Predictors of post-mastectomy reconstruction in an underserved population

Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, 763e769

Predictors of post-mastectomy reconstruction in an underserved population Erik M. Wolfswinkel a, Santiago N. Lopez a, William M. Weathers a, Sahar Qashqai b, Tao Wang c, Susan G. Hilsenbeck c, Mothaffar F. Rimawi c,d, Lior Heller a,* a

Division of Plastic Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, 6701 Fannin St. Suite 610, Houston, TX 77030, USA b University of Texas Health Science Center, Houston, TX, USA c Dan L Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA d Lester & Sue Smith Breast Center, Baylor College of Medicine, Houston, TX, USA Received 3 January 2013; accepted 21 February 2013

KEYWORDS Post-mastectomy reconstruction; Immediate reconstruction; Insurance status; Race; Minority; Breast reconstruction

Summary Objective: Past studies found insurance status, race, comorbidities and hospital setting influence the likelihood and timing of post-mastectomy breast reconstruction (BR). We evaluated these factors at a public hospital serving a predominantly minority and uninsured population. Methods: Women who underwent mastectomy and/or BR from 2005 to 2011 were reviewed. The association between patients’ characteristics and receipt of BR and timing (immediate BR vs. delayed BR) were analyzed. The 5-year overall BR rate was estimated with the KaplaneMeier method. Results: The analysis included 387 patients. 130 received BR. 85 (65%) received immediate BR and 25 (19%) underwent microsurgical repair. The total complication rate was 25%. The 5yr overall BR rate was 43% (95% CI: 36%e51%). Univariate factors positively associated with overall BR included younger age, non-smoker, lower BMI, no comorbidities, no neoadjuvant chemotherapy requirement, lower AJCC stage and negative lymph nodes. Younger age, no comorbidities, neoadjuvant chemotherapy, higher AJCC stage, and positive lymph nodes were positively associated with delayed breast reconstruction compared to immediate BR. Multivariate regression models show patient of younger age (p < 0.001), BMI less than 30 (p < 0.01), negative lymph nodes (p < 0.03) and no neoadjuvant chemotherapy requirement (p < 0.01) are more likely to have BR overall: young patients (p < 0.02) are more likely to have delayed BR. Race and insurance type were not significantly associated with BR or timing of BR given the patient population.

* Corresponding author. Tel.: þ1 832 832 3190; fax: þ1 832 825 3192. E-mail address: [email protected] (L. Heller). 1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.02.018

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E.M. Wolfswinkel et al. Conclusion: At a public hospital, serving a largely uninsured population, post-mastectomy rates of immediate BR and overall BR within 5 yrs are 22% and 43%, respectively. Overall complication rates were low and a substantial fraction of post-mastectomy patients received microsurgical BR. Contrary to previous studies, race and insurance status were not found to be the primary drivers of post-mastectomy reconstruction. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Introduction Each year over 292,000 American women are diagnosed with breast cancer. New treatment types and improved breast reconstruction techniques afford these women better options, permitting immediate breast reconstruction for the majority of post-mastectomy cancer patients. Immediate breast reconstruction (IBR) improves cosmesis, as well as psychological wellbeing. Yet, less than a quarter of women undergo immediate post-mastectomy breast reconstruction (BR).1 Using a national cancer database, one study found the IBR rates from 1985 to 1990 were as low as 3.4% while more recent studies suggest the current rates range from 20% to 35%.2e4 Given the benefits, one would expect post-mastectomy IBR utilization to be higher. Surgical trends suggest the majority of women with breast cancer choose breast conservation therapy (BCT) (57.8%) over mastectomy.5 In certain cases, mastectomy may be deemed necessary or preferred by an individual. Some indications for mastectomy include a desire to avoid radiation, limited access to radiation facilities, contraindications for BCT, increased tumor to breast size ratio, inflammatory cancer, or an attempt to avoid recurrence by excising more tissue. For these postmastectomy patients, breast reconstruction and timing of that reconstruction becomes an important and complex decision. Breast reconstruction is now multifaceted with the use of IBR and delayed breast reconstruction (DBR), and implants versus autologous reconstruction. Due to these multiple options, it is important to have early involvement of plastic surgeons to make an informed decision. The best management requires close collaboration between the plastic surgeon and the surgical oncologists, as well as attentiveness to the patient’s desires and concerns. In spite of its proven benefits, the use of IBR remains low. Studies have found that patient’s insurance status, race, medical conditions and hospital setting impact the likelihood and timing of BR.1e3,6e8 We evaluated the association of these factors with receipt of BR at a public hospital serving a predominantly minority and uninsured population.

