Inequalities in breast cancer reconstructive surgery according to social and locational status in Western Australia

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Abstract

Aims: To study the effects of demographic, locational and social status and the possession of private health insurance in Western Australia on the likelihood of women receiving breast reconstructive surgery after surgery for breast cancer.

Methods: The WA Record Linkage Project was used to extract all hospital morbidity, cancer and death records of women with breast cancer in Western Australia from 1982 to 2001. Comparisons between those receiving and not receiving breast reconstructive surgery were made after adjustment for co-variates in Cox regression.

Results: Overall, 9.1% of women received breast reconstructive surgery after surgery for breast cancer. Women who were younger, with less co-morbidity and non-indigenous women were more likely to receive breast reconstructive surgery. Women in lower socio-economic groups were much significantly less likely to receive breast reconstructive surgery (RR 0.76; 95% CI 0.54–1.06). Women from rural areas were less likely to receive breast reconstructive surgery than those from metropolitan areas (RR 0.54; 95% CI 0.25–1.15) as were those treated in a rural hospital (RR 0.78; 95% CI 0.66–0.92). Treatment in a private hospital (RR 1.25; 95% CI 1.10–1.42) or with private health insurance (RR 1.25; 95% CI 1.08–1.39) independently increased the likelihood of breast reconstructive surgery.

Conclusion: The rate of breast reconstructive surgery was lower than expected with several factors found to affect the rate; women from disadvantaged backgrounds were less likely to receive breast reconstructive surgery than those from more privileged groups.

Introduction

For many women their breasts are a symbol of their femininity and sexuality. The loss of the breast, or part of the breast, after breast cancer surgery can have serious repercussions on their psychosocial health and relationships.1., 2., 3. Breast reconstructive techniques were first described in 1895, but it was not until the 1970s and 1980s that they became more commonly available.2 Relatively few women decide to undergo reconstructive surgery, but whether this is for economic reasons or fears of interference with any future breast cancer treatments is uncertain. Figures from the United States (US) cite reconstructive rates between 9 and 30% during the 1990s.3 There is a greater uptake in younger, less socio-economically disadvantaged women4., 5., 6., 7. and those outside the Southern or Midwestern states.6

In Australia, trends and predictors of reconstructive surgery have received little attention. The question remains open as to whether all eligible women are given equal opportunity to undergo breast reconstructive surgery. We used the WA Record Linkage Project to examine factors affecting reconstructive surgery rates after surgery for breast cancer in Western Australia (WA) from 1982 to 2000. Specifically, we investigated the role of social and locational status and the possession of private health insurance on the uptake of breast reconstructive surgery.

Section snippets

Linked data and case selection

The WA Record Linkage Project was used to extract all hospital morbidity, cancer registrations and death records of all women, residing in WA, with any mention of breast cancer in any record from 1st January 1982 to 31st December 2000. The ICD codes used for this extraction were ICD-9 170.0–170.9 and ICD-10 C50.0–C50.98., 9., 10., 11. The linkages were those current at 1st October 2001.

A case was defined as a female with a diagnosis of breast cancer on either their hospital separation record or

Results

The characteristics of the 1021 women who underwent breast reconstructive surgery after either a mastectomy or breast-conserving surgery for breast cancer between 1982 and 2000 are shown in Table 1. Women who underwent reconstructive surgery were generally younger, non-indigenous and had less co-morbidity. They were less likely to be socially disadvantaged and more likely to live in or have been treated in the metropolitan area. They were also more likely to have been treated in a private

Discussion

Access to breast reconstructive surgery has not been equitably distributed across socio-demographic groups with women, who were younger, not of indigenous descent or in less socially disadvantaged groups much more likely to receive breast reconstructive surgery, as were women in metropolitan areas. Women with private health insurance or treated in a private hospital at the time of their primary breast cancer surgery were also more likely to receive breast reconstructive surgery even after

Acknowledgements

The authors would sincerely like to thank the Western Australian Data Linkage Project for their assistance with the provision of data and advice for this research. This study was funded by an NHMRC postgraduate research scholarship.

References (23)

  • Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death

    (1977)
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