Many, but not all, women who have mastectomy to treat breast cancer go on to have one or both breasts reconstructed. There are many ways to reconstruct a breast. Tissue from the back, belly, buttocks, or other part of the body can be used to create a new breast. Doctors call this autologous reconstruction. Saline or silicone gel implants are another option.
A study published by the Agency for Healthcare Research and Quality in October 2017 found that rates of breast reconstruction rose 62% from 2009 to 2014.
Now, another study suggests that minority women are less likely than white women to have immediate breast reconstruction after mastectomy, even when they live in the same area and have the same insurance as white women.
The study was published online on Oct. 25, 2017 by The American Journal of Surgery. Read the abstract of “Influence of race, insurance status, and geographic access to plastic surgeons on immediate breast reconstruction rates.”
Immediate breast reconstruction is done at the same time as mastectomy surgery. As soon as the breast is removed by the breast cancer surgeon, the plastic surgeon reconstructs the breast either with tissue from your body or with an implant (and sometimes both). Almost all the work is done during one operation, and you wake up with a rebuilt breast (or breasts).
For a number of years, research has suggested that minority women were less likely than white women to have breast reconstruction. Many doctors believed this disparity was because minority women tended to live in areas with fewer plastic surgeons and had no insurance or insurance that wouldn’t cover breast reconstruction.
"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 Paris Butler, M.D., assistant professor of plastic surgery at the University of Pennsylvania and lead author of the study.
To do the study, the researchers analyzed healthcare information from 2008 to 2012 from California, Florida, and New York. It’s estimated that these states represent 24% of the U.S. population.
The researchers found 65,246 women who had been diagnosed with breast cancer who had mastectomy. They then looked to see who had reconstruction and who didn’t.
The researchers measured the women’s access to plastic surgeons by looking at the number of plastic surgeons per 100,000 people living in each county in each of the three states. The researchers also grouped the women by race, as well as type of insurance, looking at private insurance versus public insurance -- either Medicare or Medicaid.
As they expected, the researchers found that overall, women with less access to plastic surgeons were less likely to have breast reconstruction. The type of insurance also affected the likelihood of having reconstruction:
- 60% of women with private insurance had immediate reconstruction
- 20% of women with public insurance had immediate reconstruction
Next, the researchers controlled for access to plastic surgeons by looking at immediate reconstruction rates among women by race for women who lived in the same areas. In counties with the highest number of plastic surgeons per 100,000 people:
- 59% of white women had immediate reconstruction
- 47% of Hispanic women had immediate reconstruction
- 42% of Black women had immediate reconstruction
- 41% of Asian, Pacific Islander, and Native American women had immediate reconstruction
The differences in immediate reconstruction rates were even more apparent when the researchers looked at the type of insurance the women had. Among women with private insurance who lived in areas with the highest numbers of plastic surgeons:
- 84% of white women had immediate reconstruction
- 65% of Hispanic women had immediate reconstruction
- 60% of Black women had immediate reconstruction
- 58% of Asian, Pacific Islander, and Native American women had immediate reconstruction
For women who had public insurance, immediate reconstruction rates were lower and the disparity was still there:
- 34% of white women had immediate reconstruction
- 28% of Hispanic women had immediate reconstruction
- 24% of Black women had immediate reconstruction
- 24% of Asian, Pacific Islander and Native America had immediate reconstruction
"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.
To close this gap, the researchers recommended:
- More outreach and education for women who’ve been diagnosed with breast cancer so women can be better advocates for themselves.
- Breast oncologists and primary care doctors be more vigilant about referring women to plastic surgeons to ensure that all women are informed of all their options.
- Plastic surgeons take an active role in reducing the disparity. For example, "There are fewer plastic surgeons accepting insurance, and that’s an area we can improve," Butler said.
Deciding whether to have a breast reconstructed after surgery to remove breast cancer is a very personal choice. If you’ve been diagnosed with breast cancer and are planning your surgery, you may decide not to have reconstruction, but it can be helpful to consider all your options.
It’s important to talk to all of your cancer doctors and your plastic surgeon about the best options for your unique situation. Talking to a plastic surgeon who is experienced in the options you’re considering may give you the most complete review of all your choices. When you have all the information, you can make a decision that is right for you and your personal preferences.
Here are some questions you might want to think about as you're making your decision about breast reconstruction:
- Is it important to you to have a permanent breast shape? Some women prefer to wear a prosthesis instead of having reconstruction.
- Is it important to you that your breasts look balanced when wearing a bra and bathing suits? Though you'll be able to see the difference between the rebuilt breast and your other breast when you're naked, reconstruction usually looks very natural when you're wearing a bra or bathing suit.
- In your unique situation, will breast reconstruction involve several surgeries over a long period of time? For many women, the answer is yes.
- Will your insurance pay for all the reconstruction procedures? Find out what your insurance company will cover.
- Did you have a lumpectomy that gave your breast a very different shape than it originally had? If you had a large portion of tissue removed, you might want to have reconstruction to restore a more balanced look.
- Do you have any other medical conditions that might affect your ability to heal after surgery? If you have diabetes, circulatory problems, or a bleeding disorder, it may take your body longer to heal from reconstruction surgery than someone who doesn't have these conditions.
- Do you have a condition that might give you a distorted image of your body? If you've been diagnosed with anorexia or bulimia, you may have a hard time accepting how your body looks in general, which may make it hard to accept how your reconstructed breast looks.
Talking to other women who have had breast reconstruction can give you more personal opinions about your options. There’s nothing like hearing from other women who’ve had it done -- and they may even be willing to share photos. Some great places to go are the Breastcancer.org Discussion Board forums called Breast Reconstruction and Living Without Reconstruction After a Mastectomy, where women share experiences and support each other. The site BreastFree is devoted to sharing stories, photos, and other information about opting to have no reconstruction after mastectomy. Many women call this "going flat."
For much more information, including types of reconstruction and the timing of reconstruction, visit the Breastcancer.org Breast Reconstruction pages.