Is Medicaid Expansion Narrowing Gaps in Surgical Disparities for Low-Income Breast Cancer Patients?

HHS Public Access Author manuscript Author Manuscript Ann Surg Oncol. Author manuscript; available in PMC 2023 March 01. Published in final edited form as: Ann Surg Oncol. 2022 March ; 29(3): 1763–1769. doi:10.1245/s10434-021-11137-0. Is Medicaid Expansion Narrowing Gaps in Surgical Disparities for Low-Income Breast Cancer Patients? Samilia Obeng-Gyasi, MD, MPH1, Johnie Rose, MD, PhD2,3,4, Weichuan Dong, MA2,3,4,5, Uriel Kim, PhD2,3,4, Siran Koroukian, PhD2,3,4 1Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH Author Manuscript 2Center for Community Health Integration, Case Western Reserve University School of Medicine, Cleveland, OH 3Population Cancer Analytics Shared Resource, Case Comprehensive Cancer Center, Cleveland, OH 4Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH 5Department of Geography, Kent State University, Kent, OH Abstract Author Manuscript Background.—The objective of this study is to understand the effect of Medicaid expansion under the Affordable Care Act (ACA) on patterns of surgical care among low-income breast cancer patients. Emerging literature suggests cancer patients in Medicaid expansion states are presenting with earlier stages of disease. However, less is known regarding the implications of Medicaid expansion on patterns of surgical care in low-income women. Patients and Methods.—We compared nonmetastatic 30–64-year-old uninsured or Medicaidinsured Ohio breast cancer patients diagnosed 4 years before and 4 years after the state’s 2014 Medicaid expansion (study group); the control group was the privately insured. Time-to-surgery (TTS) was defined as days from diagnosis to surgery. Demographic and treatment variables before and after expansion were examined in multivariate analysis. Author Manuscript Results.—There was a 10.4% point increase in breast conservation therapy (BCT) in the study group (pre-ACA 26.3%, post-ACA 36.7%; p < 0.01) compared with a 5.8% point increase in the control group (pre-ACA 36.0%, post-ACA 41.8%; p < 0.01). Disparities in reconstruction narrowed between the study (pre-ACA 21.4%, post-ACA 34.5%; p < 0.01) and the control (37.0% pre-ACA, 44.1% post-ACA group p < 0.01) groups. There was no statistically significant change S. Obeng-Gyasi, MD, MPH: samilia.obeng-gyasi@osumc.edu. DISCLOSURES The authors declare no conflict of interest. Supplementary Information The online version contains supplementary material available at https://doi.org/10.1245/ s10434-021-11137-0. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Meeting Presentation: Presented as an oral presentation at the 2020 San Antonio Breast Cancer Symposium, virtual meeting, December 2020. Obeng-Gyasi et al. Page 2 Author Manuscript in mean TTS in the study group (pre-ACA 42.1 days, post-ACA 43.1 days p = 0.18) but there was an increase in TTS in the control group (pre-ACA 35.0 days, post ACA 37.0 days; p < 0.01). Conclusions.—Medicaid expansion appears to have narrowed disparities in the utilization of BCT and reconstruction in low-income women. However, there was no improvement in surgical delay. Author Manuscript Breast cancer patients who are uninsured or on Medicaid are more likely to present with advanced stages of disease and less likely to receive guideline concordant cancer care, thus having higher disease specific and overall mortality.1–3 The Patient Protection and Affordable Care Act (ACA) was designed to mitigate some of the disparities faced by low-income patients by—among its many provisions—expanding Medicaid coverage to individuals with incomes up to 138% of Federal Poverty Level (FPL) and eliminating cost sharing for recommended preventive services such as mammography screening for nearly all insured Americans.4 To date, studies evaluating the impact of Medicaid expansion among breast cancer patients suggest those in expansion states are presenting with earlier stages of disease, which will portend higher survival rates.5–7 However, the majority of these studies have evaluated data from only 1–2 years post-expansion. Author Manuscript With continued attempts to disrupt the ACA at the federal level and modifications to the Medicaid program at the state level, additional studies are needed to understand the implications of Medicaid