Abstract
Background
Immediate breast reconstruction (IBR) rates in breast cancer differ between healthcare regions in Sweden. This is not explained by regional differences in patient age distribution or tumour characteristics, but by differences in patient‐reported information and patient involvement in the decision‐making process. As socioeconomic status may play a significant role in surgical decision‐making, its potential associations with IBR rates were analysed.
Methods
Women who had undergone therapeutic mastectomy for primary breast cancer in Sweden in 2013 were included in the analysis. Tumour and treatment data were retrieved from the Swedish National Breast Cancer Register, and socioeconomic background data from the Central Bureau of Statistics Sweden. Postal questionnaires regarding information about reconstruction and perceived involvement in the preoperative decision‐making process had been sent out in a previous survey.
Results
In addition to regional differences, lower tumour and nodal category, independent factors increasing the likelihood of having IBR for the 3131 women in the study were living without a registered partner, having current employment and high income per household. Patient‐reported perceived preoperative information (odds ratio (OR) 12·73, 95 per cent c.i. 6·03 to 26·89) and the feeling of being involved in the decision‐making process (OR 2·56, 1·14 to 5·76) remained strong independent predictors of IBR despite adjustment for socioeconomic factors. Importantly, responders to the survey represented a relatively young and wealthy population with a lower tumour burden.
Conclusion
Several socioeconomic factors independently influence IBR rates; however, patient‐reported information and involvement in the surgical decision‐making process remain independent predictors for the likelihood of having IBR.
Socioeconomic factors independently influence immediate breast reconstruction rates in Sweden. Patient‐reported information and involvement in the surgical decision‐making process remain independent predictors of the likelihood of undergoing immediate breast reconstruction.
Low income reduces immediate breast reconstruction
Antecedentes
El carcinoma hepatocelular con trombo tumoral (TT) en la vena cava inferior (inferior vena cava, IVC) o en la aurícula derecha (right atrium, RA) es un estado avanzado de la enfermedad raro, con un pronóstico desfavorable. En este estudio analizamos la supervivencia después de la resección quirúrgica.
Métodos
Se incluyeron pacientes con carcinoma hepatocelular con TT en la IVC o en la RA, que se sometieron a resección hepática entre febrero de 1997 y julio de 2017. Los resultados a corto y a largo plazo de estos pacientes y los detalles quirúrgicos se analizaron retrospectivamente.
Resultados
Se incluyeron 37 pacientes. Entre estos pacientes, se identificaron 16 pacientes con TT en la IVC infradiafragmática, 8 pacientes con TT en la IVC supradiafragmática y 13 pacientes con TT entrando en la AR. Doce pacientes asociaron TT avanzado en la vena porta más allá de vp 3 y 4, 10 pacientes tenían enfermedad bilobar y 12 pacientes tenían enfermedad extrahepática. A pesar de que la tasa de mortalidad hospitalaria fue cero, dos pacientes fallecieron a los 90 días. Aunque la mediana del tiempo de supervivencia no fue diferente entre el grupo al que se le realizó resección con intención curativa (18,7 meses) y aquellos con tumor residual solo en el pulmón (20,7 meses), la supervivencia fue extremadamente pobre para los pacientes con tumor residual en el hígado (8,3 meses).
Conclusión
La resección hepática con trombectomía para el carcinoma hepatocelular avanzado con trombo tumoral en la vena cava inferior o en la aurícula derecha es segura y factible, asociándose a una supervivencia moderada.
Introduction
Oncologically equivalent surgical choices in primary breast cancer are either breast‐conserving surgery (BCS) followed by whole‐breast irradiation, or mastectomy. Breast conservation has been shown1 to have a positive influence on health‐related quality of life, and may even offer survival benefits2, 3. In about 40 per cent of patients4, however, mastectomy is the selected treatment option, and reconstructive options should then be discussed. Breast reconstruction may be undertaken as an immediate procedure (at the same session as the mastectomy itself), which allows for skin‐ or nipple‐sparing options, or as a delayed procedure (delayed breast reconstruction, DBR). Immediate breast reconstruction (IBR) is an increasingly common reconstructive option, even in the setting of postmastectomy radiotherapy5. Despite the negative impact of postmastectomy radiotherapy on surgical and patient‐reported outcomes after IBR6, this option is widely accepted today, possibly due to the use of autologous techniques7, different radiation strategies8 in the USA, or the increased use of meshes and matrices, with the implant placed in the prepectoral or subpectoral space9, 10.
Known contributing factors in the choice of IBR versus DBR versus no reconstruction are tumour characteristics, expected oncological treatment, surgical competence and resources, patient co‐morbidity and body habitus, and patient preference. Moreover, retrospective cohort studies11, 12, 13 have shown that non‐white ethnicity, lower education, older age and single status decrease the likelihood of having IBR. In a Danish study14, the rate of IBR was significantly higher among women with higher education and in hospitals with plastic surgery departments. Few studies, however, have focused on the association between socioeconomic factors and patient‐reported preoperative information regarding reconstructive options, even though low satisfaction with information before breast cancer surgery is associated with an increased likelihood of experiencing anxiety and postoperative regret15, 16. Alderman and colleagues17 showed that only 33 per cent of women aged less than 80 years undergoing breast cancer surgery had discussed breast reconstruction with surgeons before surgery, and younger, more educated women with larger tumours were significantly more likely to have had this discussion. In another American study18 using retrospective chart review, disparities in preoperative discussion about IBR depended on race, education and age. Economic reimbursement patterns in the USA may partly explain these observations. It is therefore important to explore the associations between socioeconomic factors, preoperative information and IBR rates in a setting, such as Sweden, where a public healthcare system aims to provide equal treatment options for every citizen at the same low cost.
