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Barriers of Access to Breast Reconstruction: A Systematic Review

Retrouvey, Helene, M.D.C.M.; Solaja, Ogi, M.D.; Gagliardi, Anna R., Ph.D.; Webster, Fiona, Ph.D.; Zhong, Toni, M.D., M.H.S.

Plastic and Reconstructive Surgery: March 2019 - Volume 143 - Issue 3 - p 465e-476e
doi: 10.1097/PRS.0000000000005313
Breast: Original Articles
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Background: The purpose of this systematic review was to comprehensively summarize barriers of access to breast reconstruction and evaluate access using the Penchansky and Thomas conceptual framework based on the six dimensions of access to care.

Methods: The authors performed a systematic review that focused on (1) breast reconstruction, (2) barriers, and (3) breast cancer. Eight databases (i.e., EMBASE, MEDLINE, PsycINFO, CINHAL, ePub MEDLINE, ProQuest, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials) were searched. English peer-reviewed articles published between 1996 and 2016 were included.

Results: The authors’ search retrieved 4282 unique articles. Two independent reviewers screened texts, selecting 99 articles for inclusion. All studies were observational and qualitative in nature. The availability of breast reconstruction was highest in teaching hospitals, private hospitals, and national cancer institutions. Accessibility affected access, with lower likelihood of breast reconstruction in rural geographic locations. Affordability also impacted access; high costs of the procedure or poor reimbursement by insurance companies negatively influenced access to breast reconstruction. Acceptability of the procedure was not universal, with unfavorable physician attitudes toward breast reconstruction and specific patient and tumor characteristics correlating with lower rates of breast reconstruction. Lastly, lack of patient awareness of breast reconstruction reduced the receipt of breast reconstruction.

Conclusions: Using the access-to-care framework by Penchansky and Thomas, the authors found that barriers to breast reconstruction existed in all six domains and interplayed at many levels. The authors’ systematic review analyzed this complex relationship and suggested multiprong interventions aimed at targeting breast reconstruction barriers, with the goal of promoting equitable access to breast reconstruction for all breast cancer patients.

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Toronto and Kingston, Ontario, Canada

From the Division of Plastic and Reconstructive Surgery, Toronto General Hospital; the Queen’s University School of Medicine; the University Health Network; and the Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto.

Received for publication February 14, 2018; accepted July 27, 2018.

This trial is registered under the name “Barriers to Breast Reconstruction in Women Diagnosed with Breast Cancer: A Systematic Review of the Literature,” PROSPERO 2016 identification number CRD42016046936 (

Disclosure:The authors have no financial interest to declare in relation to the content of this article.

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A “Hot Topic Video” by Editor-in-Chief Rod J. Rohrich, M.D., accompanies this article. Go to and click on “Plastic Surgery Hot Topics” in the “Digital Media” tab to watch.

Toni Zhong, M.D., M.H.S., Toronto General Hospital, 200 Elizabeth Street, 8N-871, Toronto, Ontario M5G 2C4, Canada,, Twitter: @DrToniZhong, @AnnaRGagliardi, @FionaWebster1, @HeleneRetrouvey

Copyright © 2019 by the American Society of Plastic Surgeons