expansion on socioeconomically disadvantaged populations. The objective of this study is to evaluate the effects of Medicaid expansion on mitigating existing disparities in receipt of guideline-concordant locoregional management (e.g., breast conservation therapy) and in patterns of surgical care among low-income women. Specifically, we are interested in understanding the impact of Medicaid expansion under the ACA on (1) time to surgery, (2) receipt of breast conservation therapy (BCT) (breast conservation surgery + radiation therapy), and (3) utilization of breast reconstruction. These study endpoints were selected due to prior pre-ACA literature showing an association between Medicaid or uninsured status with treatment delay, lower rates of BCT, and a reduction in access to reconstruction.2,8–10 We hypothesize that increased access to care afforded by the Medicaid expansion will result in a reduction in time to surgery, increased utilization of breast conservation therapy, and higher rates of reconstruction among lowincome women. PATIENTS AND METHODS Participants Author Manuscript The main study group consisted of 30–64-year-old Ohio women diagnosed with nonmetastatic invasive breast cancer between January 1 2010 and December 31 2017 who had Medicaid insurance or were uninsured at diagnosis. A comparison group with the same demographic and diseaserelated selection criteria was comprised of privately insured women. This group served as a control for secular trends in outcomes that may have been occurring in a group unaffected by Medicaid expansion. Since interval between diagnosis and surgery was a primary outcome, we excluded subjects who did not have surgery as initial BC treatment (i.e., neoadjuvant treatment, n = 5164) (Fig. 1). Data for both groups Ann Surg Oncol. Author manuscript; available in PMC 2023 March 01. Obeng-Gyasi et al. Page 3 Author Manuscript were drawn from the Ohio Cancer Incidence Surveillance System (OCISS)—Ohio’s cancer registry to which reporting of all cancer cases to residents of the state is mandatory—linked with US Census 5-year American Community Survey (2013–2017). Variables Author Manuscript Expanded income-based Ohio Medicaid eligibility went into effect on January 1 2014. Accordingly, the main independent variable of interest was pre-Medicaid expansion versus post-expansion time periods, defined as 2010–2013 and 2014–2017, respectively. A washout period was applied, excluding cases diagnosed during the first half of 2014. Based on our primary hypothesis, the main dependent variable of interest was time-to-surgery (TTS), defined as the number of days from reported tissue diagnosis of BC to receipt of definitive surgery. We excluded individuals with TTS = 0 as this represented likely data recording error or indicates the first definitive operation was an excisional biopsy. Furthermore, consensus guidelines recommend minimally invasive biopsy techniques (e.g., core needle biopsy) as the tissue acquisition modality for a cancer diagnosis not excisional biopsy.11 Since the Ohio registry does not capture data on diagnosis modality [fine-needle aspiration (FNA) versus core-needle biopsy (CNB) versus excisional biopsy], we have chosen to exclude this group as it is unclear if the surgical procedure was a tissue acquisition modality or a definitive procedure based on an oncologic diagnosis by a minimally invasive technique. Author Manuscript Other variables included in bivariate and multivariate analyses are listed in Table 1. We defined rural or urban residence as being located in a census tract classified as metropolitan or nonmetropolitan area, respectively, based on the 2010 Rural–Urban Commuting Area (RUCA).12 As a marker of extreme resource deprivation, we identified census block groups with Area Deprivation Indices (ADI) in deciles 9 or 10 as the most deprived areas and those in deciles 1 through 8 as less deprived, based on the University of Wisconsin National Neighborhood Atlas.13,14 Stage at diagnosis, including local stage and regional stage, was defined according to the SEER Summary Stage 2000 variable in OCISS and breast conservation therapy (BCT) was defined as breast conservation surgery plus radiation. Receipt of breast conservation therapy was evaluated as a proxy for guideline concordant locoregional treatment.15 Analysis Author