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Deconstructing Reconstruction: Unpacking Patient-Preference and Health Disparities in Breast Reconst

VIrginia Neese, Dr. Bryn Esplin

Texas A&M COM

Background: Breast cancer continues to be the second most common cancer in American women, behind skin cancer, with 1 in 8 being diagnosed within their lifetime. The American Cancer Society estimates 331,530 cases of breast cancer will be diagnosed in US in 2019. Since 2000, there has been a substantial increase in post-mastectomy reconstruction. With the introduction of both the Women’s Health and Cancer Rights Act of 1998 and The Breast Cancer Patient Education Act of 2015, one anticipates an increase in post-mastectomy reconstruction rates while disparities decreased. The goal of this project was to investigate whether a disparity in reconstruction persist, possible reasons for a sustained disparity, and what impact legislation has had on breast reconstruction in the US.

Methods: Comprehensive literature review, identification and assessment of past and present policy and legislation, comparison of procedure utilization, populations, and corresponding disparities, including factors related to the healthcare system and individual/community systems.

Results: In 2017, the American Society of Plastic Surgeons reported 106,295 breast reconstruction surgeries were preformed, which translates to a 62% increase. Interestingly, there has also been a widening gap in the method used for reconstruction. Implant-based reconstructions have increased 11% annually while tissue-based reconstructions have decreased 4% annually despite previously established higher patient satisfaction and lower long term cost of care with less re-operation. These trends correlate with overall changes in the healthcare system, including payer models and growing uncertainty for future payers. However, non-monetary factors have also been cited as contributing factors to differences in reconstruction methods –namely age, disease severity, hospital teaching status, and most significantly, the year the reconstruction was performed.

Conclusion: The degree of disparity seen in methods of reconstruction has not been previously described within plastic surgery literature and therefore warrants a more thorough investigation into systemic and/or institutional factors that perpetuate the treatment gap. To ensure more equitable interventions and outcomes, some factors, such as non-representative reimbursement for tissue based reconstruction, could be directly combated through policy change and lead to greater stakeholder success and satisfaction.

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