Minorities less likely to have breast reconstruction, but not for the reason many think

October 30, 2017

PHILADELPHIA - Minority women are far less likely to undergo breast reconstruction than white women, even if they live in the same area and have similar insurance. The finding from a new study from the Perelman School of Medicine at the University of Pennsylvania challenges the commonly held belief that the disparity is based on access to plastic surgeons or a patient's insurance status. The research, which will published next month in The American Journal of Surgery, shows that even when the number of plastic surgeons in the area are the same and the patient has private insurance as opposed to public, white women are 24 percent more likely to undergo reconstruction than black women, 26 percent more likely than Asians, Pacific Islanders, and Native Americans (APINA), and 19 percent more likely than Hispanics.

"We know that insurance status and the number of plastic surgeons in a given area affect reconstruction rates, but this is the first study to look at what happens when you control for both of those, and it shows the disparity exists on racial lines alone," said the study's lead author Paris D. Butler, MD, MPH, an assistant professor of Plastic Surgery at Penn.

Butler and his team analyzed surgery databases from California, Florida, and New York and used data from 2008 through 2012. Combined, these three states represented 24 percent of the population of the United States according to the 2010 census. In total, they identified more than 65,000 women with breast cancer who underwent a mastectomy, then looked at who had reconstruction and who didn't. Researchers measured the access these patients had to plastic surgeons by using a ratio of plastic surgeons per 100,000 people living in each county within the three states. They also grouped the patients by race as well as insurance status, looking at private insurance versus public - either Medicare or Medicaid.

As expected, less access led to fewer reconstructions. Insurance status was also a major factor, with about 60 percent of privately insured patients undergoing reconstruction compared to just 20 percent of those with public insurance. Those numbers represent the entire study population and are not divided by race.

However, the truly notable findings came after the researchers accounted for people living in the same area. In counties with the highest ratios of plastic surgeons per 100,000 people, white women underwent reconstruction 59 percent of the time, compared to 47 percent for Hispanic women, 42 percent for African-Americans, and 41 percent for APINA.

The disparity was even starker when insurance status entered into the equation. White women with private insurance who live in areas with the highest plastic surgeon density had reconstruction 84 percent of the time. The number drops to 65 percent among Hispanics, 60 percent among African-Americans, and 58 percent for APINA.

Even in the public insurance group, where rates were lower across the board, researchers still found the disparity. The rate for white women was 34 percent, compared to 28 percent for Hispanics, 24 percent for African-Americans, and 24 percent for APINA.

"This shows that race alone is a predictor of who is most likely to undergo reconstruction, and that this racial disparity exists independent of geography or socioeconomic status," Butler said.

Researchers identified three key areas to address in order to close the gap. First, they point to the need for more patient outreach and education so these communities can be better advocates for themselves. Second, they believe breast oncologists and primary care physicians need to be more vigilant in referring patients to plastic surgeons to ensure women are informed of their options. Third, they say plastic surgeons need to take more ownership of this disparity.

"There are fewer plastic surgeons accepting insurance, and that's an area we can improve," Butler said.

Butler also says there is a need for more plastic surgeons nationally, which should help improve access for women across the country.
Penn Medicine is one of the world's leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania (founded in 1765 as the nation's first medical school) and the University of Pennsylvania Health System, which together form a $6.7 billion enterprise.

The Perelman School of Medicine has been ranked among the top five medical schools in the United States for the past 20 years, according to U.S. News & World Report's survey of research-oriented medical schools. The School is consistently among the nation's top recipients of funding from the National Institutes of Health, with $392 million awarded in the 2016 fiscal year.

The University of Pennsylvania Health System's patient care facilities include: The Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center -- which are recognized as one of the nation's top "Honor Roll" hospitals by U.S. News & World Report -- Chester County Hospital; Lancaster General Health; Penn Wissahickon Hospice; and Pennsylvania Hospital -- the nation's first hospital, founded in 1751. Additional affiliated inpatient care facilities and services throughout the Philadelphia region include Good Shepherd Penn Partners, a partnership between Good Shepherd Rehabilitation Network and Penn Medicine.

Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2016, Penn Medicine provided $393 million to benefit our community.

University of Pennsylvania School of Medicine

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