RESUMO
BACKGROUND: Patient and socioeconomic factors both contribute to disparities in post-mastectomy reconstruction (PMR) rates. We sought to explore PMR patterns across the US and to determine if PMR rates were associated with Medicaid expansion. METHODS: The NCDB was used to identify women who underwent PMR between 2004-2016. The data was stratified by race, state Medicaid expansion status, and region. A multivariate model was fit to determine the association between Medicaid expansion and receipt of PMR. RESULTS: In comparison to Caucasian women receiving PMR in Medicaid expansion states, African American (AA) women in Medicaid expansion states were less likely to receive PMR (OR .96 [.92-1.00] P < .001). Patients in the Northeast (NE) had better PMR rates vs any other region in the US, for both Caucasian and AA women (Caucasian NE ref, Caucasian-South .80 [.77-.83] vs AA NE 1.11 [1.04-1.19], AA-South (.60 [.58-.63], P < .001). Interestingly, AA patients residing in the NE had the highest receipt of PMR 1.11 (1.04-1.19), even higher than their Caucasian counterparts residing in the same region (ref). Rural AA women had the lowest rates of PMR vs rural Caucasian women (.40 [.28-.58] vs .79 [.73-.85], P < .001]. DISCUSSION: Racial disparities in PMR rates persisted despite Medicaid expansion. When stratified by region, however, AA patients in the NE had higher rates of PMR than AA women in other regions. The largest disparities were seen in AA women in the rural US. Breast cancer disparities continue to be a complex problem that was not entirely mitigated by improved insurance coverage.
Assuntos
Neoplasias da Mama , Medicaid , Neoplasias da Mama/cirurgia , Feminino , Disparidades em Assistência à Saúde , Humanos , Cobertura do Seguro , Mastectomia , Patient Protection and Affordable Care Act , Estados UnidosRESUMO
BACKGROUND: The authors determined the impact of postmastectomy radiotherapy (PMRT) on overall survival (OS) among patients with pT3N0M0 breast cancer in the National Cancer Data Base. METHODS: A total of 3437 patients with pT3N0M0 breast cancer who initially were treated with mastectomy between 2003 and 2011 were identified. Of these women, 1644 (47.8%) received PMRT (67% treated with chest wall RT alone and 33% treated with chest wall and regional lymph node irradiation). Univariable and multivariable analyses were conducted to identify characteristics associated with PMRT and OS. In addition, propensity score matching and interaction effect testing also were performed. RESULTS: PMRT was associated with age <40 years, private insurance coverage, treatment facility location within 10 miles of the patient's home zip code, Charlson-Deyo comorbidity score of 0, tumor size ≥7 cm, and treatment with chemotherapy or hormone therapy (all P<.05). PMRT was associated with improved 5-year OS (86.3% for patients treated with PMRT vs 66.4% for patients not treated with PMRT; P<.01). In addition to PMRT (hazard ratio, 0.72; 95% confidence interval, 0.59-0.87 [P<.01]), age ≤50 years, treatment at an academic/research program, Charlson-Deyo comorbidity score of 0, tumor size <7 cm, chemotherapy receipt, and hormone therapy receipt were associated with improved OS on multivariable analyses (all P<.05). Interaction testing found that PMRT improved OS independent of age, facility type, Charlson-Deyo comorbidity score, tumor grade and size, surgical margin status, and receipt of chemotherapy or hormone therapy (all P>.1). Finally, propensity score matching analysis confirmed the impact of PMRT on OS (P = .02). It is interesting to note that regional lymph node irradiation did not improve OS versus chest wall RT alone (P = .09). CONCLUSIONS: Among patients with pT3N0M0 breast cancer in the National Cancer Data Base, PMRT was found to be associated with improved OS regardless of surgical margin status, tumor size, and receipt of systemic therapy. Cancer 2017;123:2829-39. © 2017 American Cancer Society.