title: Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States.
abstract: OBJECTIVE
  Concerns exist regarding breast cancer patients' access to breast reconstruction, which provides important psychosocial benefits.
  
  
  METHODS
  Using the MarketScan database, a claims-based data set of US patients with employment-based insurance, we identified 20,560 women undergoing mastectomy for breast cancer from 1998 to 2007. We evaluated time trends using the Cochran-Armitage test and correlated reconstruction use with plastic-surgery workforce density and other treatments using multivariable regression.
  
  
  RESULTS
  Median age of our sample was 51 years. Reconstruction use increased from 46% in 1998 to 63% in 2007 (P < .001), with increased use of implants and decreased use of autologous techniques over time (P < .001). Receipt of bilateral mastectomy also increased: from 3% in 1998 to 18% in 2007 (P < .001). Patients receiving bilateral mastectomy were more likely to receive reconstruction (odds ratio [OR], 2.3; P < .001) and patients receiving radiation were less likely to receive reconstruction (OR, 0.44; P < .001). Rates of reconstruction receipt varied dramatically by geographic region, with associations with plastic surgeon density in each state and county-level income. Autologous techniques were more often used in patients who received both reconstruction and radiation (OR, 1.8; P < .001) and less frequently used in patients with capitated insurance (OR, 0.7; P < .001), patients undergoing bilateral mastectomy (OR, 0.5; P < .001), or patients in the highest income quartile (OR, 0.7; P = .006). Delayed reconstruction was performed in 21% of patients who underwent reconstruction.
  
  
  CONCLUSIONS
  Breast reconstruction has increased over time, but it has wide geographic variability. Receipt of other treatments correlates with the use of and approaches toward reconstruction. Further research and interventions are needed to ensure equitable access to this important component of multidisciplinary treatment of breast cancer.
authors.affiliation: Reshma Jagsi and Adeyiza O. Momoh, University of Michigan, Ann Arbor, MI; Jing Jiang, Sharon H. Giordano, Thomas A. Buchholz, Steven J. Kronowitz, Benjamin D. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Amy Alderman, The Swan Center For Plastic Surgery, Alpharetta, GA.
authors.forename: Reshma
authors.initials: R
authors.lastname: Jagsi
authors.forename: Jing
authors.initials: J
authors.lastname: Jiang
authors.forename: Adeyiza O
authors.initials: AO
authors.lastname: Momoh
authors.forename: Amy
authors.initials: A
authors.lastname: Alderman
authors.forename: Sharon H
authors.initials: SH
authors.lastname: Giordano
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Buchholz
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Kronowitz
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Smith
mesh_terms: D000328:Adult; D018427:Breast Implants / Q000706:statistics & numerical data; D001943:Breast Neoplasms / Q000601:surgery*; D005260:Female; D006801:Humans; D016015:Logistic Models; D016462:Mammaplasty / Q000379:methods / Q000706:statistics & numerical data* / Q000639:trends*; D015411:Mastectomy, Modified Radical; D008875:Middle Aged; D016017:Odds Ratio; D013524:Surgical Flaps / Q000706:statistics & numerical data; D014182:Transplantation, Autologous / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology