Barriers to Post-Mastectomy Breast Reconstruction: A Comprehensive Retrospective Study

Breast reconstruction following mastectomy improves quality of life and psychosocial outcomes, yet it is not consistently performed despite multiple federal mandates. Current data shows decreased reconstruction in minority races, those with a low socioeconomic status, and those holding public health insurance. Many barriers remain misunderstood or unstudied. This study examines barriers to post-mastectomy breast reconstruction to promote a supportive clinical climate by addressing multifactorial obstacles to equitable access to care.

The California Cancer Registry Data Surveillance, Epidemiology, and End Results (SEER) database and California Health and Human Services Agency Cancer Surgeries Database (2013-2021 and 2000-2021, respectively) were used in this retrospective observational study on mastectomy with immediate breast reconstruction (IBR), delayed breast reconstruction (DBR), or mastectomy only (MO) rates. Data were collected on age, sex, race, insurance type, hospital type, socioeconomic status, and residence. Pearson's chi-square analysis was performed.

We found that 168,494 mastectomy and reconstruction surgeries were performed (82.36% MO, 7% IBR, 10.6% DBR). The 40-49 age group received significantly less MO (38.1%) compared to the 70-74 age group (94.8%, (p = <0.001). Significantly more reconstruction was carried out in patients with private, HMO, or PPO insurance (IBR 75.86%, DBR 75.32%, p = <0.001). Almost all breast surgeries were in urban areas as opposed to rural/isolated rural areas (96.02% vs. 1.55%, p = <0.001). There was no significant difference between races. Of all surgeries, 7.46% were completed in a cancer center with significantly higher rates of IBR. LA County, San Luis Obispo/Ventura County, and Northern CA had significantly more MO than other regions (p = <0.001).

Reconstruction rates after mastectomy are low, with only 17.64% of patients undergoing reconstruction. Nationally, 70.5% of patients received MO, with 29.6% undergoing reconstruction. Significant factors positively contributing to reconstruction were private insurance, high SES, cancer center care, and urban residency. Identified barriers include public health insurance enrollment, rural or non-urban residence, older age, low SES, and non-white race/ethnicity, indicating potential monetary influences on care.