Methods The Institutional Review Board for Human Subject Research for Baylor College of Medicine and Affiliated Hospitals approved a retrospective chart review of women with breast pathology, identified by current procedural terminology codes (CPT) undergoing mastectomy and/or BR from

2005 to 2011 at Ben Taub General Hospital (BTGH). CPT codes included 19301e19307, 19340e19342, 19357, 19361, 19364, and 19366e19369. Patients’ demographics were recorded including age, race, primary language, education, employment status, insurance status, marital status, number of children, tobacco use, body mass index, number of comorbidities, mastectomy date, AJCC tumor stage, lymph node involvement, neoadjuvant chemotherapy, plastic surgeon referral, and mastectomy complications. Patients who underwent BR were further evaluated for reconstruction technique, reconstruction timing (IBR versus DBR), and reconstruction complications. Complications were defined as infection, dehiscence, seromas, hematomas, flap necrosis, contracture, implant migration, and symptomatic implants. BR techniques included tissue expander use, Latissimus Dorsi (LD) Pedicle Flap, Transverse Rectus Abdominis Myocutaneous Flap (TRAM), Deep Inferior Epigrastric Perforators Flap (DIEP), Free LD Flap, and Free TRAM. Two-sample t-tests were used to examine the association between patients’ characteristics and receipt of BR, and reconstruction timing (IBR versus DBR). The patient’s characteristics were aggregated into clinically significant variables to be analyzed in univariate analyzes. All significant factors in the initial analyzes were included in multivariate logistic regression models to determine those that are predictive. The KaplaneMeier method was used to estimate the 5-year BR rate following mastectomy at BTGH after 2005.

Results 387 patients met inclusion criteria and were included in the analysis. The majority are Hispanic (55%), unemployed (44%), uninsured (40%) or on Medicaid (36%), married (51%), nonsmokers (73%) with a mean age of 52 years. (Table 1) 19 of the patients reviewed for inclusion, presented seeking BR following mastectomy at an outside hospital secondary to a change in insurance status or residence. BR and timing of BR demographics can be seen in Table 2. We identified 130 (34%) women who received BR. 85 (22% of post-mastectomy patients, 65% of BR patients) received IBR. 25 (19% of BR patients) underwent microsurgical repair. The total BR complication rate was 25%, with wound dehiscence being most common (5%) (Table 3). The 5 year estimated BR rate was 43% (95% confidence interval 36%, 51%) (Figure 1). In the initial analyzes, younger age,, non-smoker, lower BMI, no comorbidities, no neoadjuvant chemotherapy requirement, lower AJCC stage, and negative lymph nodes

Predictors of reconstruction

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Table 1 Summarizes the demographic characteristics of the study sample. (BTGH Z Ben Taub General Hospital, OSH Z Outside Hospital, BMI Z Body Mass Index). N Z 387 Mastectomy location BTGH OSH Age Mean (standard deviation) Range Race White Black Hispanic Other Primary language English Spanish Other Education Less than 12 years High school graduate College graduate Greater than college Unknown Employment Employed Unemployed Retired Unknown Insurance Self Pay Medicaid Medicare Indigent Commercial Unknown Marital status Single Married Divorced Widowed Unknown Number of children 0 1 2 3 4 or more Unknown Current smoker No Yes Unknown BMI (kg/m2) 18e25 25e30 30e40 Greater than 40 Unknown