Manuscript For the Medicaid + uninsured study group and for the control group, we compared pre- and post-expansion values using t-tests and chi-square. To examine whether Medicaid expansion differentially benefited the low-income study group relative to the privately insured control group across multiple outcomes, we constructed simple logistic regression models with period (pre-and post-expansion) and group (uninsured/Medicaid vs. privately insured) main effects, and an interaction term involving both effects. Applying this technique, used commonly in econometrics, a statistically significant interaction term suggests that expansion affected the two groups differently for a given outcome.16 Finally, we used Cox proportional hazards regression to examine the effect of multiple covariates simultaneously on TTS. We applied a recently described probability weighting approach, which weights each observation based on the probability of having income below 138% FPL, given census Ann Surg Oncol. Author manuscript; available in PMC 2023 March 01. Obeng-Gyasi et al. Page 4 Author Manuscript block group of residence.7 As a sensitivity analysis, a nonprobability weighted version is included in the Supplementary Material. Human Subject Considerations All study activities were approved by institutional review boards from Case Western Reserve University (IRB-2016–1752) and the Ohio Department of Health (ODH IRB 2017–50). RESULTS Of the 16,131 patients who met the study criteria, 2320 (14.4%) patients were in the uninsured/Medicaid (study group) and 13,811(85.6%) were privately insured patients (control group) (Table 1). The percentage of uninsured patients was significantly reduced post-ACA (pre-ACA 32.9%, post-ACA 14.1%; p < 0.01). Author Manuscript Author Manuscript Post-expansion, there was a 10.4% point increase in the utilization of breast conservation therapy (BCT) in the study group (pre-ACA 26.3%, post-ACA 36.7%; p < 0.01) compared with a 5.8% point increase the control group (pre-ACA 36.0%, post-ACA 41.8%; p < 0.01). Among patients undergoing mastectomy, disparities in reconstruction utilization narrowed between the study (pre-ACA 21.4%, post-ACA 34.5%; p < 0.01) and the control (37.0% pre-ACA, 44.1% post-ACA group; p < 0.01) groups. There was no statistically significant change in mean TTS in the study group (pre-ACA 41.1 days, post-ACA 43.1 days; p = 0.18) but there was an increase in mean TTS the control group (pre-ACA 35.0 days, post ACA 37.0 days; p < 0.01). Examining the outcome of TTS > 60 days, there was no difference in study group between the pre- and post-ACA populations (pre-ACA 17.4%, post ACA 17.7%; p = 0.87). Conversely, in the control group, there was a 1.9% increase in the patients with TTS > 60 days (pre-ACA 9.8%, post-ACA 11.7%; p < 0.01). Logistic models combining subjects from the study and control groups with effects of group, time period (pre- vs. post-ACA) and group × period interaction (Table 2) showed a statistically significant interaction for the outcomes of BCT [adjusted odds ratio (AOR) for the study group × post-ACA interaction 1.23 (95% CI 1.01–1.49) and breast reconstruction AOR for the study group × post-ACA interaction of 1.44 (95% CI 1.10–1.89)]. This demonstrates that BCT and breast reconstruction increased significantly in the study group after expansion, relative to the control group. Author Manuscript On multivariable Cox proportional hazards modeling analysis (probability weighted), there was no statistically significant difference in TTS pre- and post-ACA in the study group (HR 0.95, 95% CI 0.86–1.06; p = 0.34) (Table 3). Differences in TTS pre-and post-ACA in the control group were statistically significant (HR 0.89; 95% CI 0.86–0.94; p < 0.01), suggesting an increase in TTS in this group. Furthermore, on subset analysis of the study group stratified by stage, there was no difference in TTS pre- and post-ACA for both local stage and regional stage in the study group (Supplementary Table 1). Modeling without probability weighting produced results consistent with the weighted analysis (Supplementary Table 2). Ann Surg Oncol. Author manuscript; available in PMC 2023 March 01. Obeng-Gyasi et al. Page 5 Author Manuscript DISCUSSION This evaluation of breast cancer patients post-implementation of Medicaid expansion in Ohio under the ACA suggests