Variations in the breast reconstruction rate in France: A nationwide study of 19,466 patients based on the French medico-administrative database

Highlights

• A nationwide cohort representative of the current French breast cancer population.

• Older age is the main factor influencing BR rate.

• Lower BR rate in older patients (>65 years) (7.5%) than in younger ones (42.1%).

• Disparity in BR rates across hospitals, especially for older patients.

• BR rate heterogeneity and unequal access to high-quality procedures.

Abstract

Background

Access to breast reconstruction (BR) surgery after a mastectomy remains limited, with a large degree of national and international variation despite its known psychological benefits and impact on quality of life. The aim of this study was to investigate the factors influencing breast reconstruction in France where cancer-related healthcare costs are fully reimbursed.

Methods

All primary mastectomies for breast carcinoma performed in 2012 and linked BR surgeries from 2012 to December 2015 were extracted from the French medico-administrative database. A three-level logistic regression analysis was performed to model the probability of breast reconstruction according to patient, hospital and administrative region characteristics.

Results

Among the 19,466 women who had a mastectomy in 2012, 5328 (27.4%) had breast reconstruction. Multivariate analysis showed that the BR rate was lower in patients living in an area with an unfavourable socioeconomic level (p < .001), in low volume hospitals (p < .001), and in public hospitals (18.6%) compared to private hospitals (25.9%), university hospitals (29.8%), and cancer centres (35.0%) (p < .001). BR rate was significantly lower in patients older than 65 compared to those younger (7.5% versus 42.1%, p < .001). The impact of age was even greater in public hospitals than in other centres (interaction test, p = .001). We also observed significant heterogeneity in the BR rate across regions, which could be partially explained by differences in the plastic surgeon density.

Conclusions

Breast reconstruction rate heterogeneity could be attributed to women choice. However, our study suggests that unequal access to high-quality procedures also plays a role, particularly for older breast cancer women.

Introduction

Breast cancer is the most frequent cancer in women in Europe, with 464,000 new cases each year and 54,062 new cases in France in 2015 [1,2]. With improved treatment options resulting in a 10-year survival rate of 76%, it is essential to pay particular attention to the patient's quality of life [1]. Breast conserving surgery is performed as often as possible however, mastectomy is still needed in approximately 30% of the women treated for breast cancer [3]. For these patients, the benefit of breast reconstruction (BR) on quality of life has been widely reported due to improved physical, psychosocial and sexual well-being [[4], [5], [6]].

A review of the international literature showed significant variation in BR rates, which ranged from 4.9% to 81.2%, depending on the patient and tumour characteristics, surgeon/hospital and on psychological factors including patient choice. Among these considerations, age appears to be an important factor that influences BR rates [7]. In France, although the cost of BR is covered by national social insurance and is recommended by public health authorities, the proportion of women who opt for BR remains low (approximately 20% before 2012) [8].

The goal of this study was to investigate factors that influence BR in France in recent years by examining patient characteristics, especially patient age, as well as hospital features, regional medical access, and the interactions between these factors.