Significant regional differences in IBR rates in Sweden have been reported previously19, and were not explained by regional differences in tumour or patient characteristics, but by disparities in patient information, availability of plastic surgery services and patient involvement in decision‐making. As socioeconomic factors were not taken into account at that time, the aim of the present study was to determine their potential association with IBR rates, as well as with patient‐reported information and involvement in the surgical decision‐making process.
Methods
This cohort study included all women operated on by mastectomy for a newly diagnosed primary breast cancer in Sweden in 2013 according to the Swedish National Breast Cancer Register (NKBC). Data on tumour characteristics, surgical procedures and planned oncological treatment were extracted from the NKBC. For a previous study19, all surviving patients from this cohort had been sent a questionnaire (Appendices S1 and S2 , supporting information) in 2015 regarding their experiences of preoperative information regarding reconstructive options and of involvement in the decision‐making process, with a response rate of 76·3 per cent. For the present study, however, the cohort was based on renewed data extraction from the NKBC, which produced a slightly higher number of breast cancer cases owing to late incoming registrations. The resulting cohort was linked to socioeconomic data from the Central Bureau of Statistics Sweden concerning family status, country of birth, educational level, occupation, socioeconomic group, and income per person and per household as per year of surgery. Disposable income was classified into three groups by dividing the cohort into equal proportions. The highest level of education was divided into four groups according to the Swedish educational system: primary school, secondary school, postsecondary school for 3 years or less, or postsecondary school for more than 3 years.
The original study was approved by the Ethics Review Board at Karolinska Institutet, Stockholm, in 2014 (2014/2106‐31/1) with an amendment in order to update and complete the original database in 2016 (2016/373‐32).
Statistical analysis
The study cohort was divided into two groups: women who had mastectomy without IBR and those who had mastectomy with IBR. Unfortunately, data on DBR are not available from the NKBC and there are no other published national data. Regarding cT status, the NKBC lists the option cT0 as ‘no obvious tumour’ as opposed to cTis, as in situ disease only. As cT0 is commonly reported based on palpation only, this was categorized as cT1.
The distribution of categorical data is presented as numbers per group with percentages, and continuous variables as median (range) values. Data were tested for normality, and non‐parametric tests used accordingly. The χ2 test or Fisher's exact test was used to analyse the distribution of categorical variables between groups. Comparison of median values for continuous variables in more than two groups was performed using the Kruskal–Wallis test; for two groups, the Mann–Whitney U test was employed.
To adjust for tumour and treatment data, as well as differences in socioeconomic characteristics between the two groups, multivariable logistic regression analyses were subsequently performed. Binary outcomes were: performance of IBR; patient‐reported preoperative information on immediate reconstruction; and patient‐reported involvement in the surgical decision‐making process. Results are presented as odds ratios (ORs) with their respective 95 per cent confidence intervals.
To assess external validity, responders and non‐responders to the postal questionnaire were compared.
All data analysis was performed using SPSS® version 24 (IBM, Armonk, New York, USA). Statistical significance was set at a level of 5 per cent for all analyses.
Results
The updated number of mastectomies from NKBC was 3210. One patient with missing data on the type of surgical procedure was excluded. For 78 women with bilateral disease, one side was selected at random, so that all subsequent analyses were based on 3131 women, 267 of whom (8·5 per cent) had IBR.
Socioeconomic differences in questionnaire responders versus non‐responders
Of 2217 responders from the previous study19, data for 46 individuals were lost on linkage to socioeconomic data, probably due to the different registration of bilateral cases. In Table 1 , survey responders are compared with 960 non‐responders regarding tumour characteristics and socioeconomic factors. All tested factors, excluding region of residence, were significantly different between the two groups; responders were younger women with more favourable disease and a higher socioeconomic status (Table 1 ).
Table 1.
Age, tumour characteristics and socioeconomic status of questionnaire responders versus non‐responders
| Total (n = 3131) | Survey responders (n = 2171) | Non‐responders (n = 960) | P * | |
|---|---|---|---|---|
| Age (years) | < 0·001 | |||
| ≤ 40 | 193 (6·2) | 117 (5·4) | 76 (7·9) | |
| 41–50 | 527 (16·8) | 382 (17·6) | 145 (15·1) | |
| 51–65 | 883 (28·2) | 686 (31·6) | 197 (20·5) | |
| > 65 | 1528 (48·8) | 986 (45·4) | 542 (56·5) | |
| Preoperative cT category | < 0·001 | |||
| cTis (in situ only) | 140 (4·5) | 116 (5·3) | 24 (2·5) | |
| cT1 (≤ 20 mm) | 1396 (44·6) | 1034 (47·6) | 362 (37·7) | |