that expansion has narrowed disparity gaps in receipt of guideline concordant locoregional management and breast reconstruction for low-income women. Unfortunately, disparities in TTS continue to persist as there was no reduction in TTS post-ACA among low-income patients. Furthermore, while increased TTS experienced by the privately insured was significant, they were modest in magnitude, and were still shorter than the pre- and post-ACA TTS of the Medicaid and uninsured. Author Manuscript The study findings of no improvement in TTS across insurance types is consistent with other studies evaluating time to earliest cancer directed therapy (surgery, radiation, etc.) within the context of Medicaid expansion.17 Using the National Cancer Database, Takvorian et al evaluated multiple cancers, including breast cancer, and found no improvements in time-to-treatment secondary to Medicaid expansion.17 Conversely, Ajkay et al. noted an increase in TTS post expansion in Kentucky.18 Although our results indicated an increase in TTS among the privately insured, their post-expansion TTS was still shorter than the preor post-ACA TTS for the Medicaid and uninsured group. The lack of improvement in the TTS disparity post-expansion is concerning as delays in TTS in breast cancer patients have been implicated in higher disease-specific and overall mortality.19–21 Possible explanations for the lack of improvement in TTS could include an interplay of established reasons such as increased utilization of additional imaging modalities, transfer of care to another hospital, or patient related factors (e.g., transportation).22–25 Author Manuscript Current National Comprehensive Cancer Network Guidelines recommend radiation therapy for nonmetastatic breast cancer patients, within the study age group, electing to undergo breast conservation surgery.26 This combination of locoregional management is known as breast conservation therapy (BCT). In this study, we noticed increased utilization of BCT among all insurance types, which is consistent with other studies evaluating Medicaid expansion in various states.18 Additional analysis evaluating an interaction between insurance group membership and period suggests a narrowing of the gap in BCT use post-ACA between the Medicaid/uninsured group and their privately insured counterparts. These findings are noteworthy as long-term studies have shown BCT results in lower rates of recurrence.27,28 Author Manuscript Previous studies pre-ACA have shown Medicaid breast cancer patient are less likely to undergo breast reconstruction compared with those with private insurance.8,29 To mitigate this disparity, federal level legislation such as the Women’s Health and Cancer Right Act have been enacted to increase access to reconstruction.30 Disparities in the utilization of reconstruction have been attributed to both patient (e.g., declining consultation with plastic surgeon) and physician level (e.g., lack of referral) factors.31–33 Our findings showed that, while there was increased utilization across insurance groups, the surgical disparities between the privately insured versus Medicaid/uninsured narrowed. Moreover, there appeared to be an interaction between insurance group membership and period for the outcome of breast reconstruction. These findings are encouraging as they suggest Medicaid expansion could be influencing reconstruction use in low-income patients. Ann Surg Oncol. Author manuscript; available in PMC 2023 March 01. Obeng-Gyasi et al. Page 6 Author Manuscript A strength of this paper lies in the fact that we leveraged US Census data to enable population weighting based on census-tract level income in Cox proportional hazard analyses. The limitations of this study include examining the impact of Medicaid expansion under the ACA in one state, which may limit the generalizability of results. In addition, it is likely that some individuals who were in the uninsured group before expansion would have moved to the privately insured control group after expansion, since the Ohio Individual Health Insurance Exchange opened at the same time that Medicaid expansion occurred. While this effect may have made the study and control groups more similar post-expansion, the likely effect is small, and the lack of an increase in the size of the control group post-expansion