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Invited Critique
November 17, 2008

Multilevel Analysis of the Impact of Community vs Patient Factors on Access to Immediate Breast Reconstruction Following Mastectomy in Maryland—Invited Critique

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Copyright 2008 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2008

Arch Surg. 2008;143(11):1081. doi:10.1001/archsurg.143.11.1081

Rosson and colleagues have hypothesized that the frequency of immediate reconstruction following mastectomy is a surrogate for “optimal” breast cancer therapy. They report a disparity in the rate of immediate reconstruction that is related to age, race/ethnicity, education status, income, and community population density. Implicit in this is the assertion that lower-income African American women in more rural areas are not receiving the same quality of breast cancer treatment as higher-income urban white women. Many factors influence the decision for immediate reconstruction after mastectomy. Some of these are purely biologic; for instance, advanced primary cancers often require postmastectomy chest wall radiation therapy, making immediate reconstruction less desirable. Other factors are related to the expediencies and biases of the patient, the expediencies and biases of the surgeon (often assimilated by the patient), and simple logistics such as local availability of expertise. Systematic inequities in our health care system must be identified and corrected. The difficulty arises, however, when the rate of immediate reconstruction is proposed as a surrogate for optimal therapy. Intelligent, affluent, and well-informed women facing a mastectomy sometimes decide that the anticipated cosmetic benefits of reconstruction do not justify the pain, inconvenience, and risk involved. Do lower immediate reconstruction rates in poorer, more rural, primarily African American communities expose a systematic inequity, or do they simply identify a group of women for whom it is expedient to complete treatment as quickly as possible so that they can return to work? I am certain that both answers are correct. That every woman should have the option of breast conservation (if it is appropriate) or immediate reconstruction after mastectomy (if that is appropriate) cannot be debated. Because of the complexities involved in either of these decisions, neither is a suitable benchmark for “quality” of breast cancer care.

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