Persistent Disparities in Breast Cancer Surgical Outcomes among Hispanic and African American Patients
Elbert J. Mets, BA, Fouad K. Chouairi, BS, Kyle S. Gabrick, MD, Tomer Avraham, MD, Michael Alperovich, MD, MSc.
Yale School of Medicine, New Haven, CT, USA.
PURPOSE: Breast cancer is a common malignancy in the United States, and is often treated with mastectomy followed by breast reconstruction. While there has been much focus on barriers for access to care around breast surgery, limited evidence exists regarding outcomes across race when these barriers are overcome. Quantifying how delayed breast cancer presentation impacts on breast cancer treatment among underserved populations has not been well elucidated. Clarifying whether there are differences in peri-operative outcomes across race can guide pre-operative counseling as well as identify areas for continued improvement beyond initial access. The present study aims to evaluate patient comorbidity profiles, breast cancer characteristics, extirpative modalities, and reconstructive outcomes by race over five consecutive years of surgical outcomes at an academic medical center.
METHODS: With institutional review board approval, records of all patients who underwent mastectomy with reconstruction at Yale New Haven Hospital between 2013 and 2017 were reviewed. Variables directly abstracted from patients' electronic medical records included patient demographics, comorbidities, operative variables, payer status, socioeconomic factors, and postoperative adverse outcomes.
RESULTS: A total of 1,045 patients underwent 1,678 breast reconstructions during the five-year period. Mean age and standard deviation was 49.8 ± 10.6 years with a BMI of 27.9 ± 6.5. Hispanic and African-American patients had significantly higher mean BMI (p < 0.001) and higher rates of ASA class III or IV (p = 0.025). Furthermore, Hispanic and African-American patients had higher rates of obesity, diabetes, and hypertension (p < 0.001 for all three comparisons), higher rates of smoking (p = 0.003), and increased history of prior abdominal surgery (p = 0.007). Comparing oncologic characteristics, this population subset had higher rates of neoadjuvant chemotherapy (p = 0.036) and prior history of radiation (p = 0.016). Hispanic and African American patients were more likely to undergo modified radical mastectomy (p = 0.002) over nipple-sparing mastectomy (p = 0.035). Reconstructive complications revealed a higher overall complication rate (p = 0.023), higher rates of partial mastectomy flap necrosis (p = 0.043), as well as arterial (p = 0.009) and venous insufficiency (p = 0.026) during microvascular reconstruction among Hispanic and African American patients.
CONCLUSION: Compared to other patients, the present study identifies higher comorbidity burdens, higher rates of prior radiation and neoadjuvant chemotherapy, and higher post-surgical complication rates among Hispanic and African American patients with breast cancer. While prior studies have noted poor access to care or reduced quality of care among some underserved racial groups, this study has identified persistent racial disparities despite comparable resources at a large academic center.
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