n

%

378 9

98% 2%

52 (11) 25e82 38 100 213 36

10% 26% 55% 9%

175 188 24

45% 49% 6%

130 80 32 3 142

34% 21% 8% 1% 37%

69 172 19 127

18% 44% 5% 33%

15 140 41 156 7 28

4% 36% 11% 40% 2% 7%

101 197 50 37 2

26% 51% 13% 10% 1%

33 35 78 45 71 125

9% 9% 20% 12% 18% 32%

282 84 21

73% 22% 5%

84 123 127 24 29

22% 32% 33% 6% 7%

were positively associated with having BR (Table 4). Younger age, no comorbidities, neoadjuvant chemotherapy requirement, higher AJCC stage, positive lymph nodes, and neo-adjuvant chemotherapy were positively associated with DBR compared to IBR (Table 4). In multivariate logistic regression models, patients with younger age (p < 0.001), BMI less than 30 (p < 0.01), negative lymph nodes (p < 0.03) and no neoadjuvant chemotherapy requirement (p < 0.01) were independent positive predictors of BR. Notably, younger patients (p < 0.02) were more likely to have DBR. Smoking, AJCC stage were not significant in the multivariate regression models. Race and insurance type were not significant predictors of having BR or reconstruction timing (IBR vs DBR) given the patient population.

Discussion Despite the Women’s Health and Cancer Rights Act (WHRCA) of 1998 requiring that health insurance plans pay for reconstruction after mastectomy, few women undergo BR. These findings suggest that the WHRCA has not resulted in an increase in BR after mastectomy nor averted disparities in care pertaining to certain patient populations.9,10 The reasons for low BR and low IBR rates are likely multifactorial. Some argue that low referral rates to plastic surgeons before mastectomy is the reason. Others express concern that the complexity of newer microsurgical BR techniques, coupled with low reimbursement, may be contributing to a reduced volume of these procedures offered by plastic surgeons.11,12 Recent studies have found that patient’s insurance status, race, bodyhabitus, comorbidities and the type of hospital all have significant influence on the type of BR offered and chosen.1e3,6e8 Low utilization of BR and IBR may be explained by several factors. Many women with new breast cancer diagnoses are overwhelmed with their diagnosis. Low rates of BR and IBR may indicate a reluctance to undergo an extra surgical procedure or a lack of awareness of the availability of IBR.7 Trouble coping with their diagnosis may make it difficult to discuss surgical options early in management. Despite the benefits of IBR, low rates of IBR are observed. This may reflect concerns that IBR might delay the use of postoperative systemic therapy or hinder the detection of local disease recurrence,7 despite IBR being shown to be safe without increasing rates of recurrence or interfering with follow-up for recurrence.13e19 Making this information available to patients and emphasizing the availability of these procedures may help mitigate patient’s perceived misconception about IBR.7 Our study supports that multiple factors influence the choice of BR after mastectomy. Younger age, non-smoking, lower BMI, no comorbidities, no neoadjuvant chemotherapy requirement, lower AJCC stage, and negative lymph nodes are positively associated with having BR surgery, suggesting healthier individuals are more likely to receive BR. It is unclear if this is due to surgeon preference or patient preference. Surgeons may refer seemingly healthier patients with a lower tumor burden for BR.25 Patients with multiple medical comorbidities who end up receiving BR, are more likely to undergo IBR. This finding is likely

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Table 2 Summarizes the study sample’s receipt of reconstruction and timing of reconstruction based on demographics, disease characteristics and treatment. (BTGH Z Ben Taub General Hospital, OSH Z Outside Hospital, BMI Z Body Mass Index). N Z 387

No reconstruction

(No Z 257) n Mastectomy location BTGH 257 OSH 0 Age Mean (SDa) 54 (11) Range 28e82 Race White 25 Black 75 Hispanic 132 Other 25 Marital status Single 60 Married 123 Divorced 40 Widowed 32 Unkown 2 Current smoker No 175 Yes 64 Unknown 18 BMI (kg/m2) 18e25 51 25e30 68 30e40 99 Greater than 40 20 Unknown 19 Comorbidities Zero 69 One 58 Two or more 115 Unknown 15 AJCC stage No cancer/DCIS 36 Stage I 64 Stage II 77 Stage III 63 Stage IV 12 Phyllodes 2 Unknown 3 Lymph nodes affected No 129 Yes 119 Unknown 9 Neoadjuvant chemotherapy No 105 Yes 121 Unknown 31 a

SD: Standard Deviation.

