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. 2024 May 29:22925503241255142. Online ahead of print. doi: 10.1177/22925503241255142

Racial Disparities in Immediate Breast Reconstruction after Mastectomy: A Systematic Review and Meta-Analysis

Les disparités raciales dans les cas de reconstruction mammaire immédiate après une mastectomie : une analyse systématique et une méta-analyse

Shurjeel Uddin Qazi 1, Sarah Aman 2, Muhammad Hassaan Wajid 2,✉, Zainab Qayyum 2, Muhammad Bilal Shahid 2, Alina Tanvir 2, Sania Javed 2, Mahnoor Saeed 2, Eesha Razia 2, Alina Nayyar 2, Osama Abdur Rehman 2, Faisal Khosa 3
PMCID: PMC11562238  PMID: 39553526

Abstract

Background: In the past few decades, there has been a gradual increase in breast reconstruction post mastectomy; however, there exists a conflict about whether race has an influence on reconstruction rates. Methods: We conducted an electronic search from MEDLINE and Cochrane CENTRAL from their inception to September 2022. Primary outcome was disparity in rates of Immediate Breast Reconstruction (IBR) in racial minorities. Odds ratios were pooled using a random-effects model. All statistical analyses were performed on the Review Manager. Quality of included studies was assessed using the Joanna Briggs Institute critical appraisal checklist. Results: Twenty studies (n = 1 840 671) were identified. The pooled analysis of all the studies showed that subjects in racial minorities were significantly less likely to receive IBR as compared to White subjects (OR = 0.62, [95% confidence interval: 0.57-0.68; P < .01, I2 = 97%]. Subgroup analyses revealed that Asian subjects were the least likely to undergo IBR among different minorities (OR = 0.43). Conclusion: There exists a significant disparity in rates of IBR in different racial minorities as compared to White subjects. Future studies are warranted to assess factors contributing to such disparities in provision of healthcare.

Keywords: racial disparity, immediate breast reconstruction, breast cancer, ‌mastectomy

Graphical abstract.

Graphical abstract

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This is a visual representation of the abstract.

Introduction

Racial disparity refers to imbalances and incongruities, including income, societal treatment, economic status, and healthcare opportunities, between different racial groups. 1 These differences, specifically the limitations in access to healthcare, lead to poorer outcomes across multiple healthcare domains, especially in response to surgical interventions in many racial minorities. This phenomenon has been widely explored in various surgical interventions.2–5

In the past few decades, there has been a gradual increase in both immediate and delayed breast reconstruction post mastectomy. 6 The National Institute of Health Care Excellence guidelines state that women undergoing mastectomy should be presented with an option of breast reconstruction during the initial consultation. 7 According to the Women's Health Care and Cancer Rights Act in 1998, health plans that offer breast cancer coverage are also required to provide coverage for breast reconstruction and prostheses. 8 In order to increase awareness and availability of reconstructive procedures among racial minorities, Breast Cancer Patient Education Action Coalition was introduced in 2015. Immediate reconstruction offers better cosmetic results, decreased psychological distress and reoperation rates.9–11 Despite the consensus of the beneficial effects of immediate breast reconstruction (IBR), literature has shown that the rates of reconstructive breast surgery are much lower in certain racial groups such as African-Americans and Hispanics.12,13

There exists a conflict about whether race has an influence on reconstruction rates, with certain studies reporting a disparity with rates being much higher in Caucasian women as compared to minority races,12,13 while others reporting a lack of significant impact of race on reconstruction rates.14,15 The factors implicated include social, cultural, and religious beliefs associated with certain races, socioeconomic status, education level, types of insurance plans, 16 regional density of races, and availability of better healthcare facilities. 17 Other factors that need to be considered are health literacy over breast reconstruction options, geographic access to a plastic surgeon, and lastly but most importantly, the physician's failing to offer IBR as an option and inconsistency in their referral pattern. 18

The aim of our study was to reach a consensus about the association between race and IBR in patients undergoing mastectomy with the hope that, in the future, the results might help surgeons ensure equal availability of reconstructive procedures among all racial groups.