| cT2 (21–50 mm) | 1223 (39·1) | 809 (37·3) | 414 (43·1) | |
| cT3 (> 50 mm) | 290 (9·3) | 177 (8·2) | 113 (11·8) | |
| cT4 | 61 (1·9) | 23 (1·1) | 38 (4·0) | |
| Missing | 21 (0·7) | 12 (0·6) | 9 (0·9) | |
| Preoperative cN category | < 0·001† | |||
| cN0 | 2534 (80·9) | 1814 (83·6) | 720 (75·0) | |
| cN1 | 566 (18·1) | 337 (15·5) | 229 (23·9) | |
| Missing | 31 (1·0) | 20 (0·9) | 11 (1·1) | |
| Immediate breast reconstruction | 0·008† | |||
| Yes | 267 (8·5) | 204 (9·4) | 63 (6·6) | |
| No | 2864 (91·5) | 1967 (90·6) | 897 (93·4) | |
| Family status | < 0·001† | |||
| Partnership/married | 1651 (52·7) | 1229 (56·6) | 422 (44·0) | |
| Single | 1454 (46·4) | 925 (42·6) | 529 (55·1) | |
| Missing | 26 (0·8) | 17 (0·8) | 9 (0·9) | |
| Own birth country | < 0·001 | |||
| Sweden | 2708 (86·5) | 1916 (88·3) | 792 (82·5) | |
| Europe, not Sweden | 269 (8·6) | 164 (7·6) | 105 (10·9) | |
| Outside Europe | 154 (4·9) | 91 (4·2) | 63 (6·6) | |
| Highest level of education | < 0·001 | |||
| Primary school | 871 (27·8) | 508 (23·4) | 363 (37·8) | |
| Secondary school | 1210 (38·6) | 872 (40·2) | 338 (35·2) | |
| Postsecondary school, ≤ 3 years | 390 (12·5) | 296 (13·6) | 94 (9·8) | |
| Postsecondary school, > 3 years | 625 (20·0) | 477 (22·0) | 148 (15·4) | |
| Missing | 35 (1·1) | 18 (0·8) | 17 (1·8) | |
| Occupation | < 0·001 | |||
| Clerk/civil servant | 734 (23·4) | 592 (27·3) | 142 (14·8) | |
| Entrepreneur | 98 (3·1) | 76 (3·5) | 22 (2·3) | |
| Labourer | 421 (13·4) | 305 (14·0) | 116 (12·1) | |
| Unemployed/retired | 1838 (58·7) | 1194 (55·0) | 644 (67·1) | |
| Missing | 40 (1·3) | 4 (0·2) | 36 (3·8) | |
| Income per household | < 0·001 | |||
| Low | 1230 (39·3) | 730 (33·6) | 500 (52·1) | |
| Middle | 936 (29·9) | 693 (31·9) | 243 (25·3) | |
| High | 955 (30·5) | 742 (34·2) | 213 (22·2) | |
| Missing | 10 (0·3) | 6 (0·3) | 4 (0·4) | |
| Region | 0·054 | |||
| North | 231 (7·4) | 145 (6·7) | 86 (9·0) | |
| Stockholm/Gotland | 583 (18·6) | 410 (18·9) | 173 (18·0) | |
| South | 662 (21·1) | 462 (21·3) | 200 (20·8) | |
| South‐East | 383 (12·2) | 286 (13·2) | 97 (10·1) | |
| Uppsala/Örebro | 661 (21·1) | 451 (20·8) | 210 (21·9) | |
| West | 611 (19·5) | 417 (19·2) | 194 (20·2) |
Values in parentheses are percentages.
χ2 test, except
Fisher's exact test.
Tumour data, socioeconomic factors and regional reconstruction rates
Preoperative and postoperative patient and tumour characteristics are shown in Table 2 . As expected, patients who underwent IBR were younger and had more favourable tumour characteristics. Likewise, socioeconomic background data (Table 3 ) showed that women having an IBR tended to have a higher socioeconomic status. When the six Swedish healthcare regions were compared (Table 4 ), socioeconomic background, tumour data and IBR rates differed significantly among the women treated with mastectomy. The region of Stockholm/Gotland, with the highest IBR rate of 25·6 per cent, had the lowest rate of small cT1 tumours and the youngest age at surgery, but also the highest rate of non‐Swedish born women, a higher level of education, fewest unemployed or retired individuals, and the largest high‐income group.
Table 2.
Age and tumour characteristics of 3131 women treated by therapeutic mastectomy in Sweden in 2013
| Mastectomy without IBR (n = 2864) | Mastectomy with IBR (n = 267) | P § | |
|---|---|---|---|
| Age (years) | < 0·001 | ||
| ≤ 40 | 147 (5·1) | 46 (17·2) | |
| 41–50 | 416 (14·5) | 111 (41·6) | |
| 51–65 | 790 (27·6) | 93 (34·8) | |
| > 65 | 1511 (52·8) | 17 (6·4) | |
| Preoperative cT category | |||
| cTis (in situ only) | 94 (3·3) | 46 (17·2) | < 0·001 |
| cT1 (≤ 20 mm) | 1269 (44·3) | 127 (47·6) | |
| cT2 (21–50 mm) | 1156 (40·4) | 67 (25·1) | |
| cT3 (> 50 mm) | 270 (9·4) | 20 (7·5) | |
| cT4 | 56 (2·0) | 5 (1·9) | |
| Missing or unknown | 19 (0·7) | 2 (0·7) | |
| Preoperative cN category | < 0·001¶ | ||
| cN0 | 2289 (79·9) | 245 (91·8) | |
| cN1 | 546 (19·1) | 20 (7·5) | |
| Missing | 29 (1·0) | 2 (0·7) | |
| Neoadjuvant treatment | 297 (10·4) | 23 (8·6) | < 0·001 |
| Postoperative invasive tumour size (mm) *, † | 22 (0–150) | 18 (0–90) | < 0·001# |
| Postoperative histopathological node status | < 0·001 | ||
| Negative | 1509 (52·7) | 186 (69·7) | |
| Positive | 1170 (40·9) | 60 (22·5) | |
| Missing | 185 (6·5) | 21 (7·9) | |
| Invasiveness | < 0·001 | ||
| In situ only | 211 (7·4) | 92 (34·5) | |
| Invasive | 2354 (82·2) | 152 (56·9) | |
| Missing | 299 (10·4) | 23 (8·6) | |
| Presence of multifocality | 700 (24·4) | 47 (17·6) | < 0·001 |
| Nottingham histological grade | 0·254 | ||
| 1 | 349 (12·2) | 32 (12·0) | |
| 2 | 1360 (47·5) | 111 (41·6) | |
| 3 | 1019 (35·6) | 109 (40·8) | |
| Missing | 136 (4·7) | 15 (5·6) | |
| Oestrogen receptor status ‡ | n = 2630 | n = 2630 | < 0·001 |
| Negative | 444 (16·9) | 23 (13·4) | |
| Positive | 2158 (82·1) | 146 (84·9) | |
| Missing | 28 (1·1) | 3 (1·7) | |
| Progesterone receptor status ‡ | n = 2630 | n = 172 | < 0·001 |
| Negative | 788 (30·0) | 40 (23·3) | |
| Positive | 1804 (68·6) | 128 (74·4) | |
| Missing | 38 (1·4) | 4 (2·3) | |
| Her2/neu status ‡ | n = 2630 | n = 172 | < 0·001 |
| Negative | 2150 (81·7) | 139 (80·8) | |
| Positive | 407 (15·5) | 26 (15·1) | |
| Missing | 73 (2·8) | 7 (4·1) | |
| Proliferation (% Ki‐67) *, ‡ | 25 (0–100) | 22 (0–95) | < 0·001# |
Values in parentheses are percentages unless indicated otherwise;
values are median (range).