is reassuring. Of note, some patients may have obtained Medicaid insurance through the National Breast and Cervical Cancer Early Detection Program and not secondary to expansion. Another study limitation includes the lack of information on timing of enrollment in Medicaid as studies have shown differences in clinical outcomes based on enrollment before and after diagnosis.34 The SEER summary stage was used instead of the AJCC TNM staging system due to a high level of missingness of the TNM data. Consequently, granular information about tumor size and positive nodes as drivers of surgical management could not be explored, which is a limitation of this study. Author Manuscript CONCLUSIONS Author Manuscript The results from this study indicate post-ACA low-income breast cancer patients are experiencing a reduction in uninsured rates, a narrowing of the gap in BCT use relative to the privately insured, and a higher utilization of breast reconstruction. Unfortunately, the TTS results highlight continued barriers in receiving timely surgical treatment among low-income patients and worsening TTS for the privately insured. Future studies should focus on identifying barriers to timely care across insurance types and how to further leverage improvements in surgical management post-ACA among low-income Ohioans. Supplementary Material Refer to Web version on PubMed Central for supplementary material. ACKNOWLEDGMENTS This study includes data provided by the Ohio Department of Health, which should not be considered an endorsement of this study or its conclusions. FUNDING Author Manuscript Samilia Obeng-Gyasi is funded by the Paul Calabresi Career Development Award (K12 CA133250). Siran Koroukian is supported by Grants from the National Cancer Institute, Case Comprehensive Cancer Center (P30 CA043703); National Institutes of Health (R15 NR017792, and UH3-DE025487); The American Society (132678RSGI-19–213-01-CPHPS and RWIA-20–111-02 RWIA); and by contracts from Cleveland Clinic Foundation, including a subcontract from Celgene Corporation. Johnie Rose is supported by Grants from the National Cancer Institute, Case Comprehensive Cancer Center (P30 CA043703), National Institute of Dental and Craniofacial Research (1UH2DE025487–01), and the American Cancer Society (RWIA-20–111-02 RWIA). Ann Surg Oncol. Author manuscript; available in PMC 2023 March 01. Obeng-Gyasi et al. Page 7 Author Manuscript REFERENCES Author Manuscript Author Manuscript Author Manuscript 1. Ayanian JZ, Kohler BA, Abe T, Epstein AM. 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Women’s Health and Cancer Rights Act, 2020. https://www.cancer.org/treatment/finding-and-paying-for-treatment/understanding-healthinsurance/health-insurance-laws/womens-health-and-cancer-rights-act.html. Accessed 20 Dec 2020. 31. Bauder AR, Gross CP, Killelea BK, Butler PD, Kovach SJ, Fox JP. The relationship between geographic access to plastic surgeons and breast reconstruction rates among women undergoing mastectomy for cancer. Ann Plast Surg. 2017;78(3):324–9. 10.1097/sap.0000000000000849. [PubMed: 28177978] 32. Tseng JF, Kronowitz SJ, Sun CC, et al. The effect of ethnicity on immediate reconstruction rates after mastectomy for breast cancer. Cancer. 2004;101(7):1514–23. 10.1002/cncr.20529. [PubMed: 15378473] 33. Kruper L, Holt A, Xu XX, et al. Disparities in reconstruction rates after mastectomy: patterns of care and factors associated with the use of breast reconstruction in Southern California. Ann Surg Oncol. 2011;18(8):2158–65. 10.1245/s10434-0111580-z. [PubMed: 21308486] 34. Koroukian SM, Bakaki PM, Raghavan D. Survival disparities by Medicaid status: an analysis of 8 cancers. Cancer. 2012;118(17):4271–9. 10.1002/cncr.27380. [PubMed: 22213271] Ann Surg Oncol. Author manuscript; available in PMC 2023 March 01. Obeng-Gyasi et al. Page 9 Author Manuscript Author Manuscript Author Manuscript FIG. 1. Study cohort inclusion criteria Author Manuscript Ann Surg Oncol. Author manuscript; available in PMC 2023 March 01. Author Manuscript Author Manuscript Author Manuscript 769 (65.3) 448 (38.1) Regional Ann Surg Oncol. Author manuscript; available in PMC 2023 March 01. 