Materials and Methods

Data Sources and Search Strategy

We used the guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). 19 Our search strategy included all the relevant search terms that had any relationship to either the target population or the outcome being studied.

We conducted an electronic search from MEDLINE, Cochrane CENTRAL, from their inception to September 2022 with no language restrictions. The search string for all the databases was (mastectomy OR breast surgery) AND (race OR racial disparity OR blacks OR African American OR people of African descent OR Asians OR Hispanics OR whites OR Caucasians OR Indians OR browns) AND (immediate breast reconstruction OR IBR). The reference lists of the articles were also manually checked for any relevant studies that could have been missed during the initial search. In addition, we also searched through the World Health Organization's website for any relevant data. The detailed search string including all the syntax elements is given in Supplemental Table 1.

Eligibility Criteria

Only those studies were eligible that included: (a) adult females (≥18 years old) who underwent IBR postmastectomy; (b) adjusted odds ratio (AOR) as effect size while comparing race with rate of IBR; and (c) white population as a reference.

Studies having any of the following were excluded: (a) target population ≤18 years old (b) comparison of nonwhite population as a reference with other races; (c) reporting of effect sizes other than AORs for correlation between race and IBR; (d) case reports, review articles, and meta-analyses.

Selection Process

All the retrieved results were uploaded to Google Sheets alongside the links to the articles. Duplicates among the databases were identified and removed promptly. Two independent reviewers (Z and MS) screened the remaining articles (kappa = 0.92) and only the studies that strictly met the eligibility criteria were included in the analysis. Initially, the titles and abstracts of the studies were checked for relevance, however, in case of reasonable doubt regarding relevance, full-text articles were studied. Any disagreement between the reviewers was resolved by a discussion with the third investigator (SUQ). The primary outcome was disparity in rates of IBR in different racial minorities as compared to the White population.

Quality Assessment

To assess the reliability of the included studies, all the shortlisted studies were assessed by Joanna Briggs Institute (JBI) Critical Appraisal Checklist.

Statistical Analysis

All statistical analyses were performed on Review Manager (Version 5.4.1, Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014). A detailed analysis was conducted using the AOR with 95% confidence intervals (CIs), and the results were pooled using a random effects model. Higgins I2 was used to assess the statistical heterogeneity between trials, an I2 statistic of more than 50% was considered to have significant heterogeneity, and a value less than 50% for I2 was considered acceptable. In all cases, a P-value of .05 or less was regarded as significant. Detailed subgroup and sensitivity analyses were conducted to eliminate the heterogeneity obtained using Higgins I2, and forest plots were drafted to visualize the results. Publication bias was identified using a funnel plot.

Results

Literature Search Results

A total of 252 results were retrieved after the initial search. After removing the duplicates and screening the studies based on inclusion and exclusion criteria, 20 studies were evaluated.18,20–38 The results are summarized in the PRISMA flowchart (Figure 1).

Figure 1.

Figure 1.

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Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram elaborating the literature review process.

Study Attributes and Baseline Characteristics

All the included studies were retrospective and had data extracted from the local and national databases. All of them included White patients whereas only 18 included Black patients,18,20–28,30–34,35(p321),37,38 12 included Hispanic patients,20–22,24–27,31–33,35 and 9 included Asian patients.18,20,21,24,26,27,31,34,35 The studies evaluated a total of 1 840 671 participants undergoing mastectomy out of which 485 943 (26.40%) underwent IBR. Baseline characteristics of all the included studies are shown in Table 1.

Table 1.

Baseline Characteristics of Included Studies.

