January 24, 2006

U-M expert: mandated insurance hasn’t increased breast reconstruction following mastectomy and racial disparities still exist; other factors may be hindering practice

ANN ARBOR, MI –Fewer than 20 percent of American women eligible for breast reconstruction following mastectomy, or removal of the breast, for breast cancer undergo the procedure, according to experts at the University of Michigan Health System.

In a letter published in the Jan. 25 issue of the Journal of the American Medical Association (JAMA), study lead author and U-M Health System Plastic Surgeon Amy K. Alderman, M.D., MPH, writes that despite mandated insurance coverage of breast reconstruction after mastectomy, disparities still exist in its use among certain races, including African Americans, Hispanics and Asians, and for women in certain regions of the country.

The findings, from a UMHS study of all women undergoing mastectomy for breast cancer from 1998 to 2002, assessed the impact of the Women’s Health and Cancer Rights Act. The WHCRA was established in 1999 to mandate insurance coverage of breast reconstruction after mastectomy. 

"We know that women who undergo breast reconstruction gain large improvements in their emotional, social and functional well-being, and hoped the law would increase use of reconstruction following mastectomy, since prior to the law, insurance companies did not cover the procedure," says Alderman, assistant professor in the Department of Surgery at the U-M Medical School and the Ann Arbor VA Health Care System.  "But our study found that the law has done nothing to improve usage among women. And with such large variations of use by geography and race, it brings up a lot of questions as to whether there is a problem, and if there is, how do we correct it?"

Where a woman lives can factor into the likelihood that she will undergo reconstruction too. The study found high rates of reconstruction in Detroit, Mich., and Atlanta, Ga., but low rates throughout the states of Iowa Connecticut, for example. 

To uncover other factors beyond insurance that may be driving patient patterns with breast reconstruction, Alderman calls for further research into breast cancer patients’ knowledge and preferences about reconstruction and access to reconstructive surgeons, especially among women of different races and ethnicities.

For her study of  breast reconstruction rates following the implementation of WHCRA, Alderman and her colleagues identified all women who had undergone mastectomy for breast cancer from 1998 to 2002 using the Surveillance, Epidemiology and End Results (SEER) program public-use data file. SEER, created by the National Cancer Institute, provides a sample population representative of approximately 26 percent of the U.S. population that covers all insurance and socioeconomic groups, and patient ages. 

To assess trends in breast reconstruction use before and after passage of the WHCRA, the study looked at women’s use of the procedure by race and region in 1998, and from 2000 to 2002.

The study revealed that, despite implementation of the WHCRA, there was no increase in breast reconstruction. Of the 51,184 women with breast cancer treated with a mastectomy between 1998 and 2002, only 16.5 percent of eligible patients underwent reconstruction.

There also was no measurable change in the racial and geographic disparities that existed prior to WHCRA. Compared to Caucasians, African Americans were still half as likely to undergo reconstruction, as were Hispanics and Asians, says Alderman.

"Race seems to be a big predictor of whether or not a woman will undergo reconstruction," she says. "So we need to find out if certain races simply are not getting the knowledge they need to make an educated decision, if they have different values and preferences regarding breast reconstruction, or if there are other access barriers not eliminated by WHCRA. We need to know what the ‘right’ rate of breast reconstruction is for women of different cultural backgrounds. We have a lot of hypotheses, but need more concrete answers."

 Alderman’s co-authors in the Department of Surgery at the U-M Health System were Yongliang Wei, MS, research assistant; and John D. Birkmeyer, M.D., George D. Zuidema Professor of Surgery and Chair, Surgical Outcomes Research.

Reference: JAMA, Jan. 25, 2006, Vol.295, No. 4.

Related links:

U-M to lead initiative to improve breast cancer treatment in Michigan

Many choose more aggressive breast cancer surgery despite breast-sparing option

Women overestimate breast cancer risk, U-M study finds

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