Excluding patients who had neoadjuvant treatment;
excluding patients with only in situ disease. IBR, immediate breast reconstruction.
χ2 test, except
Fisher's exact test and
Mann–Whitney U test.
Table 3.
Socioeconomic characteristics of 3131 women who had therapeutic mastectomy in Sweden in 2013
| Mastectomy without IBR (n = 2864) | Mastectomy with IBR (n = 267) | P * | |
|---|---|---|---|
| Family status | 0·007† | ||
| Registered partnership/married | 1489 (52·0) | 162 (60·7) | |
| Single | 1351 (47·2) | 103 (38·6) | |
| Missing | 24 (0·8) | 2 (0·7) | |
| Own birth country | 0·001 | ||
| Sweden | 2487 (86·8) | 221 (82·8) | |
| Europe, not Sweden | 249 (8·7) | 20 (7·5) | |
| Outside Europe | 128 (4·5) | 26 (9·7) | |
| Highest level of education | < 0·001 | ||
| Primary school | 841 (29·4) | 30 (11·2) | |
| Secondary school | 1106 (38·6) | 104 (39·0) | |
| Postsecondary school, ≤ 3 years | 353 (12·3) | 37 (13·9) | |
| Postsecondary school, > 3 years | 530 (18·5) | 95 (35·6) | |
| Missing | 34 (1·2) | 1 (0·4) | |
| Occupation | < 0·001 | ||
| Clerk/civil servant | 588 (20·5) | 146 (54·7) | |
| Entrepreneur | 88 (3·1) | 10 (3·7) | |
| Labourer | 360 (12·6) | 61 (22·8) | |
| Unemployed/retired | 1792 (62·6) | 46 (17·2) | |
| Missing | 36 (1·3) | 4 (1·5) | |
| Income per household | < 0·001 | ||
| Low | 1187 (41·4) | 43 (16·1) | |
| Middle | 859 (30·0) | 77 (28·8) | |
| High | 808 (28·2) | 147 (55·1) | |
| Missing | 10 (0·3) | 0 |
Values in parentheses are percentages. IBR, immediate breast reconstruction.
χ2 test, except
Fisher's exact test.
Table 4.
Regional variations in immediate breast reconstruction rates, preoperative patient and tumour characteristics, and socioeconomic status for 3131 women treated by therapeutic mastectomy for breast cancer in 2013
| North (n = 231) | Stockholm/Gotland (n = 583) | South (n = 662) | South‐East (n = 383) | Uppsala/Örebro (n = 661) | West (n = 611) | P † | |
|---|---|---|---|---|---|---|---|
| IBR | 10 (4·3) | 149 (25·6) | 31 (4·7) | 23 (6·0) | 40 (6·1) | 14 (2·3) | < 0·001 |
| Preoperative cT category | < 0·001 | ||||||
| cT1 | 105 (45·5) | 224 (38·4) | 311 (47·0) | 206 (53·8) | 265 (40·1) | 285 (46·6) | |
| cT2 | 85 (36·8) | 236 (40·5) | 247 (37·3) | 131 (34·2) | 280 (42·4) | 244 (39·9) | |
| cT3 | 20 (8·7) | 81 (13·9) | 36 (5·4) | 33 (8·6) | 74 (11·2) | 46 (7·5) | |
| cT4 | 11 (4·8) | 12 (2·1) | 12 (1·8) | 4 (1·0) | 16 (2·4) | 6 (1·0) | |
| In situ only | 8 (3·5) | 27 (4·6) | 49 (7·4) | 6 (1·6) | 24 (3·6) | 26 (4·3) | |
| Missing | 2 (0·9) | 3 (0·5) | 7 (1·1) | 3 (0·8) | 2 (0·3) | 4 (0·7) | |
| Preoperative cN category | 0·657 | ||||||
| cN0 | 180 (77·9) | 481 (82·5) | 527 (79·6) | 315 (82·2) | 545 (82·5) | 486 (79·5) | |
| cN1 | 42 (18·2) | 100 (17·2) | 124 (18·7) | 65 (17·0) | 112 (16·9) | 123 (20·1) | |
| Missing | 9 (3·9) | 2 (0·3) | 11 (1·7) | 3 (0·8) | 4 (0·6) | 2 (0·3) | |
| Age at surgery (years) * | 65 (28–97) | 62 (21–96) | 64 (26–94) | 63 (21–93) | 65 (24–94) | 65 (26–97) | 0·001‡ |
| Family status | 0·002 | ||||||
| Partnership/married | 121 (52·4) | 308 (52·8) | 328 (49·5) | 239 (62·4) | 331 (50·1) | 324 (53·0) | |
| Single | 106 (45·9) | 272 (46·7) | 327 (49·4) | 140 (36·6) | 326 (49·3) | 283 (46·3) | |