Serial number Author(s) Year of publication Time period (of database search) Study design Setting/Database Total no. of Mastectomy patients/Population size (n) No. of patients who underwent IBR (n) Races reported in the study Type of IBR (Implant vs Autologous)
1 Meade et al 2022 Oct 2016-Oct 2019 Retrospective Chart review (safety-net hospital) 645 180 White, Non-White (Hispanic, African American, Asian) Combination
2 Mandelbaum et al 2021 2005-2014 Retrospective NIS database 729 340 301 055 White, Black, Hispanic, Asian, Other (combined group of Native American and other races as reported by NIS) Combination
3 Siotos et al 2020 2003-2015 Retrospective Johns Hopkins SKCCC Tumor Registry 1459 984 Caucasian, African American, Asian, Hispanic, Other Combination
4 Sergesketter et al 2019 1998-2014 Retrospective USA (SEER database) 346 418 75 506 White, Black, Hispanic, Other Combination
5 Momoh et al 2019 July 2013-Sept 2014 Retrospective USA (SEER database) 936 484 White, Black, Latina, Asian NA
6 Wirth et al 2018 2000-2013 Retrospective USA (SEER Database) 51 862 10 113 Black, White Combination
7 Richards et al 2018 2004-2008 Retrospective US/ Nationwide Inpatient Sample (NIS), National Cancer institute (NCI), 5760 2385 Black, White, Hispanic, Asian, Other NA
8 Schumacher et al 2017 2004-2013 Retrospective USA (The National Cancer Database (NCDB)) 297 121 145 577 White, Black, Other Combination
9 Offodile et al 2015 2005-2011 Retrospective ACS-NSQIP database (USA) 44 597 16 642 White, Black, Asian, Hispanic NA
10 Mahmoudi et al 2015 1998-2006 Retrospective US/New York State inpatient database 44 621 NA White, African American, Hispanic Implant
11 Butler et al 2015 2005-2011 Retrospective US/ ACS-NSQIP 48 564 16 150 Caucasian, African American, Hispanic, Other Autologous
12 Fischer et al 2014 2005-2011 Retrospective ACS-NSQIP datasets 42 823 12 383 White, Black, Hispanic, Other Combination
13 Kruper et al 2013 2003-2007 Retrospective OSHPD database 4395 402 White, Hispanic, African American, Asian, Other (6 American Indians/Alaskan natives, 14 native Hawaiians/ other Pacific Islanders, 303 with races other than as stated above, and 160 white with unknown ethnicity) Implant
14 Hershman et al 2012 Jan 2000-March 2010 Retrospective US (Perspective database) 123 702 37 360 White, Black, Other Combination
15 Kruper, Holt et al 2011 2003-2007 Retrospective US/ California office of statewide health planning and development hospital discharge database (OSHPD) 15 794 4152 White, African American, Asian, Other, Unknown Combination
16 Kruper, Xu, et al 2011 2003-2007 Retrospective US (OSHPD) 18 222 5270 White, Hispanic, African American, Asian, Other (one Native American patient, 74 patients with races other than white, African American, or Asian, and 80 white patients with unknown ethnicity), Unknown NA
17 Jeevan et al 2010 April 2006-Feb 2009 Retrospective UK (HES database) 44 837 7375 White, non-White Combination
18 Rosson et al 2008 Jan 1, 1995-Dec 31, 2004 Retrospective US (Maryland Hospital Discharge Database) 17 925 4994 White, African American NA
19 Morrow et al 2005 Dec 2001-Jan 2003 Retrospective USA (SEER database) 646 245 White, African American, Other NA
20 Tseng et al 2004 Jan,1 2001-Dec 31, 2002 Retrospective USA (The University of Texas M. D. Anderson Cancer Center) 1004 376 White, African American, Hispanic, Asian, Middle Eastern NA
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Abbreviations: NA, not applicable; IBR, immediate breast reconstruction.

Results of the Meta-Analysis

All the studies reported rates of IBR following mastectomy in individual racial minorities, using White patients as the reference population. The pooled analysis of all the studies showed that patients in racial groups other than White (Asian, Hispanic, and Black populations) were significantly less likely to receive IBR as compared to White patients (OR = 0.62, [95% CI: 0.57-0.68; P < .01, I2 = 97%]. Subgroup analysis based on the individual racial minorities revealed the following trends: Black patients were 33% less likely to undergo IBR compared to White patients (OR = 0.67 [95% CI: 0.61-0.74]; P < .01, I2 = 97%), while Asian patients underwent IBR at a rate that was 57% lower (OR = 0.43 (95% CI: 0.35-0.53); P < .01, I2 = 81%). Finally, Hispanic patients were 27% less likely to receive IBR compared to their White counterparts (OR = 0.73 (95% CI: 0.64-0.84); P < .01, I2 = 91%). Figure 2 summarizes these results.

