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

Discussion

Based on the results of our systematic review that examined access to breast reconstruction following breast cancer treatment over the past 20 years, we found that significant barriers existed in each of the six domains of the modified Penchansky and Thomas conceptual framework.[33–35,38] In the "availability" domain, the institution's designation and a paucity of plastic surgeons decreased access to breast reconstruction. In the "accessibility" domain, the rural geographic location of the institution or the patient decreased the likelihood of breast reconstruction. In the "accommodation" domain, the complex organizational demands required to provide breast reconstruction negatively impacted delivery of breast reconstruction. In the "affordability" domain, high costs of the procedure or poor reimbursement by insurance companies negatively influenced access to breast reconstruction. Costs affecting access included both direct surgical costs and indirect costs (e.g., loss of financial income from undergoing a major elective operation). In the acceptability domain, the physicians' views of breast reconstruction determined whether they discussed breast reconstruction, and ultimately influenced breast reconstruction rates. In the "awareness" domain, lack of information about breast reconstruction reduced patients' access to breast reconstruction.

Our review showed that each stakeholder had a role in the complex relationship between barriers and access to breast reconstruction. Patient factors, such as advanced age, non-Caucasian ethnicity, and lower socioeconomic status were negatively associated with access to breast reconstruction.[7,18,21,62,72,80,85,104] The location and type of hospital also influenced patient access to breast reconstruction; patients treated at a teaching hospital or in an urban setting were more likely to have access to breast reconstruction.[7,41,47,52,58–61] One possible explanation for this association may be that physicians in urban teaching hospitals are more likely to discuss breast reconstruction with younger and more educated patients.[16,56,72,75,98,101,103,106,107] The finding that patients treated in rural geographic locations have lower access to breast reconstruction is troublesome. A quick temporary solution is to ensure that smaller centers without a breast reconstruction service is partnered with a larger breast cancer center of excellence where patients can travel to undergo breast reconstruction if interested. A more equitable and long-term solution, however, is to build capacity in breast reconstruction service delivery in underserviced areas so that patients can be treated local to their home.

This review discusses the challenging topic of barriers of access to an essential component of cancer care, specifically breast reconstruction. Breast reconstruction is particularly vulnerable to inequity in access because of the multiple factors involved in its delivery. To tackle this challenging topic, barriers to breast reconstruction were categorized into a well-accepted access-to-care framework, ensuring an organized and comprehensive review of the relevant factors influencing access. In addition, the inclusion of a large number of studies allowed for the evaluation of barriers from multiple perspectives.

Modifiable barriers were found in the availability, awareness, and acceptability domains. Potential interventions to address these barriers include streamlining of care through improved referral processes and educational initiatives to inform patients and physicians. Automatic referral of eligible patients to a plastic surgeon for discussion of breast reconstruction could address the availability and awareness domains.[128–132] In the United States, this process could be facilitated by centers becoming accredited breast centers by the National Accreditation Program for Breast Centers.[133,134] Educational initiatives, such as the creation of a computer-based educational program, could provide high-quality information on the treatment options available to patients.[128–131] Furthermore, refining physician knowledge of the indications for breast reconstruction through the use of clinical guidelines may reduce the negative perceptions of physicians toward breast reconstruction. The proposed interventions target some of the identified modifiable barriers. Future research is needed to evaluate the feasibility and potential effectiveness of the proposed interventions.

This study was limited by the quality of the literature on barriers of access to breast reconstruction. The review included only observational studies, as no randomized clinical trials were available in the literature. Although the methodology of systematic reviews promotes the use of randomized clinical trials when possible, the research question was not amenable to such a study design. The inclusion of high-quality observational studies allowed for a comprehensive review of barriers to breast reconstruction from multiple perspectives, generating rich information. Also, studies included in this review were published in the English language. It is possible that some barriers faced by non–English-speaking countries differ from those presented. Another limitation is the lack of detailed understanding of the influence of each factor on access to breast reconstruction. The majority of articles included in the review were retrospective cohort studies, which described associations between factors and rates of breast reconstruction. This did not allow for the evaluation of factors such as patient preference. Future qualitative research that evaluates patient, physician, and institutional views of access to breast reconstruction may improve our understanding of these factors.

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