Reconstruction

(No Z 130)

Reconstruction (N Z 130) Immediate reconstruction

Delayed reconstruction

(No Z 85)

(No Z 45)

%

n

%

n

%

n

%

100% 0%

121 9

93% 7%

85 0

100% 0%

36 9

80% 20%

48 (9) 25e71

49 (10) 25e71

44 (7) 28e59

10% 29% 51% 10%

13 25 81 11

10% 19% 62% 9%

10 14 53 8

12% 16% 62% 10%

3 11 28 3

7% 24% 62% 7%

23% 48% 16% 13%

41 74 10 5

31% 57% 8% 4%

25 48 7 5

29% 57% 8% 6%

16 26 3 0

35% 58% 7% 0%

73% 27%

107 20 3

84% 16%

71 13 1

85% 15%

36 7 2

84% 16%

21% 29% 42% 8%

33 55 28 4 10

28% 46% 23% 3%

21 39 16 3 6

27% 49% 20% 4%

12 16 12 1 4

29% 39% 29% 3%

29% 24% 47%

48 27 44 11

40% 23% 37%

27 21 34 3

33% 26% 41%

21 6 10 8

57% 16% 27%

14% 25% 30% 25% 5% 1%

25 41 33 13 1 5 13

21% 35% 28% 11% 1% 14%

23 30 19 6 1 5 1

27% 36% 23% 7% 1% 6%

2 11 14 7 0 0 11

6% 32% 41% 21% 0% 0%

52% 48%

90 27 13

77% 23%

68 12 5

85% 15%

22 15 8

59% 41%

46% 54%

68 37 25

65% 35%

54 20 11

73% 27%

14 17 14

45% 55%

Predictors of reconstruction Table 3 summary.

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Overall breast reconstruction complication

N Z 130

Complications No

Infection Dehiscence Seromas Swelling Hematoma Flap necrosis Scar & contracture Implant migration Symptomatic implant Infection & implant migration & contracture Infection & dehiscence Infection & flap necrosis Hematoma & flap necrosis Dehiscence & flap necrosis

%

3 7 0 2 4 4 2 1 2 1

2.3 5.4 0.0 1.5 3.1 3.1 1.5 0.8 1.5 0.8

1 2 2 1 32

0.8 1.5 1.5 0.8 24.6

explained by a surgeon’s desire to limit the number of procedures performed in this high-risk patient population. BR in patients with a higher tumor burden, such as a higher AJCC stage or positive lymph nodes, is negatively associated with IBR, likely due to the concern of postmastectomy radiation. Our finding that younger females are more likely to undergo BR is supported by many studies, with some suggesting age as the most significant variable associated with post-mastectomy BR.2,8,20 It may be that these patients are more concerned with their aesthetic outcome or that these patients are in better health without comorbidities dictating their treatment options. Additionally, the referring physician may be biased about how they treat various age groups, with elderly patients less likely to be referred for BR compared to younger patients.25 Interestingly,

Proportion of reconstruction

1.0

0.8

0.6

0.4

0.2

0.0 0

20

40

60

80

100

Months from mastectomy

Figure 1 KaplaneMeier curve for time to reconstruction. The reconstruction rate at 60 months (5 years) is 43%, 95% confidence interval 36%e51%.

