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

Results

We identified 6497 articles from our search, from which 2215 duplicates were removed. We performed a title and abstract screen, which deemed 310 articles as potentially relevant (Figure 1). A full-text review further eliminated 211 articles based on topic relevance, population, mastectomy indication, and publication type.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009;6:e1000097.

Study Characteristics

Of the 99 studies included in the review, the majority (61 of 99) were published in the United States, followed by Australia (10 of 99), the United Kingdom (seven of 99), and Canada (five of 99). The number of publications per year increased from 1.4 studies per year (1996 to 2000) to 17.6 studies per year (2012 to 2016). Retrospective cohort studies (57 percent) and surveys (36 percent) were the most commonly published study designs.

Barriers to Access

Availability of Service. Institutional characteristics affected the availability of reconstructive services (Table 1). Patients had greater odds of undergoing breast reconstruction when treated at an academic or teaching hospital compared with a nonteaching hospital (nine studies).[7,27,41–49] A greater number of plastic surgeons at the institution[7] or a higher density of plastic surgeons in the patient's geographic location[43,50–52] led to a higher likelihood of undergoing breast reconstruction (five studies).[7,43,50–52] A Canadian study found that institutions with two or more plastic surgeons had higher odds of performing immediate breast reconstruction (OR, 2.01; 95 percent CI, 1.53 to 2.65).[7] Patients treated at a private hospital (five studies),[21,47,53–55] at a national cancer institution center (two studies),[43,47] or at a higher volume hospital (eight studies)[7,27,45,47,49,53,56,57] had greater likelihood of undergoing breast reconstruction. Thus, the designation of the institution, caseload of the hospital, and the supply of plastic surgeons at the institution affect the availability of breast reconstruction.

Geographic AccessibilityWhere a patient lives and where the hospital is located both affect access to breast reconstruction.[47,52,58–61] Rural geographic location of the institution (10 studies) or of the patient (seven studies) was associated with reduced odds of breast reconstruction (10 studies).[7,18,21,27,41–43,45,46,48,52,57,62–65] A greater distance between the patient and the provider was associated with decreased odds of breast reconstruction (three studies); one study showed that patients needed to travel significantly farther (31.3 miles versus 25.8 miles; p < 0.01) to undergo breast reconstruction than mastectomy alone.[7,41,66] Rural geographic location of the patient or the institution was association with reduced access to breast reconstruction, and led to greater travel distances for patients to undergo breast reconstruction.

Accommodation or Organization of Care. The complex organizational demands needed to offer breast reconstruction at the institution can negatively impact the volume of breast reconstruction performed. The need for availability of resources, such as the operating room and the reconstructive team, was reported to negatively influence a patient's access to breast reconstruction.[67,68] Sandelin et al. found that access to operating room time was the most common barrier to breast reconstruction in the public sector.[67] In addition, the lack of access to a plastic surgeon is a barrier to the delivery of breast reconstruction.[69] Studies have shown that higher rates of breast reconstruction are performed in centers with plastic surgery departments or a greater number of plastic surgeons.[7,51] Some patients treated at centers without reconstructive services were dissuaded from seeking breast reconstruction because of the additional organization it would involve.[68] The resource-intense nature of breast reconstruction led to difficulty for some institutions to offer this procedure, impacting access to breast reconstruction.

Affordability. Breast reconstruction may not be affordable to all patients because of the cost of the procedure or because of poor insurance coverage. Patients with lower median income and in lower socioeconomic groups were found to have lower rates of breast reconstruction (19 studies).[7,19,21,42,43,45,57,61,70–81] The association between income and low rates of breast reconstruction was observed even in countries with health care coverage of this procedure, such as in Canada and Denmark.[7,19,82] These findings suggest that lower socioeconomic status affects access to breast reconstruction, even when ability to pay is not a factor.

Poor reimbursements of the procedural costs by insurance companies affected patients' decision to undergo breast reconstruction. The highest rates of breast reconstruction were found among those patients with private health insurance (25 studies).[16,21,22,27,42,44,46,48,49,57,63,65,71,72,76,82–91] One study reported that 16.7 percent of patients did not undergo breast reconstruction because of a lack of insurance.[92] For patients who had insurance, difficulties obtaining reimbursements for this procedure were frequently encountered.[93] Direct and indirect costs of the procedure, poor access to insurance, and difficulty obtaining insurance reimbursements acted as affordability barriers for this procedure.

Acceptability by the Patient and Provider. Physicians' characteristics and beliefs toward breast reconstruction influenced their acceptability of breast reconstruction, thus affecting their likelihood of offering breast reconstruction. Older male surgeons with lower caseloads and a greater number of years in practice were found to be less likely to perform breast reconstruction (five studies).[57,67,69,94,95] Furthermore, physicians' beliefs and opinions of breast reconstruction influenced their likelihood of recommending it. Despite contrary evidence demonstrating the oncologic safety of breast reconstruction, the majority (41 to 70 percent) of general surgeons believed breast reconstruction interfered with adjuvant therapy, and a significant proportion (25 to 76.5 percent) were concerned that breast reconstruction may mask the detection of local recurrence, leading them not to recommend this procedure.[69,94,96–100] Thus, physicians' characteristics, previous experience, and views of breast reconstruction influenced access to breast reconstruction.

