Geographic Variation in Breast Reconstruction Modality Use Among Women Undergoing Mastectomy

Purpose Despite changes in legislation and an increase in public awareness, many women may not have access to the various types of breast reconstruction. The purpose of this study was to evaluate variation in reconstructive modality at the health service area (HSA) level and its relationship to the plastic surgeon workforce in the same area. Methods Using the Arkansas, California, Florida, Nebraska, and New York state inpatient databases, we conducted a cross-sectional study of adult women undergoing mastectomy for cancer from 2009 to 2012. The primary outcomes were receipt of reconstruction and the reconstructive modality (autologous tissue versus implant) used. All data were aggregated to the HSA level and augmented with plastic surgeon workforce data. Correlation coefficients were calculated for the relationship between the outcomes and workforce. Results The final sample included 67,984 women treated across 103 HSAs. The average patient was 58.5 years, had private insurance (53.5%), and underwent unilateral mastectomy for invasive cancer. At the HSA level, the median immediate breast reconstruction rate was 25.0% and varied widely (interquartile range, 43.2%). In areas where reconstruction was performed, the median autologous (10.2%) and free tissue (0.4%) reconstruction rates were low, with more than 30% of HSAs never using autologous tissue. There was a direct correlation between an HSA's plastic surgeon density and autologous reconstruction rate (r = 0.81, P < 0.001). Conclusions Despite efforts to remove financial barriers and improve patients' awareness, accessibility to various modalities of reconstruction is inadequate for many women. Efforts are needed to improve the availability of more comprehensive breast reconstruction care.