younger patients were more likely to undergo DBR (p < 0.02) in our study, while other studies found they are more likely to undergo IBR.2,6e8,18,21e24 Even though younger age increases the likelihood of having BR overall, there are conflicting data as to whether or not age is a significant predictor of a patient’s choice of IBR versus DBR. This may be explained by both patient and hospital preferences, as well as the patient population being treated. The influence of race on breast cancer treatment has been the focus of several studies. Race and low socioeconomic status are associated with worse outcomes for several diseases including breast cancer.26 Several studies have demonstrated the influence of race on the timing and likelihood of undergoing BR. In a study performed at M.D. Anderson (MDA), African-American women underwent IBR at significantly lower rates than others (20.2% of AfricanAmerican women, compared with 40.0% of white women, 42.0% of Hispanic women, 42.2% of Asian women).6 Morrow et al. found that African American women were one-third as likely to undergo IBR as white women.7 Several studies have shown that BR rates were significantly lower in African American women in general, approximately half the rate of whites.2,23,27 This has been explained by African American patients being less likely to be referred for and offered BR.27 Additionally, it has been shown that African American women are less likely to follow-up with referrals or opt to have reconstruction.23,27 Perception of obstacles and lack of education about the procedures may explain why African Americans are not undergoing BR as often as other populations.7 A study of post-mastectomy BR patients in Connecticut reported that the use of BR was related to age at diagnosis and poverty level and not related to the patient’s race.8 In our study population, consisting of Hispanics (55%), African American (26%), Whites (10%) and other, we did not demonstrate a significant difference between races undergoing BR or opting for IBR versus DBR This suggests that in different hospital settings, the racial disparities in reconstruction rates and timing may be confounded by other variables. Similar trends for BR have been seen in Latin and Hispanic populations. At MDA, Hispanic women did not have significantly different IBR rates than white women.6 In an article by Alderman et al., they divided patients into acculturated Latinas and less acculturated Latinas. For the less acculturated patients they found that language barriers significantly reduced the patients understanding of what options were available for BR, what those options entailed and ultimately reduced utilization of BR. The less acculturated Latinas comprised mostly of uninsured women or women on Medicaid, were significantly less likely to receive BR as compared with those with private insurance or Medicare.28 Financial barriers related to limited insurance coverage for BR and access to plastic surgeons may be responsible for the difference in BR utilization. This trend has been supported by other studies, as well, where uninsured or Medicaid patients received less BR.2,3,8,18,21,29 This may be attributed to language barriers, information barriers, access to BR and that low income patients find it more difficult to spend additional time away from work.28 Despite our findings that race did not influence BR or the use of IBR, it is important to consider these factors as barriers to treatment.

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E.M. Wolfswinkel et al.

Table 4 Univariate and multivariate analyzes results based on clinically relevant study sample characteristics. (BMI Z Body Mass Index).

Age Race Black/others Hispanic/others Marital status Married/others Current smoker Yes/no BMI (kg/m2) 30/<30 Comorbidities One/no AJCC stage Stage III/
No reconstruction/reconstruction

Immediate reconstruction/delayed reconstruction

Univariate

Multivariates

Univariate

Multivariates

P

Odds ratio

P

P

Odds ratio

P

<0.001

0.93

<0.001

<0.01

0.90

P < 0.02

0.03 0.04

0.82 0.95

0.69 0.90

0.09

0.27 1.00 0.91

<0.05

0.59

0.22

0.88

<0.001

0.31

<0.01

0.35

<0.05

1.50

0.27

<0.05

0.76

0.67

<0.01

0.46

0.21

<0.05

2.32

0.52

<0.001

0.38

<0.03

<0.01

2.64

0.25

<0.01

0.38

<0.01

<0.01

2.22

0.20

The types of hospital and surgeon availability have been associated predictors of post-mastectomy BR. Alderman et al. found that most IBR was being performed at teaching hospitals or NCI Comprehensive Cancer Centers (NCIeCCC) in large urban settings. Teaching hospitals were twice as likely to perform IBR compared with nonteaching hospitals.28 Reuben et al. also demonstrated that having a mastectomy at a teaching hospital increased the likelihood of receiving BR overall. Patients undergoing mastectomies in an urban setting were significantly more likely to undergo BR.3 Increased BR rates in these settings have been attributed to the availability of plastic surgeons.18 In a survey looking at patterns of reconstruction, American Society of Plastic Surgeon’s correspondents described the lack of resident availability as significant barriers to the provision of post-mastectomy BR.30 This is a limiting factor, especially at rural or community hospitals.1 NCIeCCC’s post-mastectomy BR rates have been reported as high as 42%, with patients being 40% more likely to undergo BR following mastectomy at these hospitals compared to other hospital settings.2,21 BTGH is a large community hospital, associated with an academic center, making it able to provide a variety of BR types and techniques. The estimated 5-year postmastectomy BR rate was 43% (95% confidence interval 36%, 51%), comparable to that of NCIeCCC’s 42%.2,21 Of the 130 patients receiving BR, 85 (65% of BR patients) received IBR and 25 (19% of BR patients) underwent microsurgical repair with autologous reconstruction. The total BR complication rate was 25%. These findings are consistent with those reported nationally for all hospital settings.3 Of note, 19 patients presented seeking medical refuge for BR at BTGH. These patients had undergone

