivery of breast reconstruction services remains inequitable, suggesting that barriers of access persist.

Studies have evaluated this issue and offer limited insight into the barriers of access to breast reconstruction. Without detailed and comprehensive knowledge of these barriers, no effective interventions can be designed to target these barriers to breast reconstruction. Although the decision to pursue breast reconstruction is ultimately that of the individual patient, the current inequitable rates of breast reconstruction suggest that this option is not being presented to all women. Thus, the purpose of this systematic review was to identify and comprehensively summarize barriers of access to breast reconstruction using the Penchansky and Thomas access-to-care framework.

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