Stalled at the intersection: insurance status and disparities in post-mastectomy breast reconstruction.

PURPOSE: Post-mastectomy breast reconstruction (PMBR) is an important component of breast cancer treatment, but disparities relative to insurance status persist despite legislation targeting the issue. We aimed to study this relationship in a large health system combining a safety-net hospital and a private academic center. METHODS: Data were collected on all patients who underwent mastectomy for breast cancer from 2011 to 2019 in a private academic center and an adjacent public safety-net hospital served by the same surgical teams. Multivariable logistic regression was used to assess the effect of insurance status on PMBR, controlling for covariates that included socioeconomic, demographic, and clinical factors. RESULTS: Of 1554 patients undergoing mastectomy for breast cancer, 753 (48.5%) underwent PMBR, of which 592 (79.9%) were privately insured, 50 (6.7%) Medicare, 68 (9.2%) Medicaid, and 31 (4.2%) uninsured. Multivariable logistic regression showed a significantly higher likelihood of not undergoing PMBR for uninsured (OR 6.0, 95% CI 3.7-9.8; p < 0.0001), Medicare (OR 1.9, (95% CI 1.2-3.0; p = 0.006), and Medicaid (OR 1.5, 95% CI 1.0-2.3; p = 0.04) patients compared with privately insured patients. Age, stage, race and ethnicity, and hospital type confounded this relationship. CONCLUSION: Patients without health insurance have dramatically reduced access to PMBR compared to those with private insurance. Expanding access to this important procedure is essential to achieve greater health equity for breast cancer patients.

Persistent and interdependent: Racial disparities and their mechanisms in postmastectomy breast reconstruction.

BACKGROUND: Racial disparities in accessing postmastectomy breast reconstruction persist despite expansion of insurance coverage. An updated examination with a broad assessment of mediating factors in a "majority minority" community is needed. METHODS: Data were collected on all patients undergoing mastectomy for breast cancer from 2011 to 2019 in a private academic center and adjacent safety-net hospital. Multivariable logistic regression was used to assess the effect of race on postmastectomy breast reconstruction, controlling for predetermined potentially mediating and confounding variables. RESULTS: Of 1,554 patients, 63.8% (n = 203) of non-Hispanic White, 33.4% (n = 102) of Black, and 47.9% (n = 438) of Hispanic patients underwent postmastectomy breast reconstruction. Multivariable logistic regression showed that Black patients (odds ratio [OR] 3.6, 95% confidence internal [CI]: 2.2-5.9; P < .0001) undergo significantly less postmastectomy breast reconstruction than White patients. Age, insurance status, stage, and hospital type mediated this relationship. CONCLUSION: Black patients have substantially reduced rates of postmastectomy breast reconstruction compared with White patients, which is mediated by socioeconomic factors.

The Effect of Hospital Volume on Outcomes of Patients with Occult Breast Cancer.

INTRODUCTION: With limited data in regards to management, occult breast cancer (OBC) poses a challenging surgical scenario. Current surgical management includes axillary lymphadenectomy (ALND) with or without mastectomy. We sought to investigate the impact of hospital volume on surgical approach and survival outcomes of patients with OBC. METHODS: Patients with cT0N+ breast cancer were selected from the National Cancer Data Base (NCDB, 2004-2014). Primary outcome was overall survival (OS), calculated using Kaplan-Meier methods compared according to hospital volume: community cancer center (CC), comprehensive community cancer center (COMP), and academic center (AC). Secondary outcome was the rate of modified radical mastectomy (MRM). RESULTS: We identified 574 patients with OBC, 11.1% were treated at a CC, 51.8% at a COMP, and 37.0% at an AC. Patients treated at CC had lower socioeconomic status compared with COMP or AC (23.1%, 14.1%, 19.3%; p = 0.005, respectively). There was no difference in access to radiation therapy (p = 0.888) or neoadjuvant chemotherapy (p = 0.221). Patients treated at CC had worse OS compared with COMP or AC (87.04, 105.29, 108.06 mo, p = 0.026, respectively). There was an increased rate of MRM at CC compared with COMP or AC (54.7%, 41.2%, 30.5%, p = 0.003, respectively). CONCLUSIONS: A direct association seems to exist between hospital volume and outcomes of patients with OBC. Patients with OBC treated at AC were more likely to undergo breast-conserving approaches and had better survival than those treated at CC.