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.


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

In This Article

Patients and Methods

Research Design

Our review followed guidance published by the Centre for Reviews and Dissemination and the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.[30–32] A protocol for this systematic review was registered using Prospero (CRD42016046936). This study complies with the principles of the Declaration of Helsinki.

Access was defined as the "concept representing the degree of fit between the [users] and the system" according to Penchansky and Thomas.[33] The degree of fit referred to the six-domain model of access to care described by Penchansky and Thomas (Table 1).[33–40] This framework was chosen as Penchansky explicitly conceptualizes access in terms of the degree of fit between the characteristics of providers and health services as well as the characteristics and expectations of clients.

Study Eligibility Criteria

The study population included women with a diagnosis of breast cancer, and physicians and institutions offering care to women with breast cancer. The intervention was defined as factors influencing access to breast reconstruction. The outcome of interest was the ability or inability to access breast reconstruction performed for oncologic purposes. Randomized clinical trials, observational studies, and qualitative research were included.

Search Strategy

The search was created by an experienced medical librarian. Eight databases were searched to retrieve relevant citations, specifically EMBASE, MEDLINE, PsycINFO, CINHAL, ePub MEDLINE, ProQuest, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. Results were limited to peer-reviewed articles published since 1996 in the English language. This period was chosen to review the past 20 years of breast reconstruction, which reflects modern breast reconstruction practice. The search strategies were divided into three sections: (1) breast reconstruction, (2) barriers, and (3) breast cancer. (See Appendix, Supplemental Digital Content 1, which shows the MEDLINE search strategy. This appendix constitutes the detailed MEDLINE search strategy performed to find all potential articles to include in the systematic review. We share this search strategy with authors to facilitate future systematic reviews on similar topics, All articles retrieved were assessed independently by two reviewers, first through title and abstract screen and then through full-text review; disagreements were resolved through consensus.

Data Collection

Key data extracted included article descriptive information (year of publication, country of publication, study design), rates of breast reconstruction, and barriers of access to care. Data extraction was performed independently by two reviewers; disagreements were resolved through consensus.


Summary statistics were used to describe the number of studies by year published, the country of publication, the study design, and the studied population. Barriers to breast reconstruction were analyzed and categorized using the six dimensions of access-to-care framework by Penchansky and Thomas.[33–38] This allowed for the creation of a narrative synthesis.