Exploring provider- and practice-level drivers of cost-consciousness in breast cancer reconstruction—secondary analysis of a survey of the American Society of Plastic Surgeons



The role of physicians in dampening health care costs is a renewed focus of policy-makers. We examined provider- and practice-level factors affecting four domains of cost-consciousness among plastic surgeons performing breast reconstruction.


Secondary analysis was performed on the survey responses of 329 surgeons who routinely performed breast reconstruction. Using a 5-point Likert scale, we queried four domains of cost-consciousness: out-of-pocket cost awareness, cost discussions, cognizance of patients’ financial burden, and attitudes regarding cost discussions. Multivariable linear regression was performed to identify provider- and practice-level factors affecting these domains according to composite scores.


Overall cost-consciousness scores (CS) were moderate and ranged from 2.14 to 4.30. There were no significant differences across practice settings. Male gender (p = 0.048), Hispanic ethnicity (p = 0.021), and increasing clinical experience (p = 0.015) were associated with higher out-of-pocket cost awareness. Increasing surgeon experience was also associated with having cost discussions (p = 0.039). No provider- or practice-level factors were associated with cognizance of patients’ financial burden. Salaried physicians displayed a more positive attitude toward out-of-pocket cost discussions (p = 0.049). On pairwise testing, the out-of-pocket cost awareness was significantly different between Hispanic surgeons and white surgeons (4.30 vs. 3.55), and between surgeons with more than 20 years’ experience and with less than 5 years’ experience (3.87 vs. 3.37).


Surgeon gender, ethnicity, and experience and practice compensation type inform various domains of cost-consciousness in breast reconstruction. Structural and behavioral interventions could possibly increase physicians’ cost-consciousness.

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  1. 1.

    Mariotto A, Yabroff K, Shao Y, Feuer E, Brown M (2011) Projections of the cost of cancer care in the U.S.: 2010–2020. J Natl Cancer Inst 103(2):117–128

    Article  Google Scholar 

  2. 2.

    De Souza JA (2012) The cost of cancer care: there is more than one elephant in the room. Oncology 26(10):926–928

    PubMed  Google Scholar 

  3. 3.

    Levit L, Balogh E, Nass S 2013 Delivering high-quality cancer care: charting a new course for a system in crisis, National Academies Press (US), Washington (DC).

  4. 4.

    Schnipper LE (2009) ASCO task force on the cost of cancer care. J Oncol Pract 5:218–219

    Article  Google Scholar 

  5. 5.

    Ramsey SD, Bansal A, Fedorenko CR, Blough DK, Overstreet KA, Shankaran V et al (2016) Financial insolvency as a risk factor for early mortality among patients with cancer. J Clin Oncol 34(9):980–986

    CAS  Article  Google Scholar 

  6. 6.

    Ramsey S, Blough D, Kirchhoff A, Kreizenbeck K, Fedorenko C, Snell K et al (2013) Washington state cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis. Health Aff (Millwood) 32(6):1143–1152

    Article  Google Scholar 

  7. 7.

    Lentz R, Benson A, Kircher S (2019) Financial toxicity in cancer care: prevalence, causes, consequences, and reduction strategies. J Surg Oncol 120(1):85–92

    Article  Google Scholar 

  8. 8.

    Lathan CS, Cronin A, Tucker-Seeley R, Zafar SY, Ayanian JZ, Schrag D (2016) Association of financial strain with symptom burden and quality of life for patients with lung or colorectal cancer. J Clin Oncol 34(15):1732–1740

    CAS  Article  Google Scholar 

  9. 9.

    Resnicow K, Patel MR, Mcleod MC, Katz SJ, Jagsi R (2019) Physician attitudes about cost consciousness for breast cancer treatment: differences by cancer sub-specialty. Breast Cancer Res Treat 173(1):31–36

    Article  Google Scholar 

  10. 10.

