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Insurance, distance to care can be barriers to breast reconstruction

July 28, 2016

CHAPEL HILL - Women were less likely to have breast reconstruction surgery after mastectomy if they had Medicaid or Medicare rather than private insurance or if they lived 10 or more miles from a plastic surgeon's office, a University of North Carolina Lineberger Comprehensive Cancer Center study has found.

Researchers said the findings, published in the journal Plastic and Reconstructive Surgery, highlight additional barriers to breast reconstruction alongside other obstacles that have been identified including race, socioeconomic class and age. The new data are concerning, researchers said, as they say the procedure can help with self-esteem, sexuality and body image after cancer treatment.

"We know that breast cancer affects not only the physical wellbeing of the patient, but also her psychosocial wellbeing, and we know that breast reconstruction can help address those issues," said the study's first author Michelle Roughton, MD, an assistant professor of surgery and the program director for the UNC School of Medicine Section of Plastic and Reconstructive Surgery. "These findings highlight the fact that there are more barriers to breast reconstruction access than we previously recognized."

In the study, researchers analyzed insurance claims data for 5,381 women in North Carolina diagnosed with breast cancer between 2003 and 2006. The study included women with Medicaid, Medicare, or private insurance health plans, who had a mastectomy within six months of diagnosis and who continued to maintain their insurance coverage for at least two years after the procedure. Twenty percent of women included in the study chose breast reconstruction.

The study drew upon UNC Lineberger's Integrated Cancer Information Surveillance System (ICISS), a research tool that links to population and clinical data to health claims data for about 5.5 million people insured by Medicare, Medicaid, or private insurance policies.

In the raw, unadjusted data, they found that 56 percent of women with private insurance received breast reconstruction, compared with 10 percent of women with Medicare, or 11 percent of those with Medicaid. The study found after adjusting for related patient factors such as age or stage of disease, Medicare recipients had 42 percent lower odds of receiving breast reconstruction than women with private insurance, and women with Medicaid had 76 percent lower odds.

"Even when you control for age, the type of insurance patients had was still an independent predictor of whether patients received breast reconstruction," Roughton said.

By federal law, group health plans that pay for mastectomy must also cover breast prosthetics and reconstructive procedures. Medicare does cover the procedure, while Medicaid coverage can vary by state. Roughton said one factor affecting access to reconstruction may be that not all surgeons accept all types of insurance for the procedure.

"As doctors working for the state's flagship cancer hospital, we aim to provide breast reconstruction to every woman who desires it despite distance and payer," Roughton said.

Distance to the nearest plastic surgeon was also predictive of whether women underwent reconstruction. The study found that women living 20 or more miles away had 27 percent lower odds of receiving breast reconstruction compared to women living within 10 miles of a surgeon. Women living 10 to 20 miles away from the nearest surgeon had 22 percent lower odds.

The study also found that minority women had 50 percent lower odds of receiving reconstruction compared to non-Hispanic whites, and, consistent with previous studies, they found that increasing age at diagnosis, advanced cancer stage, and radiation treatment also decreased

odds. Roughton said she has tried to overcome distance obstacles for her patients by using telemedicine for initial consultations, and by using text and email to help assess patients after the operation.
The study was supported by the University Cancer Research Fund.

In addition to Roughton, other authors include: Paul DiEgidio, MD, of the UNC School of Medicine; Lei Zhou, MSPH, of UNC Lineberger; Karyn Stitzenberg, MD, MPH, of the UNC School of Medicine; and Anne Marie Meyer, PhD, of UNC Lineberger and the UNC Gillings School of Global Public Health.

UNC Lineberger Comprehensive Cancer Center

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