| Missing | 4 (1·7) | 3 (0·5) | 7 (1·1) | 4 (1·0) | 4 (0·6) | 4 (0·7) | |
| Own birth country | < 0·001 | ||||||
| Sweden | 212 (91·8) | 467 (80·1) | 580 (87·6) | 341 (89·0) | 570 (86·2) | 538 (88·1) | |
| Europe, not Sweden | 13 (5·6) | 67 (11·5) | 61 (9·2) | 25 (6·5) | 61 (9·2) | 42 (6·9) | |
| Outside Europe | 6 (2·6) | 49 (8·4) | 21 (3·2) | 17 (4·4) | 30 (4·5) | 31 (5·1) | |
| Highest level of education | < 0·001 | ||||||
| Primary school | 70 (30·3) | 113 (19·4) | 201 (30·4) | 115 (30·0) | 194 (29·3) | 178 (29·1) | |
| Secondary school | 77 (33·3) | 211 (36·2) | 262 (39·6) | 160 (41·8) | 285 (43·1) | 215 (35·2) | |
| Postsecondary school, ≤ 3 years | 31 (13·4) | 83 (14·2) | 82 (12·4) | 36 (9·4) | 77 (11·6) | 81 (13·3) | |
| Postsecondary, > 3 years | 51 (22·1) | 168 (28·8) | 109 (16·5) | 69 (18·0) | 100 (15·1) | 128 (20·9) | |
| Missing | 2 (0·9) | 8 (1·4) | 8 (1·2) | 3 (0·8) | 5 (0·8) | 9 (1·5) | |
| Occupation | < 0·001 | ||||||
| Clerk/civil servant | 53 (22·9) | 190 (32·6) | 133 (20·1) | 84 (21·9) | 137 (20·7) | 137 (22·4) | |
| Entrepreneur | 6 (2·6) | 27 (4·6) | 13 (2·0) | 15 (3·9) | 20 (3·0) | 17 (2·8) | |
| Labourer | 21 (9·1) | 61 (10·5) | 106 (16·0) | 68 (17·8) | 88 (13·3) | 77 (12·6) | |
| Unemployed/retired | 147 (63·6) | 301 (51·6) | 405 (61·2) | 212 (55·4) | 404 (61·1) | 369 (60·4) | |
| Missing | 4 (1·7) | 4 (0·7) | 5 (0·8) | 4 (1·0) | 12 (1·8) | 11 (1·8) | |
| Income per household | < 0·001 | ||||||
| Low | 102 (44·2) | 175 (30·0) | 276 (41·7) | 124 (32·4) | 285 (43·1) | 268 (43·9) | |
| Average | 70 (30·3) | 171 (29·3) | 195 (29·5) | 135 (35·2) | 206 (31·2) | 159 (26·0) | |
| High | 59 (25·5) | 236 (40·5) | 188 (28·4) | 122 (31·9) | 168 (25·4) | 182 (29·8) | |
| Missing | 0 | 1 (0·2) | 3 (0·5) | 2 (0·5) | 2 (0·3) | 2 (0·3) |
Values in parentheses are percentages unless indicated otherwise;
values are median (range). IBR, immediate breast reconstruction.
χ2 test, except
Kruskal–Wallis test.
In the previously reported study19 of a similar cohort, younger age, non‐invasive tumours, no clinically involved lymph nodes and residence in the Stockholm/Gotland region were independent predictors of undergoing IBR, as well as the availability of in‐house plastic surgery services, patient information and involvement in decision‐making. This raised the question of whether the observed regional differences could be associated with differences in socioeconomic factors. To assess this, univariable and multivariable analyses were performed. Apart from the above‐mentioned clinical factors, which retained their independent significance, socioeconomic factors that independently increased the likelihood of having an IBR are shown in Table 5 . Although being single appeared to decrease the likelihood of IBR in univariable analysis, this association reversed when adjusted for age, as being single strongly interacted with younger age. Despite these adjustments for socioeconomic status, the single most important independent predictor remained patient‐reported preoperative information about the possibility of IBR. Patient‐reported involvement in the surgical decision‐making process was also confirmed as a significant independent factor for IBR.
Table 5.