Figure 2.

Figure 2.

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Subgroup analysis based on ethnicity.

Quality Assessment

The detailed assessment of quality of the included studies is summarized in Table 2.

Table 2.

Quality Assessment Using JBI Critical Appraisal Checklist.

Study Study population Exposure Ascertainment of exposure Confounders identification Adjustment for confounders Presence of outcome of interest Assessment of outcome Follow-up time Follow-up loss Strategies for loss to follow-up Statistical analysis Score
Fischer et al22 Y Y Y Y Y Y Y NA NA NA Y 8
Jeevan et al29 Y Y Y Y Y Y Y NA NA NA Y 8
Kruper et al21 Y Y Y Y Y Y Y NA NA NA Y 8
Mahmoudi et al32 Y Y U Y Y Y N NA NA NA Y 6
Mandelbaum et al20 Y Y Y Y Y Y Y NA NA NA Y 8
Meade et al36 Y Y Y Y Y Y Y NA NA NA Y 8
Butler et al33 Y Y Y Y Y Y Y NA NA NA Y 8
Hershman et al38 Y Y U Y Y Y Y NA NA NA Y 7
Kruper et al35 Y Y Y Y Y Y Y NA NA NA Y 8
Momoh et al18 Y Y N Y Y Y N NA NA NA Y 6
Morrow et al30 Y Y N Y Y U N NA NA NA Y 5
Offodile et al24 Y Y N Y Y Y Y NA NA NA Y 7
Richards et al31 Y Y Y Y Y Y Y NA NA NA Y 8
Schumacher et al28 Y Y Y Y Y Y Y NA NA NA Y 8
Sergesketter et al25 Y Y N Y Y Y Y NA NA NA Y 7
Siotos et al26 Y Y N Y Y Y Y NA NA NA Y 7
Tseng et al27 Y Y N Y Y Y Y NA NA NA Y 7
Wirth et al23 Y Y Y Y Y Y Y NA NA NA Y 8
Rosson et al37 Y Y Y Y Y Y Y NA NA NA Y 8
Kruper et al34 Y Y Y Y Y Y Y NA NA NA Y 8
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Abbreviations: Y, yes; N, no; U, unclear; NA, not applicable; JBI, Joanna Briggs Institute.

Publication Bias

Funnel Plot analysis, shown in Figure 3, of the three racial minorities suggests a significant publications bias especially for Asian patients where studies clutter around 0.5. This means that most studies published were focusing on Asian patients having lower odds of receiving IBR than White subjects. Studies which were not published were not included. While the funnel plot of Black and Hispanic patients is not uniform enough to rule out publication bias, most studies gather near the value of 1, suggesting a smaller difference in the odds of receiving IBR when compared with the White population. This could also explain the high heterogeneity in the results, especially for Asian minorities. Well-published studies covering all aspects of a particular outcome may help to configure more causes of disparity and may also reduce heterogeneity for future meta-analyses.

Figure 3.

Figure 3.

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Funnel plot analysis for the ethnic minorities.

Discussion

This meta-analysis was conducted to evaluate the association between race and the receipt of IBR in postmastectomy patients. The results showed a decreased likelihood of receiving IBR in all racial minorities compared to the White population. The discrepancy was most pronounced in Asian patients, with a 57% lower likelihood of receiving IBR. This was followed by Black patients, which had a 33% lower likelihood, and finally, Hispanic patients with a 27% lower likelihood of receiving IBR.

In general, the available evidence was assessed as having moderate quality. Out of the 20 studies included in the final analysis, 17 provided combined AORs. Sensitivity and subgroup analyses had only minimal impact on the odds ratios, with the overall results consistently demonstrating a significant positive association.

