Travel Distance Is Still a Barrier to Breast Reconstruction after Mastectomy

Long travel distances continue to be a significant obstacle to breast reconstruction after mastectomy for breast cancer, reports a study in the January issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

"While greater patient awareness and insurance coverage have contributed to breast reconstruction rates in the United States, geographic barriers to access this service remain, particularly to academic centers," according to the new research by ASPS Member Surgeon Evan Matros, MD, and colleagues of Memorial Sloan Kettering Cancer Center, New York.

Geographic Barriers to Breast Reconstruction Suggest 'Unmet Need'

The researchers analyzed the relationship between travel distance and breast reconstruction in more than 1 million US women undergoing mastectomy from 1998 to 2011. Information for the study was drawn from the National Cancer Database. During the period studied, the overall rate of immediate breast reconstruction approximately tripled: from 10.6 percent in 1998 to 32.2 percent in 2011.

That trend likely reflected the Women's Health and Cancer Rights Act (WHCRA) of 1998, which mandated insurance payer coverage of breast reconstruction after mastectomy. The increase was greatest for implant-based reconstructions, although autologous breast reconstructions (using the patient's own tissues) also increased.

Based on distances from their home to the treatment center, "Patients who underwent mastectomy with immediate reconstruction had to travel significantly greater distances than patients who did not undergo reconstruction," Dr. Matos and coauthors write. Reconstruction was performed in about 14 percent of women who traveled zero to 20 miles for breast cancer treatment, compared to nearly 25 percent of those traveling 100 to 200 miles.

In addition, the travel distance for patients undergoing breast reconstruction increased during the study period: by two percent per year, compared to no significant change for women who didn't undergo reconstruction.

Reconstruction rates also varied by type of hospital: about ten percent for women treated at community hospitals, 20 percent at comprehensive community hospitals (which provide a broader range of services), and 26 percent at academic (university-affiliated) hospitals. Average travel distance was about 20 miles for the two groups of community hospitals versus 47 miles for academic hospitals.

Travel distance to high-volume hospitals performing autologous reconstruction more than doubled: from 22 to 53 miles. That reflected the high concentration of such specialized centers in metropolitan areas.

Geography is a key contributor to unequal healthcare access, which is an important source of variation in healthcare outcomes. "The greater distance traveled by women undergoing breast reconstruction, as compared to mastectomy without reconstruction, suggests the presence of a geographic disparity" Dr. Matos and colleagues write.

The researchers believe their findings suggest that measures providing insurance coverage—such as the WHRCA and the Affordable Care Act—will not be sufficient to eliminate barriers to accessing breast reconstruction after mastectomy. They conclude, "Greater numbers of plastic surgeons, especially in community [hospitals], would be one method of addressing this inequality."

Plastic and Reconstructive Surgery® is published by Wolters Kluwer.