mastectomy at an outside hospital and then lost access to BR options at that hospital secondary to a change in insurance status or residence. These findings illuminate the quality of care provided at BTGH and the philosophy of our institution of providing universal access to care regardless of insurance status, socioeconomic class, or racial background. Retrospective studies are inherently limited in their ability to identify cause and predict outcome. To provide this missing information, further prospective studies are needed regarding the effect of patient demographics, including race and ethnicity on predicting post-mastectomy decision making in breast cancer management. Additionally, our study has limited generalization as it focuses on a single large community hospital in a large urban setting in Texas. Several studies have demonstrated geographical variations for BR after mastectomy.3,4,24 Our 34% overall BR rate is consistent with that reported for southern states but may not reflect national trends in breast cancer care. Other variables that influence the use of BR may not have been recorded confounding some of the results. Past research has shown that IBR improves patient’s psychological and sexual well-being. Yet, only a small percentage of women are receiving IBR. Many studies have found women who are uninsured or underinsured, who are older, who are black, and who are treated at rural or nonteaching hospitals are less likely to have IBR surgery. Efforts must be aimed at reducing the financial and information barriers faced by these women. These interventions need to focus on providing information on treatment options and availability prior to the patient’s initial surgery. Some of these issues are being addressed at various hospitals around the country but more intervention is needed.

Predictors of reconstruction

Conclusion The etiology of low BR and IBR rates remains multifactorial, varying for certain populations. In our review at a large public hospital serving a largely uninsured population, postmastectomy rates of IBR and estimated BR within 5 years are 22% and 43%, respectively. The serious complication rate was low and microsurgical reconstruction was used in a substantial fraction. These results are comparable to those seen nationally. Therefore, it is possible that increased accessibility to care, as seen in a county hospital setting, may negate race and insurance status as the largest predictors of post-mastectomy reconstruction.

Financial disclosures/commercial associations None.

Products/devices/drugs None.

References 1. Kruper L, Holt A, Xu XX, et al. Disparities in reconstruction rates after mastectomy: Patterns of care and factors associated with the use of breast reconstruction in Southern California. Ann Surg Oncol 2011;18(8):2158e65. 2. Morrow M, Scott SK, Menck HR, Mustoe TA, Winchester DP. Factors influencing the use of breast reconstruction postmastectomy: a National Cancer Database study. J Am Coll Surg 2001;192(1):1e8. 3. Reuben BC, Manwaring J, Neumayer LA. Recent trends and predictors in immediate breast reconstruction after mastectomy in the United States. Am J Surg 2009;198(2):237e43. 4. Polednak AP. Geographic variation in postmastectomy breast reconstruction rates. Plast Reconstr Surg 2000;106(2): 298e301. 5. Tuttle TM, Habermann EB, Grund EH, Morris TJ, Virnig BA. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol 2007;25(33):5203e9. 6. Tseng JF, Kronowitz SJ, Sun CC, et al. The effect of ethnicity on immediate reconstruction rates after mastectomy for breast cancer. Cancer 2004;101(7):1514e23. 7. Morrow M, Mujahid M, Lantz PM, et al. Correlates of breast reconstruction: results from a population-based study. Cancer 2005;104(11):2340e6. 8. Polednak AP. How frequent is postmastectomy breast reconstructive surgery? A study linking two statewide databases. Plast Reconstr Surg 2001;108(1):73e7. 9. Centers for Medicare and Medicaid Services. Available at: http://www.cms.gov/HealthInsReformforConsume/06_ TheWomen’sHealthandCancerRightsAct.asp. [Accessibility verified 01.07.12] 10. Alderman AK, Wei Y, Birkmeyer JD. Use of breast reconstruction after mastectomy following the Women’s Health and Cancer Rights Act. JAMA 2006;295(4):387e8. 11. Alderman AK, Storey AF, Nair NS, Chung KC. Financial impact of breast reconstruction on an academic surgical practice. Plast Reconstr Surg 2009;123(5):1408e13.