In comparison with the two largest studies that have been conducted previously, Mandelbaum et al 20 and Sergesketter et al, 25 our study corroborates the existing notion that racial disparity exists between various races despite the increasing trend of postmastectomy IBR in recent years. Our meta-analysis reinforces the trend observed in the receipt of IBR in association with race. Due to the larger pool included in the analysis, it can be highlighted with greater certainty that racial minorities are lagging behind the White population in receiving IBR after undergoing mastectomy.

Wirth et al 23 explained how geographical regions have an impact on the receipt of IBR among the different races themselves, later comparing them to the White population. Black subjects belonging to the Southwest region were more likely to receive postmastectomy breast reconstruction than those living in the Pacific Coast. Other regions showing disparity included the East and Southwest regions. Mandelbaum et al 20 explained that factors such as an age less than 40, private insurance coverage along with top income quartile range, a high load of patients, an urban-teaching hospital setting, and bilateral mastectomy, were associated with an increased odds of IBR.

Segesketter et al 25 pointed out that the type of IBR also influences the rates of IBR. Compared to the White population, which prefers implant-based reconstruction, tissue-based IBR is preferred in the Black and Hispanic populations. Similar results were explained by Offodile et al 24 which revealed that the Asian subgroup preferred a free-transfer autologous reconstruction over an implant-based reconstruction.

An increasing trend of IBR due to expansion of the state Medicaid rules shown by Mahmoudi et al 32 entails how factors influencing race or minorities have influenced the receipt of IBR, further explaining the disparity.

A comprehensive investigation is warranted to examine the entirety of the patient journey, spanning from the diagnosis of breast cancer in individuals of a specific race to their interaction with healthcare facilities and providers, culminating in mastectomy and receipt of IBR. This exploration should encompass a wide range of factors, including personal preferences as well as socioeconomic and geographical considerations. The results of our meta-analysis highlight that further thought be put into establishing schemes to tackle it.

An enhanced doctor–patient communication system is essential for effectively addressing language barriers. It is crucial for doctors to place particular emphasis on patients of diverse racial backgrounds who intentionally choose not to pursue IBR, which entails ensuring these patients are well-informed about the potential benefits of IBR and addressing any misconceptions they may have. Encouraging community-driven programs to raise awareness about IBR and conducting surveys to gather individual insights into the challenges faced by individuals from different racial backgrounds when considering IBR are important steps to take. Our efforts should be specifically directed toward racial groups exhibiting significantly lower rates of IBR compared to the White population. Moreover, government-led strategies should be devised and implemented to ensure IBR is covered by all insurance programs. The utilization of IBR has a significant role in restoring self-esteem for patients who experience a negative impact on their body image during breast cancer treatment. As healthcare providers, it is our responsibility to support patients throughout the entirety of their care journey, addressing all aspects of their well-being.39,40

A qualitative study would be an excellent addition to the literature regarding the topic as that will help to better rule out the exact causes of disparities and the subjectivity associated with it. A good addition to the literature could be looking at the trends in racial disparity and geographical differences.

Moreover, a few implications toward future research would be to assess economic and healthcare accessibility. If there is any social stigma associated with IBR that should be checked out as well. Patient and physician awareness is necessary regarding the benefits of IBR and should be offered to all the patients after mastectomy. A possible cause of disparity could be a difference in complications among different racial groups and more studies should be structured considering the aforementioned. This will not only help improve the outcomes for individual patients but also help in better policy making.

Limitations

Our study provides a comprehensive review of existing literature to assess the influence of race on the rate of receiving IBR following mastectomy. However, it is important to interpret the results in light of certain limitations. Firstly, we excluded studies that did not utilize individuals of White race as the reference race and those that did not report AORs. Moreover, our analysis revealed significant heterogeneity, likely stemming from the inclusion of minority populations from various geographic regions, which could have greatly impacted the findings. Additionally, the varying time spans considered for sample sizes should be taken into account as an important factor. Furthermore, like all meta-analyses, our study is susceptible to selection bias, and this should be considered when evaluating and implementing the results.