Univariable and multivariable binary logistic regression analysis of clinical and socioeconomic factors, with performance of immediate breast reconstruction rather than conventional mastectomy as the binary endpoint
| Univariable analysis | Multivariable analysis | |||
|---|---|---|---|---|
| Hazard ratio | P | Hazard ratio | P | |
| Age (years) | ||||
| ≤ 40 | 1·00 (reference) | |||
| 41–50 | 0·85 (0·58, 1·26) | 0·425 | 0·88 (0·43, 1·78) | 0·715 |
| 51–65 | 0·38 (0·25, 0·56) | < 0·001 | 0·54 (0·27, 1·09) | 0·087 |
| > 65 | 0·04 (0·02, 0·06) | < 0·001 | 0·11 (0·04, 0·30) | < 0·001 |
| Preoperative cT category | ||||
| cTis (in situ only) | 1·00 (reference) | |||
| cT1 (≤ 20 mm) | 0·21 (0·14, 0·30) | < 0·001 | 0·42 (0·23, 0·77) | 0·005 |
| cT2 (21–50 mm) | 0·12 (0·08, 0·18) | < 0·001 | 0·23 (0·12, 0·45) | < 0·001 |
| cT3 (> 50 mm) | 0·15 (0·09, 0·27) | < 0·001 | 0·31 (0·13, 0·74) | 0·008 |
| cT4 | 0·18 (0·07, 0·49) | 0·001 | 0·29 (0·02, 3·49) | 0·326 |
| Preoperative cN category | ||||
| cN0 | 1·00 (reference) | |||
| cN1 | 0·34 (0·22, 0·55) | < 0·001 | 0·30 (0·14, 0·67) | 0·003 |
| Family status | ||||
| Partnership/married | 1·00 (reference) | |||
| Single | 0·70 (0·54, 0·91) | 0·007 | 1·81 (1·04, 3·17) | 0·037 |
| Own birth country | ||||
| Sweden | 1·00 (reference) | |||
| Europe, not Sweden | 0·90 (0·56, 1·46) | 0·677 | 0·97 (0·44, 2·14) | 0·940 |
| Outside Europe | 2·29 (1·47, 3·56) | < 0·001 | 0·83 (0·37, 1·87) | 0·653 |
| Highest level of education | ||||
| Primary school | 1·00 (reference) | |||
| Secondary school | 2·64 (1·74, 4·00) | < 0·001 | 0·62 (0·32, 1·20) | 0·155 |
| Postsecondary school, ≤ 3 years | 2·94 (1·79, 4·83) | < 0·001 | 0·76 (0·35, 1·66) | 0·498 |
| Postsecondary school, > 3 years | 5·03 (3·29, 7·68) | < 0·001 | 0·85 (0·41, 1·75) | 0·659 |
| Occupation | ||||
| Clerk/civil servant | 1·00 (reference) | |||
| Entrepreneur | 0·46 (0·23, 0·90) | 0·024 | 0·63 (0·22, 1·85) | 0·403 |
| Labourer | 0·68 (0·49, 0·95) | 0·022 | 0·94 (0·55, 1·63) | 0·830 |
| Unemployed/retired | 0·10 (0·07, 0·15) | < 0·001 | 0·52 (0·27, 1·00) | 0·049 |
| Income per household | ||||
| Low | 1·00 (reference) | |||
| Middle | 2·47 (1·69, 3·63) | < 0·001 | 1·90 (0·97, 3·70) | 0·061 |
| High | 5·02 (3·53, 7·14) | < 0·001 | 2·79 (1·25, 6·22) | 0·012 |
| Region | ||||
| North | 1·00 (reference) | |||
| Stockholm/Gotland | 7·59 (3·92, 14·69) | < 0·001 | 6·62 (2·70, 16·20) | < 0·001 |
| South | 1·09 (0·52, 2·25) | 0·825 | 0·98 (0·38, 2·51) | 0·958 |
| South‐East | 1·41 (0·66, 3·02) | 0·374 | 1·45 (0·54, 3·94) | 0·462 |
| Uppsala/Örebro | 1·42 (0·70, 2·90) | 0·329 | 1·32 (0·50, 3·44) | 0·577 |
| West | 0·52 (0·23, 1·18) | 0·119 | 0·57 (0·19, 1·77) | 0·334 |
| Received preoperative information | ||||
| Yes | 1·00 (reference) | |||
| No | 32·99 (18·26, 59·59) | < 0·001 | 12·73 (6·03, 26·89) | < 0·001 |
| Involved in decision‐making | ||||
| Yes | 1·00 (reference) | |||
| No | 13·71 (7·21, 26·07) | < 0·001 | 2·56 (1·14, 5·76) | 0·023 |
Values in parentheses are 95 per cent confidence intervals.
Socioeconomic factors and patient‐reported received information about breast reconstruction
As patient‐reported received information about IBR was a significant factor for the likelihood of having an IBR, factors associated with self‐reported patient information were examined. Independent predictive factors for patient‐reported preoperative information were having a non‐invasive tumour (OR 3·56, 95 per cent c.i. 2·29 to 5·55), living in the Stockholm/Gotland region (OR 2·64, 1·70 to 4·11) and being born outside Europe (OR 2·83, 1·68 to 4·77). Negative predictive factors were being more than 65 years old (OR 0·43, 0·26 to 0·71) and having no current employment (including retirement) (OR 0·69, 0·49 to 0·97). The small group of 154 women with a non‐European background, mostly born in Asia, were younger and had a higher educational level than the Swedish or European‐born women, and most of them lived in the Stockholm/Gotland area.
Discussion
Socioeconomic factors significantly influenced IBR rates and patient‐reported preoperative information on IBR. Despite adjustment for socioeconomic factors, previously reported regional differences in IBR rates, patient information and involvement remained. Patient‐reported information and involvement in the decision‐making process regarding breast reconstruction were confirmed as strong predictive factors for the performance of IBR. Of note, women who reported their own experiences by responding to the questionnaire were more likely to be younger, and to have less advanced tumours and a higher socioeconomic index; thus, the questionnaire results cannot easily be generalized to all women with breast cancer facing mastectomy. Rather, the presented results might, in reality, be even more pronounced considering that it is the socioeconomically weaker women in this cohort who are under‐represented.
