title: Access to breast reconstruction after mastectomy and patient perspectives on reconstruction decision making.
abstract: OBJECTIVE
  Most women undergoing mastectomy for breast cancer do not undergo breast reconstruction.
  
  
  OBJECTIVE
  To examine correlates of breast reconstruction after mastectomy and to determine if a significant unmet need for reconstruction exists.
  
  
  METHODS
  We used Surveillance, Epidemiology, and End Results registries from Los Angeles, California, and Detroit, Michigan, for rapid case ascertainment to identify a sample of women aged 20 to 79 years diagnosed as having ductal carcinoma in situ or stages I to III invasive breast cancer. Black and Latina women were oversampled to ensure adequate representation of racial/ethnic minorities. Eligible participants were able to complete a survey in English or Spanish. Of 3252 women sent the initial survey a median of 9 months after diagnosis, 2290 completed it. Those who remained disease free were surveyed 4 years later to determine the frequency of immediate and delayed reconstruction and patient attitudes toward the procedure; 1536 completed the follow-up survey. The 485 who remained disease free at follow-up underwent analysis.
  
  
  METHODS
  Disease-free survival of breast cancer.
  
  
  METHODS
  Breast reconstruction at any time after mastectomy and patient satisfaction with different aspects of the reconstruction decision-making process.
  
  
  RESULTS
  Response rates in the initial and follow-up surveys were 73.1% and 67.7%, respectively (overall, 49.4%). Of 485 patients reporting mastectomy at the initial survey and remaining disease free, 24.8% underwent immediate and 16.8% underwent delayed reconstruction (total, 41.6%). Factors significantly associated with not undergoing reconstruction were black race (adjusted odds ratio [AOR], 2.16 [95% CI, 1.11-4.20]; P = .004), lower educational level (AOR, 4.49 [95% CI, 2.31-8.72]; P < .001), increased age (AOR in 10-year increments, 2.53 [95% CI, 1.77-3.61]; P < .001), major comorbidity (AOR, 2.27 [95% CI, 1.01-5.11]; P = .048), and chemotherapy (AOR, 1.82 [95% CI, 0.99-3.31]; P = .05). Only 13.3% of women were dissatisfied with the reconstruction decision-making process, but dissatisfaction was higher among nonwhite patients in the sample (AOR, 2.87 [95% CI, 1.27-6.51]; P = .03). The most common patient-reported reasons for not having reconstruction were the desire to avoid additional surgery (48.5%) and the belief that it was not important (33.8%), but 36.3% expressed fear of implants. Reasons for avoiding reconstruction and systems barriers to care varied by race; barriers were more common among nonwhite participants. Residual demand for reconstruction at 4 years was low, with only 30 of 263 who did not undergo reconstruction still considering the procedure.
  
  
  CONCLUSIONS
  Reconstruction rates largely reflect patient demand; most patients are satisfied with the decision-making process about reconstruction. Specific approaches are needed to address lingering patient-level and system factors with a negative effect on reconstruction among minority women.
authors.affiliation: Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Monica
authors.initials: M
authors.lastname: Morrow
authors.affiliation: School of Public Health, University of Michigan, Ann Arbor.
authors.forename: Yun
authors.initials: Y
authors.lastname: Li
authors.affiliation: The Swan Center for Plastic Surgery, Alpharetta, Georgia.
authors.forename: Amy K
authors.initials: AK
authors.lastname: Alderman
authors.affiliation: Department of Radiation Oncology, University of Michigan, Ann Arbor.
authors.forename: Reshma
authors.initials: R
authors.lastname: Jagsi
authors.affiliation: Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles.
authors.forename: Ann S
authors.initials: AS
authors.lastname: Hamilton
authors.affiliation: Department of Radiation Oncology, Robert Wood Johnson Medical School, New Brunswick, New Jersey.
authors.forename: John J
authors.initials: JJ
authors.lastname: Graff
authors.affiliation: Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan8Medical School, University of Michigan, Ann Arbor9School of Public Health, University of Michigan, Ann Arbor.
authors.forename: Sarah T
authors.initials: ST
authors.lastname: Hawley
authors.affiliation: Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Katz
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D018270:Carcinoma, Ductal, Breast / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D003657:Decision Making; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D015141:Los Angeles / Q000453:epidemiology; D016462:Mammaplasty; D008408:Mastectomy; D008824:Michigan / Q000453:epidemiology; D008875:Middle Aged; D009367:Neoplasm Staging; D017060:Patient Satisfaction; D018426:SEER Program