Physicians' beliefs and opinions of breast reconstruction also influenced their patient interactions and referral patterns, ultimately affecting rates of breast reconstruction.[9,56,69,75,93,97,99,101–106] In the literature, large variability was reported in rates of discussion of breast reconstruction by cancer care providers and primary care providers, from 33 to 81 percent.[75,101,103,104] The difference in rates of discussion or referral by breast surgeons directly affects rates of breast reconstruction. In one study where 66.5 percent of mastectomy patients were referred for breast reconstruction, 91.7 percent of those referred underwent breast reconstruction, whereas 100 percent of those not referred did not undergo breast reconstruction.[107] Thus, lower rates of discussion and referral for breast reconstruction are linked with lower rates of breast reconstruction.

These variations in the rates of referral by physicians can be explained in part by the selection of patients based on their clinical and tumor characteristics (nine studies).[56,72,75,87,88,91,101,103,106] Patient characteristics that were more likely to lead to discussion of breast reconstruction included younger age, healthy, more educated, English speaking, Caucasians who had insurance, higher income, or a less invasive breast cancer (nine studies[16,56,72,75,98,101,103,106,107]). Sociodemographic background of patients and clinical characteristics therefore influenced the likelihood of a physician to suggest breast reconstruction.

To further corroborate the link between patient characteristics and breast reconstruction, other studies have found a direct correlation between patient or tumor characteristics and rates of breast reconstruction, irrespective of physician referrals. Advanced age (59 studies[7,9,16,18–22,27,42–44,46,49,50,52–55,57–65,73–80,84–87,89–91,93,103,104,108–120]) and non-Caucasian race (35 studies[9,16,22,27,42–46,48,50,55,58–62,64,72,78–81,83,84,89,91,93,103,104,106,110,113,114,121]) have been associated with significantly lower rates of breast reconstruction, whereas more educated women (15 studies[9,19,20,22,49,63,73,74,76,93,103,104,112,115,122]), married women (12 studies[21,27,43,60,62,63,73,75,77,109,121,123]), and patients with fewer comorbidities (16 studies[19,21,22,27,43,46,55,58,65,73,76,90,91,103,114,119]) have been found to have significantly higher rates of breast reconstruction. Tumor characteristics also impacted rates of breast reconstruction: advanced tumor stage (28 studies[7,18,42–44,49,55,57,59–62,71,73,76,77,79,84–87,89,91,104,110,112,115,116,123,124]) and the need for postoperative chemotherapy or radiotherapy (17 studies[16,22,52,57,59,62–64,75,76,84,85,90,91,103,110,116]) were associated with significantly lower rates of breast reconstruction. Sociodemographic background of patients and tumor characteristics therefore directly impact rates of breast reconstruction and may be related to acceptability of this surgical option by the physician, the patient, or both.

Awareness of Treatment and Indications. Patients' lack of awareness of breast reconstruction was consistently found to be a barrier of access to breast reconstruction.[17,22,49,68,92,101,104,108,119,125–127] Many women were not aware of the option to undergo breast reconstruction after mastectomy; anywhere from 5.4 to 66 percent of patients were unaware and therefore unable to pursue the option of breast reconstruction (seven studies).[22,92,101,104,108,119,125] Furthermore, many women had difficulty making an informed decision about breast reconstruction because of a lack of high-quality information; up to 85 percent reported that it was the main reason they did not undergo breast reconstruction (six studies).[17,49,68,92,125,126,17,49,68,92,104,127] A lack of awareness or quality information therefore negatively impacted access to breast reconstruction.

Stakeholder Roles

Stakeholders—specifically patients, physicians, and institutions—impacted access to breast reconstruction through varying roles and relationships with the six access-to-care domains (Figure 2). Patients were found to have impaired access to breast reconstruction because of their geographic location, ability to afford breast reconstruction, and awareness of the procedure, categorized, respectively, as accessibility, affordability, and awareness barriers. Physicians impacted access through their differing views of breast reconstruction and their availability to perform the procedure, leading to acceptability and availability barriers. Furthermore, their role in informing patients of the option of breast reconstruction affected patient awareness. Lastly, institutions played a role in the delivery of breast reconstruction through varying availability or ability to accommodate for breast reconstruction. From the patient perspective, barriers of access to breast reconstruction were present from the diagnosis of breast cancer diagnosis to breast reconstruction delivery (Figure 3). The lack of awareness of breast reconstruction options acted as the first barrier to access. Once aware of the option, patients needed to be able to discuss the surgery with a plastic surgeon, a process that depended on physician availability and institution accessibility. Lastly, to undergo the procedure, patients must have been able to afford the operation and the institution needed to be able to accommodate for breast reconstruction. Thus, the barriers categorized into the six access-to-care domains interplayed at many levels with the different key stakeholders, illustrating the complexity of the identified barriers.

Figure 2.

The roles of key stakeholders in access to breast reconstruction, categorized using the Penchansky and Thomas framework. BC, breast cancer; BR, breast reconstruction.

Figure 3.

The patient's experience with barriers to access to breast reconstruction.

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