867 (73.7) 525 (78.6) No reconstruction after Mastectomy* Rural–urban commuting area 143 (21.4) Reconstruction after Mastectomy* Reconstruction 310 (26.3) 362 (65.5) 191 (34.5) 723 (63.3) 420 (36.7) 553 (48.4) 668 (56.8) Without BCT 590 (51.6) With BCT Breast conserving therapy (BCT) Without BCS With BCS 982 (85.9) 161 (14.1) 353 (30.9) 790 (69.1) 726 (63.5) 417 (36.5) 509 (43.2) 790 (67.1) Medicaid Breast conserving surgery (BCS) 387 (32.9) Uninsured Insurance 729 (61.9) Local Stage at diagnosis 408 (34.7) 918 (80.3) 908 (77.1) Other 225 (19.7) 269 (22.9) 52.8 (8.1) 202 (17.7) 205 (17.4) 51.6 (8.4) 941 (82.3) 43.1 (33.7) 972 (82.6) 41.1 (37.1) Married/Partnered Marital status Other Non-Hispanic Black Race/Ethnicity Age at diagnosis, mean (SD) > 60 days ≤ 60 days TTS TTS, days, mean (SD) 0.03 < 0.01 <0.01 < 0.01 < 0.01 < 0.01 < 0.01 0.38 0.07 < 0.01 0.87 0.18 2349 (63.0) 1379 (37.0) 4608 (64.0) 2591 (36.0) 3728 (51.8) 3471 (48.2) NA NA 2231 (31.0) 4968 (69.0) 2009 (27.9) 5190 (72.1) 6587 (91.5) 612 (8.5) 52.9 (7.7) 703 (9.8) 6469 (90.2) 35.0 (26.6) 1662 (55.9) 1312 (44.1) 3848 (58.2) 2764 (41.8) 2974 (44.5) 3638 (55.0) NA NA 1786 (27.0) 4826 (73.0) 1836 (27.8) 4776 (72.2) 6093 (92.2) 519 (7.8) 53.7 (7.5) 774 (11.7) 5838 (88.3) 37.0 (21.9) Post-ACA (n = 6612) Pre-ACA (n = 7199) p-Value Pre-ACA (n = 1177) Post-ACA (n = 1143) Control group (privately insured) Study group (Medicaid + uninsured) 0.02 < 0.01 <0.01 < 0.01 < 0.01 < 0.01 0.87 0.17 < 0.01 < 0.01 < 0.01 p-Value Characteristics of women diagnosed with local/regional stage breast cancer before and after Ohio Medicaid expansion Author Manuscript TABLE 1 Obeng-Gyasi et al. Page 10 Non-metro area 903 (76.7) 274 (23.3) Most deprived (rank = 9 or 10) 238 (20.8) 905 (79.2) 232 (20.3) 285 (24.2) Less deprived (rank < 9) Area deprivation index 911 (79.7) 892 (75.8) Denominator for percentage calculations consists of only women undergoing mastectomy * Author Manuscript Metro area p-Value 0.17 432 (6.0) 6767 (94.0) 1161 (16.1) 6038 (83.9) 352 (5.3) 6260 (94.7) 1162 (17.6) 5450 (82.4) Post-ACA (n = 6612) Pre-ACA (n = 7199) Post-ACA (n = 1143) Pre-ACA (n = 1177) Author Manuscript Control group (privately insured) Author Manuscript Study group (Medicaid + uninsured) 0.09 p-Value Obeng-Gyasi et al. Page 11 Author Manuscript Ann Surg Oncol. Author manuscript; available in PMC 2023 March 01. Author Manuscript Author Manuscript 1.37 (1.27–1.47) post-ACA 1 [Reference] 1.23 (1.01–1.49) Other Study group and post-ACA Interaction with group and time period 1 [Reference] 0.65 (0.56–0.74) 1 [Reference] Breast conserving therapy (BCT) 1.44 (1.10–1.89) 1 [Reference] 1.35 (1.22–1.48) 1 [Reference] 0.46 (0.38–0.57) 1 [Reference] Reconstruction 0.88 (0.73–1.06) 1 [Reference] 0.82 (0.77–0.89) 1 [Reference] 1.37 (1.20–1.56) 1 [Reference] Regional (vs. local) 0.83 (0.65–1.06) 1 [Reference] 1.23 (1.10–1.37) 1 [Reference] 1.95 (1.65–2.31) 1 [Reference] TTS > 60 days (vs. ≤ 60 days) Adjusted odds ratio (95% confidence interval) for primary and secondary outcomes pre-ACA Time period Study group Control group Group Author Manuscript Logistic regression for the four major outcomes in the study Author Manuscript TABLE 2 Obeng-Gyasi et al. Page 12 Ann Surg Oncol. Author manuscript; available in PMC 2023 March 01. Obeng-Gyasi et al. Page 13 TABLE 3 Author Manuscript Cox proportional hazards model (probability weighted) for TTS Variable Adjusted HR (95% CI) Main group Control group 30–49 years 1 [Reference] 1 [Reference] 50–64 years 0.93 (0.83–1.03) 1.01 (0.96–1.06) Non-Hispanic Black 1 [Reference] 1 [Reference] Other 1.34 (1.17–1.53) 1.18 (1.09–1.28) pre-ACA 1 [Reference] 1 [Reference] post-ACA 0.95 (0.86–1.06) 0.89 (0.86–0.94) Local 1 [Reference] 1 [Reference] Regional 1.01 (0.89–1.13) 1.11 (1.05–1.17) Married/partnered 1 [Reference] 1 [Reference] Other 0.88 (0.78–1.00) 0.92 (0.88–0.97) Age at diagnosis Race Year of diagnosis Author Manuscript Stage at diagnosis Marital status Breast conserving surgery (BCS) With BCS 1 [Reference] 1 [Reference] Without BCS 0.81 (0.72–0.92) 0.84 (0.79–0.89) Breast reconstruction surgery (BRS) Author Manuscript With BRS 1 [Reference] 1 [Reference] Without BRS 1.47 (1.30–1.67) 1.40 (1.32–1.49) Rural–urban commuting area Metro area 1 [Reference] 1 [Reference] Non-metro area 1.06 (0.92–1.23) 1.01 (0.95–1.07) Less deprived 1 [Reference] 1 [Reference] Most deprived 0.96 (0.85–1.08) 0.93 (0.86–1.01) Area deprivation index Author Manuscript Ann Surg Oncol. Author manuscript; available in PMC 2023 March 01.