Disparities in Breast Reconstruction Persist After ACA, Reports Plastic and Reconstructive Surgery®
More women are undergoing post-mastectomy reconstruction, but racial gaps remain

Despite steady increases in rates of immediate breast reconstruction (IBR) after mastectomy, racial disparities in IBR have persisted in the years since implementation of the Affordable Care Act (ACA), reports a study in the May issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS). The journal is published in the Lippincott portfolio by Wolters Kluwer.

"Our study demonstrates that Hispanic women are more likely to undergo post-mastectomy breast reconstruction compared to their non-Hispanic counterparts in the post-ACA era," comments lead author Rachel E. Schafer, MPH, a medical student at Cleveland Clinic Lerner College of Medicine. "However, our analysis shows persistent racial disparities in breast reconstruction care. To better understand these trends, future studies are needed for targeted interventions to ensure equitable reconstructive care for all patients with breast cancer."

Upward trends in breast reconstruction under ACA

The researchers used data from the American College of Surgeons' National Surgical Quality Improvement Project to analyze trends in IBR. The analysis focused on the impact of the ACA, which had some provisions – such as expanding protections for pre-existing conditions and reducing the number of uninsured Americans – with the potential to enhance healthcare access to historically marginalized groups. The analysis included 224,506 patients undergoing mastectomy in 2005-08, before passage of the ACA, or 2016-22, after full ACA implementation.

Pre-ACA data showed significant racial disparities in IBR. Reconstruction rates ranged from 35.1% in White patients to 28.8% in Asian patients, 22.3% in Black/African American patients and 3.8% in American Indian/Alaska Native patients. Patients of Hispanic ethnicity were also less likely to undergo IBR: 28.0%, compared to 33.4% in non-Hispanic patients.

After ACA implementation, IBR rates increased across racial groups. The largest increases were seen for American Indian/Alaska Native and Black/African American patients: by 27.6% and 24.2%, respectively, compared to a 16.9% increase among White patients. Smaller but significant increases were seen in Asian patients and those classified as "other" race. Hispanic patients had a 25.8% increase in IBR, compared to 14.5% in non-Hispanic patients.

Racial disparities remain; Hispanic patients now more likely to have reconstruction

However, racial minority groups continued to have lower IBR rates in the years since the ACA rollout. In 2016-22, the IBR rate was 52.0% among White patients, compared to 46.5% for Black/African American, 38.7% for Asian and 31.4% in American Indian/Alaska Native patients. In contrast, Hispanic patients were more likely to undergo IBR compared to non-Hispanic patients: 56.6% versus 45.7%.

The researchers note some important limitations of their study. It cannot account for the wide range of factors affecting access to reconstructive surgery or for the "complex interplay of cultural, social and individual factors" affecting decisions about breast reconstruction.

For patients undergoing mastectomy, breast reconstruction can restore form and enhance patient satisfaction. The new analysis shows "a steady increase in immediate breast reconstruction rates in all minority groups when compared to White patients" since the ACA.

"However, despite this advancement, disparities persist among different racial groups, indicating a complex landscape of reconstructive surgery rates despite legislative efforts," the researchers write. "These findings underscore the need for continued efforts to address disparities and promote equitable reconstructive care."

Plastic and Reconstructive Surgery® is published by Wolters Kluwer.

Click here to read "Legislative Impact and Persistent Disparities: Postmastectomy Breast Reconstruction Rates in the United States among 224,506 Patients"

Article: "Legislative Impact and Persistent Disparities: Postmastectomy Breast Reconstruction Rates in the United States among 224,506 Patients" (doi: 10.1097/PRS.0000000000011815)