Patients appear more likely to have immediate breast reconstruction after mastectomy if they live in communities with higher household incomes, lower population density and more individuals who have gone to college, according to a report in the November issue of Archives of Surgery, one of the JAMA/Archives journals.
Breast cancer affects 134 of every 100,000 women each year in the United States, according to background information in the article. Many women consequently undergo mastectomy, or surgical removal of the breast. If women choose to have reconstructive breast surgery, they can do it at the same time or after a delay. "Immediate reconstruction has been shown to be superior to delayed reconstruction for overall aesthetics, psychosocial well-being and cost-effectiveness," the authors write. "With these established benefits of immediate breast reconstruction, we hypothesized that we could use immediate reconstruction as a surrogate for optimal therapy and access to care for patients undergoing mastectomy."
Gedge D. Rosson, M.D., and colleagues at the Johns Hopkins University School of Medicine, Baltimore, analyzed data from 18,690 patients (average age 60.1) who underwent mastectomy in Maryland between 1995 and 2004. Community demographics were obtained from a commercially available software program.
The researchers focused their analysis on 17,925 patients who were white or African-American. Of these, 4,994 (27.9 percent) underwent breast reconstruction during the same hospitalization as their mastectomy. "We found that increasing income and increasing population density of the city in which the patient lives had statistically significant positive associations with the likelihood of immediate breast reconstruction," the authors write. "African American race/ethnicity, older age, increasing percentage of the patient's neighborhood with a high school education or less and increasing African American composition of the patient's neighborhood had statistically significant negative associations."
On an individual level, African Americans were 47 percent less likely to receive immediate reconstruction, and the likelihood decreased with increasing age. However, community factors were still associated with access to immediate reconstruction, independent of patient characteristics.
"In clinical medicine, we normally treat individuals, but this multilevel database analysis points to the need also to evaluate the community in which the patient lives," the authors conclude. "The racial/ethnic mix, mean [average] income and education level of the neighborhood and community are associated with breast cancer management outcomes. Prospective public health measures, including educational and informative programs, can be developed and implemented in the community to address these inequalities (particularly racial/ethnic disparities based on neighborhood) and to increase the likelihood that patients with breast cancer and mastectomy obtain immediate reconstruction."
- Gedge D. Rosson; Navin K. Singh; Nita Ahuja; Lisa K. Jacobs; David C. Chang. Multilevel Analysis of the Impact of Community vs Patient Factors on Access to Immediate Breast Reconstruction Following Mastectomy in Maryland. Arch Surg, 2008; 143 (11): 1076-1081.
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