While the number of women who undergo breast reconstruction surgery post-mastectomy for breast cancer has risen over the last 20 years, racial disparities continue to exist, according to Paris Butler, MD, MPH, a professor of plastic surgery at Penn Medicine.
Butler, who specializes in plastic and reconstructive surgery, has documented the problem nationally and investigated the role of private vs. public insurance in determining which patients receive reconstructive surgery. While his work has found that insurance status and geographic availability to plastic surgeons likely play a role in the disparities, "we strongly believe it's something about patients' race and ethnicity that goes beyond insurance status and access to care." Recently, we asked him a few questions about his work, which he presented to the American College of Surgeons in D.C. on October 20th.
Q. Are there statistics on racial disparities when it comes to reconstruction after breast cancer?
A. In early 2000, a survey of nationwide breast reconstruction showed that approximately 40% of Caucasian and approximately 20% of African American women were receiving reconstructive breast surgery. With the passage in 1998 of the Women's Health and Cancer Rights Act (WHCRA), that requires that group insurance plans must cover breast reconstruction after a mastectomy, as well as legislation in specific states, the numbers rose to about 45 percent for all women.
In a study in 2015, our plastic surgery group at the University of Pennsylvania used national surgery datasets to study more than 48,000 women who had mastectomy only, or mastectomy with breast reconstruction between 2005 and 2011. Overall, reconstruction rates rose from 26% of women in 2005 to 40% in 2011. Yet while Caucasian women had a 40% rate of surgical reconstruction, other racial and ethnic groups were at approximately 30%, a ten percent difference.
Q. Why do you think these disparities exist?
A. We've examined several factors. In one study we looked at who had access to breast reconstruction based on how many plastic surgeons practiced in a geographic area. In this study looking at New York, California, and Florida, we found that among all women as there was an increase in the number of plastic surgeons practicing in a community, the rate of breast reconstruction increased. Unfortunately, though, even in these areas that had a higher propensity of plastic surgeons, women of color still had lower rates of reconstruction than their Caucasian counterparts.
As a result we then examined insurance coverage status. In this analysis we found that among all women, having private insurance (non-Medicare/non-Medicaid) led to greater rates of breast reconstruction for all. However sadly, when looking more closely at women that had private insurance, we found that privately insured Caucasian women had a breast reconstruction rate of approximately 85%, while privately insured African-American and Latino women had reconstruction rates of just 60% and 65%, respectively. Thus private insurance helps, but does not assist all racial/ethnic groups equally.
These findings are obviously troubling, because according to our research, even if these women have access to plastic surgeons and have private insurance, race and ethnicity still play a part in terms of whether or not they will receive breast reconstruction.
Q. What are some possible remedies to this problem?
First, patients have to be made aware of the reconstructive options. This includes both implant-based reconstruction as well autologous "flap" procedures, where a person's own tissue is used for reconstruction rather than implants. By improving this community's health literacy, it is our hope that they would feel empowered to ask "What are my reconstructive options?" at the time they are diagnosed.
Secondly, we are strongly advocating that all women diagnosed with a breast cancer that will require a mastectomy, be referred to a plastic and reconstructive surgeon regardless of their age or race/ethnicity. We believe that all women are, at a minimum, entitled to discuss the possibility of breast reconstruction with a specialist in that field.
Lastly, we as plastic and reconstructive surgeons need to ensure that all of our colleagues are providing the same dialogue with breast cancer patients regardless if they are Caucasian or a woman of color. We must provide an environment that not only allows us to further educate these women of their reconstructive options, but also allows them and their families to ask any and all questions regarding these procedures whether seemingly significant or trivial. In short, the open dialogue has to be there.