American Indian/Alaska Native patients less likely to undergo breast reconstruction

American Indian/Alaska Native (AI/AN) women with breast cancer have consistently lower rates of breast reconstruction after mastectomy compared to non-Hispanic White women, reports a paper in the July issue of Plastic and Reconstructive Surgery.

"Despite an upward trend in reconstruction, AI/AN women continue to be less likely to undergo breast reconstruction," comments Jane Hui, MD, MS, of University of Minnesota, Minneapolis. "While our findings point to some possible approaches to reducing this disparity, it will be essential to also determine Native women's opinions related to breast reconstruction."

Focus on factors affecting breast reconstruction in AI/AN women

Using data from the National Cancer Database, the researchers identified 1,980 AI/AN women and 414,036 non-Hispanic White women who underwent mastectomy for breast cancer between 2004 and 2017. Annual breast reconstruction rates were compared between groups, along with factors associated with decisions about reconstruction.

The two groups differed in some important characteristics. American Indian/Alaska Native women had higher rates of other medical diagnoses (comorbidity), 20% versus 12%; were more likely to have public health insurance, 49% versus 20%; and more likely to undergo single-breast (unilateral) mastectomy.

Over the 13-year study period, breast reconstruction increased in both groups: from 13% to 47% for AI/AN women and from 29% to 62% from non-Hispanic White women. After adjustment for other factors, AI/AN women remained nearly one-half less likely to undergo reconstruction.

Other factors associated with lower reconstruction rates included older age, earlier year of diagnosis, more advanced cancer, unilateral mastectomy, public insurance, and living in an area of lower educational attainment. Within the AI/AN group, reconstruction was more likely for younger women; those with more recent diagnosis, less-advanced cancer, and less comorbidity; and those living in urban areas or areas with a higher level of educational attainment.

Insights for addressing breast reconstruction disparity in Native women

Breast reconstruction after mastectomy has known benefits for some, including improved quality of life and body image. However, breast reconstruction is a personal decision—there is "no optimal proportion" of patients who should opt for reconstruction, Dr. Hui and colleagues note.

American Indian/Alaska Native women face a wide range of health disparities and barriers to medical care, including elevated rates of chronic health conditions, later diagnosis and higher mortality from breast cancer.

"Complicating the health care environment in which AI/AN receive medical care is chronic underfunding of the Indian Health Service (IHS), implicit bias against AI/AN, and fraught relationships between physicians and AI/AN patients," the researchers write.

Their study offers insights into factors associated with the lower rate of breast reconstruction for AI/AN women with breast cancer. "Multidisciplinary efforts to improve care delivery to AI/AN women may continue to minimize disparities through earlier diagnosis and treatment," Dr. Hui and co-authors conclude.

"Simultaneously, qualitative research into AI/AN perspectives on breast cancer care could improve shared decision-making between physicians and AI/AN patients, empowering AI/AN women to choose post-mastectomy reconstruction if they so desire."