Conclusion

Our analysis concludes that there is a significant association between race and utilization of IBR. Minority races especially Black, Hispanic, and Asian populations are less likely to undergo reconstruction postmastectomy compared to White population. Since disparity still exists, this sets the stage for further research to identify the exact causes and strategies for mitigation.

Supplemental Material

sj-pdf-1-psg-10.1177_22925503241255142 - Supplemental material for Racial Disparities in Immediate Breast Reconstruction after Mastectomy: A Systematic Review and Meta-Analysis
sj-pdf-1-psg-10.1177_22925503241255142.pdf (49.4KB, pdf)

Supplemental material, sj-pdf-1-psg-10.1177_22925503241255142 for Racial Disparities in Immediate Breast Reconstruction after Mastectomy: A Systematic Review and Meta-Analysis by Shurjeel Uddin Qazi, MBBS, Sarah Aman, MBBS, Muhammad Hassaan Wajid, MBBS, Zainab Qayyum, MBBS, Muhammad Bilal Shahid, MBBS, Alina Tanvir, MBBS, Sania Javed, MBBS, Mahnoor Saeed, MBBS, Eesha Razia, MBBS, Alina Nayyar, MBBS, Osama Abdur Rehman, MD, and Faisal Khosa, MD in Plastic Surgery

Acknowledgment

The authors express their gratitude to the Research Council of Pakistan for their invaluable support throughout the entire process of conducting this meta-analysis.

Footnotes

Author Contributions: SUQ: Inception of the idea, overall supervision of the project and relevant guidance where needed. SA: Article Search, Article Selection, Data Extraction, Data Analysis, Quality Appraisal and Referencing. MHW: This author was involved in Article Search, Article Selection, Data Extraction, Data Analysis, Manuscript Writing. ZQ: Article Search, Article Selection, Data Extraction, Data Analysis and Manuscript Writing. MBS: Article Search, Article Selection, Data Analysis, Manuscript Writing and Referencing. AT: Article Search, Article Selection, Data Extraction and Referencing. SJ: Article Search, Article Selection, Data Extraction, Data Analysis and Manuscript Writing. MS: Article Search, Article Selection, Data Extraction, Data Analysis and Manuscript Writing. ER: Article Search, Article Selection, Data Extraction, Data Analysis and Manuscript Writing. AN: Article Search, Article Selection, Data Extraction and Data Analysis. OAR: Article Search, Article Selection and Data Extraction. FK: Mentorship and supervision during the project.

Authors’ Note: Faisal Khosa is the recipient of the Michael Smith Health Research BC Health Professional-Investigator award (2023-2028); Don Rix Physician Leadership Lifetime Achievement Award (2022); BC Achievement Foundation – Mitchell Award of Distinction (2022); University of British Columbia – Distinguished Achievement Award for Equity, Diversity & Inclusion (2022) and Vancouver Medical Dental & Allied Staff Association – Equity, Diversity & Inclusion Award (2022).

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material: Supplemental material for this article is available online.

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Supplementary Materials

sj-pdf-1-psg-10.1177_22925503241255142 - Supplemental material for Racial Disparities in Immediate Breast Reconstruction after Mastectomy: A Systematic Review and Meta-Analysis
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Supplemental material, sj-pdf-1-psg-10.1177_22925503241255142 for Racial Disparities in Immediate Breast Reconstruction after Mastectomy: A Systematic Review and Meta-Analysis by Shurjeel Uddin Qazi, MBBS, Sarah Aman, MBBS, Muhammad Hassaan Wajid, MBBS, Zainab Qayyum, MBBS, Muhammad Bilal Shahid, MBBS, Alina Tanvir, MBBS, Sania Javed, MBBS, Mahnoor Saeed, MBBS, Eesha Razia, MBBS, Alina Nayyar, MBBS, Osama Abdur Rehman, MD, and Faisal Khosa, MD in Plastic Surgery

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