The process of patient information cannot be regarded as unidirectional. Reasons for the patient not reporting information on reconstructive options may originate from the informing part (the surgeon or breast nurse) or the receiving part (the patient), or a combination of both. As the patient–physician relationship has evolved from the paternalistic, physician‐dominant model to the shared‐decision‐making and informed‐consumerist model, women who adopt a more active role have a higher general patient satisfaction compared with those reporting paternalistic decision‐making18. This active role may be linked to a general information‐seeking behaviour, which is reported to be more common in those with a higher educational level20. The questionnaire concerned questions regarding received preoperative information in general, not specifically from the surgeon. Preoperative information may be retrieved from several sources, such as the breast cancer team with specialized nurses, social workers and psychologists, but also from information booklets and online resources. These results may suggest a lack of information given to those with a lower socioeconomic status, but also a need to adapt patient information better to educational level, health literacy and desire to be involved. Involvement in decision‐making and health literacy are key components rooted in socioeconomic reality, and may demand more flexibility in patient–physician, or rather patient–professional team, communication, information and choice of decision‐making model18.
Other than socioeconomic factors, patient co‐morbidity should affect patient information about reconstructive options. Known risk factors such as smoking or obesity, as well as co‐morbidity such as poor general health or ongoing non‐breast cancer treatments, would be expected to lead to less information about reconstructive options. Unfortunately, information on these factors, which are more prevalent in individuals with a lower socioeconomic status, was not available20, 21, 22, 23, 24. Another limitation of any retrospective audit is the risk of recall bias; patients received questionnaires up to 2 years after their surgical treatment. Interestingly, recall bias may also be influenced by socioeconomic status: women with low income and low educational level reported feeling extremely well informed in a study by Sepucha and colleagues25, although feeling informed was not associated with the actual level of knowledge. With such a directional recall bias, women with a low socioeconomic status should have reported a higher level of information, which was not confirmed in the present study. This raises the question whether information actually received was still lower than that perceived and reported by this subgroup.
A higher non‐response rate in lower socioeconomic groups has been reported previously26. Among American women after different types of breast reconstruction, non‐white race, Hispanic or Latino ethnicity, and low household income were associated with a higher non‐response rate27. In the present study, non‐responder bias analysis revealed a majority of responders with a higher socioeconomic status, which reduces the external validity of the results. The disparity in received information and involvement, however, would thus have been even more significant if more of the non‐responders had completed their survey. There was also a trend towards lower response rates from the North and South‐East regions, with no signs that these particular regions differed significantly from the others in terms of socioeconomic factors. Finally, although the reported IBR rates are from 2013, national annual reports have shown persisting regional differences, although the average IBR rate has been slowly increasing over the past few years.
The main strength of this study is the use of continuously registered population‐based data on all patients with breast cancer by combining information from two national registries containing detailed clinical and socioeconomic information of high quality and validity28, 29. Furthermore, the impact of socioeconomic status is of special interest in the Swedish universal healthcare setting, where the influence of reimbursement bias should be negligible.
Acknowledgements
This study was approved by the steering committee in the Swedish National Breast Cancer Register (NKBC) and received funding from the Swedish Breast Cancer Association (BRO).
Disclosure: The authors declare no conflict of interest.
Supporting information
Appendix S1. Questionnaire on patient information and involvement in preoperative decision‐making: English version
Appendix S2. Questionnaire on patient information and involvement in preoperative decision‐making: Swedish version
Funding information
Swedish Breast Cancer Association (BRO)
References
- 1. Sun Y, Kim SW, Heo CY, Kim D, Hwang Y, Yom CK et al Comparison of quality of life based on surgical technique in patients with breast cancer. Jpn J Clin Oncol 2014; 44: 22–27. [DOI] [PubMed] [Google Scholar]
- 2. de Boniface J, Frisell J, Bergkvist L, Andersson Y. Breast‐conserving surgery followed by whole‐breast irradiation offers survival benefits over mastectomy without irradiation. Br J Surg 2018; 105: 1607–1614. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. van Maaren MC, de Munck L, de Bock GH, Jobsen JJ, van Dalen T, Linn SC et al 10 year survival after breast‐conserving surgery plus radiotherapy compared with mastectomy in early breast cancer in the Netherlands: a population‐based study. Lancet Oncol 2016; 17: 1158–1170. [DOI] [PubMed] [Google Scholar]
- 4.Regionala Cancercentrum i Samverkan. Årsrapport 2015 från Nationella Bröstcancerregistret; 2016. https://www.cancercentrum.se/globalassets/cancerdiagnoser/brost/kvalitetsregister/nationell_brostcancer_rapport_2015-2pdf.pdf [accessed 20 March 2019].