769 12. Alderman AK, Hawley ST, Waljee J, Morrow M, Katz SJ. Correlates of referral practices of general surgeons to plastic surgeons for mastectomy reconstruction. Cancer 2007;109(9):1715e20. 13. Osteen RT. Reconstruction after mastectomy. Cancer 1995; 76(10 Suppl.):2070e4. 14. Howard MA, Polo K, Pusic AL, et al. Breast cancer local recurrence after mastectomy and TRAM Flap reconstruction: Incidence and treatment options. Plast Reconstr Surg 2006; 117(5):1381e6. 15. Murphy Jr RX, Wahhab S, Rovito PF, et al. Impact of immediate reconstruction on the local recurrence of breast cancer after mastectomy. Ann Plast Surg 2003;50(4):333e8. 16. Kroll SS, Schusterman MA, Tadjalli HE, Singletary SE, Ames FC. Risk of recurrence after treatment of early breast cancer with skin-sparing mastectomy. Ann Surg Oncol 1997;4(3):193e7. 17. Medina-Franco H, Vasconez LO, Fix RJ, et al. Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg 2002;235(6):814e9. 18. Rosson GD, Singh NK, Ahuja N, Jacobs LK, Chang DC. Multilevel analysis of the impact of community vs patient factors on access to immediate breast reconstruction following mastectomy in Maryland. Arch Surg-Chicago 2008;143(11):1076e81. 19. Rivadeneira DE, Simmons RM, Fish SK, et al. Skin-sparing mastectomy with immediate breast reconstruction: A critical analysis of local recurrence. Cancer J 2000;6(5):331e5. 20. Desch CE, Penberthy LT, Hillner BE, et al. A sociodemographic and economic comparison of breast reconstruction, mastectomy, and conservative surgery. Surgery 1999;125(4):441e7. 21. Christian CK, Niland J, Edge SB, et al. A multi-institutional analysis of the socioeconomic determinants of breast reconstruction: A study of the National Comprehensive Cancer Network. Ann Surg 2006;243(2):241e9. 22. Rowland JH, Desmond KA, Meyerowitz BE, Belin TR, Wyatt GE, Ganz PA. Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst 2000;92(17):1422e9. 23. Alderman AK, McMahon Jr L, Wilkins EG. The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors. Plast Reconstr Surg 2003;111(2):695e703. 24. Joslyn SA. Patterns of care for immediate and early delayed breast reconstruction following mastectomy. Plast Reconstr Surg 2005;115(5):1289e96. 25. Lipa JE, Youssef AA, Kuerer HM, Robb GL, Chang DW. Breast reconstruction in older women: Advantages of autogenous tissue. Plast Reconstr Surg 2003;111(3):1110e21. 26. Cross CK, Harris J, Recht A. Race, socioeconomic status, and breast ccarcinoma in the U.S.: what have we learned from clinical studies? Cancer 2002;(95):1988e99. 27. Al-Ghazal SK, Fallowfield L, Blamey RW. Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur J Cancer 2000;36(15):1938e43. 28. Alderman AK, Hawley ST, Janz NK, et al. Racial and ethnic disparities in the use of postmastectomy breast reconstruction: results from a population-based study. J Clin Oncol 2009; 27(32):5325e30. 29. Chen JY, Malin J, Ganz PA, et al. Variation in physician-patient discussion of breast reconstruction. J Gen Intern Med 2009; 24(1):99e104. 30. Alderman AK, Atisha D, Streu R, et al. Patterns and correlates of postmastectomy breast reconstruction by U.S. plastic surgeons: results from a national survey. Plast Reconstr Surg 2011; 127(5):1796e803.