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Ethnic Disparities Persist in the Field of Plastic and Reconstructive Surgery: An Analysis of a Large Post-Mastectomy Prospective Cohort
Jose M. Flores, MPH, Gerard Anderson, PhD, Justin Bellamy, BSc, Carisa M. Cooney, MPH, CCRP, Karim A. Sarhane, MD, MSc, Ruth Lucas, MD, MPH, Gedge D. Rosson, MD.
Johns Hopkins University, Baltimore, MD, USA.

Purpose: Although ethnic disparities have been widely reported in breast cancer patients, analyses have tended to focus on the early stages of management. We hypothesized that undue disparities also permeate into the operating room in the field of plastic and reconstructive surgery. This analysis examined the association between a patient’s ethnicity and 30-day post-surgical morbidity within three treatments: mastectomy alone, immediate reconstruction, and delayed reconstruction.
Methods: The cohort under study is a subset of a nationwide, random sample of patients prospectively followed by the American College of Surgeons (via ACS NSQIP®). A total of 50,045 women observed between 2008 and 2010 were grouped into one of three surgical categories based upon respective CPT coding in the medical record: 1) mastectomy only, 2) immediate reconstruction with concurrent mastectomy, and 3) delayed reconstruction. Pearson chi-square tests were used to detect differences in treatment utilization by ethnicity. Multivariable logistic regression models were then used to estimate the odds of post-operative surgical and medical morbidity reflecting risk of infections, wound disruption, graft failure, return to OR, and other serious medical complications.
Results: Our analysis exposed a differential pattern of use of the breast surgeries by ethnicity (Pearson's chi-square = 388.8157; p < 0.001). The fraction of Non-Hispanic Blacks electing to undergo mastectomy without reconstruction was higher than the pooled proportion (82.4% vs. 73.7%). Only 14.7% of Non-Hispanic Black patients underwent immediate reconstruction, compared to 21.9% of Non-Hispanic Whites. Adjusted odds ratios showed that Asian patients are least likely to develop surgical complications compared to all other ethnic groups (OR_BLACK=1.45, p<0.005; OR_HISPANIC=1.38, p<0.05; OR_WHITE=1.52, p<0.001). Ethnicity was a significant predictor of morbidity in the combined cohort as well as in those undergoing mastectomy alone and immediate reconstruction.
Conclusions: We present the analysis of large sample of patients (n=50,045) to show that undue ethnic disparities are present among breast cancer patients treated surgically. First, despite the established benefits of some breast procedures over others, the patterns of treatment utilization differ significantly between ethnic groups. Second, Asian patients enjoy a better profile of post-surgical complications compared to all other ethnic groups. Characterizing the nature of such a protective association could lead to interventions that reduce the morbidity gap between people of different ethnicities in the United States.


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