January 24, 2006
Few eligible women opt to rebuild breast after removal
for breast cancer, despite insurance coverage
U-M expert: mandated insurance
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.
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
"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
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,
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.
Alderman also notes the importance of measuring physician attitudes
about reconstruction, as part of the effort to minimize variations
in reconstruction rates by race and geography.
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
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
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.
The study was funded by the Ann Arbor VA Health Services Research
and Development, and the U-M Health System.
Reference: JAMA, Jan. 25, 2006, Vol.295, No. 4.
Written by Krista Hopson
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