Variations in the breast reconstruction rate in France: A nationwide study of 19,466 patients based on the French medico-administrative database

Background: Access to breast reconstruction (BR) surgery after a mastectomy remains limited, with a large degree of national and international variation despite its known psychological benefits and impact on quality of life. The aim of this study was to investigate the factors influencing breast reconstruction in France where cancer-related healthcare costs are fully reimbursed. Methods: All primary mastectomies for breast carcinoma performed in 2012 and linked BR surgeries from 2012 to December 2015 were extracted from the French medico-administrative database. A three-level logistic regression analysis was performed to model the probability of breast reconstruction according to patient, hospital and administrative region characteristics. Results: Among the 19,466 women who had a mastectomy in 2012, 5328 (27.4%) had breast reconstruction. Multivariate analysis showed that the BR rate was lower in patients living in an area with an unfavourable socioeconomic level (p <.001), in low volume hospitals (p <.001), and in public hospitals (18.6%) compared to private hospitals (25.9%), university hospitals (29.8%), and cancer centres (35.0%) (p <.001). BR rate was significantly lower in patients older than 65 compared to those younger (7.5% versus 42.1%, p <.001). The impact of age was even greater in public hospitals than in other centres (interaction test, p = .001). We also observed significant heterogeneity in the BR rate across regions, which could be partially explained by differences in the plastic surgeon density. Conclusions: Breast reconstruction rate heterogeneity could be attributed to women choice. However, our study suggests that unequal access to high-quality procedures also plays a role, particularly for older breast cancer women. (C) 2018 Elsevier Ltd. All rights reserved.