- 5. Razdan SN, Cordeiro PG, Albornoz CR, Disa JJ, Panchal HJ, Ho AY et al National breast reconstruction utilization in the setting of postmastectomy radiotherapy. J Reconstr Microsurg 2017; 1: 312–317. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Eriksson M, Anveden L, Celebioglu F, Dahlberg K, Meldahl I, Lagergren J et al Radiotherapy in implant‐based immediate breast reconstruction: risk factors, surgical outcomes, and patient‐reported outcome measures in a large Swedish multicenter cohort. Breast Cancer Res Treat 2013; 142: 591–601. [DOI] [PubMed] [Google Scholar]
- 7. Kamali P, Paul MA, Ibrahim AMS, Koolen PGL, Wu W, Schermerhorn ML et al National and regional differences in 32 248 postmastectomy autologous breast reconstruction using the updated national inpatient survey. Ann Plast Surg 2017; 78: 717–722. [DOI] [PubMed] [Google Scholar]
- 8. Cordeiro PG, Snell L, Heerdt A, McCarthy C. Immediate tissue expander/implast breast reconstruction after salvage mastectomy for cancer recurrence following lumpectomy/irradiation. Plast Reconstr Surg 2012; 129: 341–350. [DOI] [PubMed] [Google Scholar]
- 9. Sinnott CJ, Persing SM, Pronovost M, Hodyl C, McConnell D, Ott Young A. Impact of postmastectomy radiation therapy in prepectoral versus subpectoral implant‐based breast reconstruction. Ann Surg Oncol 2018; 25: 2899–2908. [DOI] [PubMed] [Google Scholar]
- 10. Craig ES, Clemens MW, Koshy JC, Wren J, Hong Z, Butler CE et al Outcomes of acellular dermal matrix for immediate tissue expander reconstruction with radiotherapy: a retrospective cohort study. Aesthet Surg J 2019; 39: 279–288. [DOI] [PubMed] [Google Scholar]
- 11. Zhong T, Fernandes KA, Saskin R, Sutradhar R, Platt J, Beber BA et al Barriers to immediate breast reconstruction in the Canadian universal health care system. J Clin Oncol 2014; 32: 2133–2141. [DOI] [PubMed] [Google Scholar]
- 12. Schumacher JR, Taylor LJ, Tucholka JL, Poore S, Eggen A, Steiman J et al Socioeconomic factors associated with post‐mastectomy immediate reconstruction in a contemporary cohort of breast cancer survivors. Ann Surg Oncol 2017; 24: 3017–3023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Cemal Y, Albornoz CR, Disa JJ, McCarthy CM, Mehrara BJ, Pusic AL et al A paradigm shift in US breast reconstruction: part 2. The influence of changing mastectomy patterns on reconstructive rate and method. Plast Reconstr Surg 2013; 131: 320–326. [DOI] [PubMed] [Google Scholar]
- 14. Hvilsom GB, Hölmich LR, Frederiksen K, Steding‐Jessen M, Friis S, Dalton SO. Socioeconomic position and breast reconstruction in Danish women. Acta Oncol 2011; 50: 265–273. [DOI] [PubMed] [Google Scholar]
- 15. Contant CM, van Wersch AM, Wiggers T, Wai RT, Van Geel AN. Motivations, satisfaction, and information of immediate breast reconstruction following mastectomy. Patient Educ Couns 2000; 40: 201–208. [DOI] [PubMed] [Google Scholar]
- 16. Sheehan J, Sherman KA, Lam T, Boyages J. Association of information satisfaction, psychological distress and monitoring coping style with post‐decision regret following breast reconstruction. Psychooncology 2007; 16: 342–351. [DOI] [PubMed] [Google Scholar]
- 17. Alderman AK, Hawley ST, Waljee J, Mujahid M, Morrow M, Katz SJ. Understanding the impact of breast reconstruction on the surgical decision‐making process for breast cancer. Cancer 2008; 112: 489–494. [DOI] [PubMed] [Google Scholar]
- 18. Polacek GN, Ramos MC, Ferrer RL. Breast cancer disparities and decision‐making among US women. Patient Educ Couns 2007; 65: 158–165. [DOI] [PubMed] [Google Scholar]
- 19. Frisell A, Lagergren J, de Boniface J. National study of the impact of patient information and involvement in decision‐making on immediate breast reconstruction rates. Br J Surg 2016; 103: 1640–1648. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Richardson A, Allen JA, Xiao H, Vallone D. Effects of race/ethnicity and socioeconomic status on health information‐seeking, confidence, and trust. J Health Care Poor Underserved 2012; 23: 1477–1493. [DOI] [PubMed] [Google Scholar]
- 21. Ashraf AA, Colakoglu S, Nguyen JT, Anastasopulos AJ, Ibrahim AM, Yueh JH et al Patient involvement in the decision‐making process improves satisfaction and quality of life in postmastectomy breast reconstruction. J Surg Res 2013; 184: 665–670. [DOI] [PubMed] [Google Scholar]
- 22. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross‐sectional study. Lancet 2012; 380: 37–43. [DOI] [PubMed] [Google Scholar]
- 23. Kim R, Kawachi I, Coull BA, Subramanian SV. Contribution of socioeconomic factors to the variation in body‐mass index in 58 low‐income and middle‐income countries: an econometric analysis of multilevel data. Lancet Glob Health 2018; 6: e777–e786. [DOI] [PubMed] [Google Scholar]
- 24. Hiscock R, Bauld L, Amos A, Fidler JA, Munafò M. Socioeconomic status and smoking: a review. Ann N Y Acad Sci 2012; 1248: 107–123. [DOI] [PubMed] [Google Scholar]
- 25. Sepucha KR, Fagerlin A, Couper MP, Levin CA, Singer E, Zikmund‐Fisher BJ. How does feeling informed relate to being informed? The DECISIONS survey. Med Decis Making 2010; 30: 77–84. [DOI] [PubMed] [Google Scholar]
- 26. Ekholm O, Gundgaard J, Rasmussen NK, Hansen EH. The effect of health, socio‐economic position, and mode of data collection on non‐response in health interview surveys. Scand J Public Health 2010; 38: 699–706. [DOI] [PubMed] [Google Scholar]
- 27. Berlin NL, Hamill JB, Qi J, Kim HM, Pusic AL, Wilkins EG. Nonresponse bias in survey research: lessons from a prospective study of breast reconstruction. J Surg Res 2018; 224: 112–120. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Nationellt kvalitetsregister för bröstcancer (NKBC). Årsrapport 2018 https://statistik.incanet.se/brostcancer/ [accessed 20 March 2019].
- 29.Projektrapport Validering av Nationellt kvalitetsregister för bröstcancer; 2015. https://www.cancercentrum.se/globalassets/cancerdiagnoser/brost/kvalitetsregister/rapport_master_validering_brostregister2015-10-14.pdf [accessed 20 March 2019].
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Appendix S1. Questionnaire on patient information and involvement in preoperative decision‐making: English version
Appendix S2. Questionnaire on patient information and involvement in preoperative decision‐making: Swedish version