    Grover M, Abraham N, Chang YH, Tilburt J (2016) Physician cost consciousness and use of low-value clinical services. J Am Board Family Med 29(6):785–792

    Article  Google Scholar 

  11. 11.

    Greenup RA, Rushing CN, Fish LJ et al (2019) Perspectives on the costs of cancer care: a survey of the American society of breast surgeons. Ann Surg Oncol 26(10):3141–3151

    Article  Google Scholar 

  12. 12.

    Tilburt JC, Wynia MK, Sheeler RD, Thorsteinsdottir B, James KM, Egginton JS et al (2013) Views of US physicians about controlling health care costs. JAMA 10(4):380–388

    Article  Google Scholar 

  13. 13.

    Ryskina KL, Halpern SD, Minyanou NS, Goold SD, Tilburt JC (2015) The role of training environment care intensity in US physician cost consciousness. Mayo Clin Proc 90(3):313–320

    Article  Google Scholar 

  14. 14.

    Bailey CM, Selber J, Liu J, Lee CN, Offodile AC (2020) Current practice and perceptions regarding cost communication in breast cancer reconstruction: survey results of the American society of plastic surgeons. Ann Surg Oncol. https://doi.org/10.1245/s10434-020-08750-w

    Article  PubMed  Google Scholar 

  15. 15.

    Jagsi R, Ward KC, Abrahamse PH, Wallner LP, Kurian AW, Hamilton AS et al (2018) Unmet need for clinician engagement regarding financial toxicity after diagnosis of breast cancer. Cancer 124(18):3668–3676

    Article  Google Scholar 

  16. 16.

    Gilligan T, Coyle N, Frankel RM, Berry DL, Bohlke K, Epstein RM et al (2017) Patient-clinician communication: American society of clinical oncology consensus guideline. J Clin Oncol 35(31):3618–3632

    Article  Google Scholar 

  17. 17.

    Meropol NJ, Schrag D, Smith TJ, Mulvey TM, Langdon RM, Blum D et al (2009) American society of clinical oncology guidance statement: the cost of cancer care. J Clin Oncol 27(23):3868–3874

    Article  Google Scholar 

  18. 18.

    Hunter WG, Zafar SY, Hesson A, Davis JK, Kirby C, Barnett JA et al (2017) Discussing health care expenses in the oncology clinic: analysis of cost conversations in outpatient encounters. J Oncol Pract 13(11):e944-956

    Article  Google Scholar 

  19. 19.

    Dean C, Chetty U, Forrest AP (1983) Effects of immediate breast reconstruction on psychosocial morbidity after mastectomy. Lancet 1(8322):459–462

    CAS  Article  Google Scholar 

  20. 20.

    Wilkins EG, Cederna PS, Lowery JC, Davis JA, Kim HM, Roth RS et al (2000) Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan breast reconstruction outcome study. Plast Reconstr Surg 106(5):1014–1025

    CAS  Article  Google Scholar 

  21. 21.

    Stevens LA, Mc Grath M, Druss RG, Kister SJ, Gump FE, Forde KA (1984) The psychological impact of immediate breast reconstruction for women with early breast cancer. Plast Reconstr Surg 73(4):619–628

    CAS  Article  Google Scholar 

  22. 22.

    Lee CN, Belkora J, Chang Y, Moy B, Partridge A, Sepucha K (2011) Are patients making high-quality decision about breast reconstruction after mastectomy? Plast Reconstr Surg 127(1):18–26

    CAS  Article  Google Scholar 

  23. 23.

    Smith BD, Jiang J, Shih YC, Giordano SH, Huo J, Jagsi R et al (2017) Cost and complications of local therapies for early-stage breast cancer. J Natl Cancer Inst. https://doi.org/10.1093/jnci/djw178

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    Greenup RA, Rushing C, Fish L, Campbell BM, Tolnitch L, Hyslop T et al (2019) Financial costs and burden related to decisions for breast cancer surgery. J Oncol Pract 15(8):e666–e676

    Article  Google Scholar 

  25. 25.

    Wilson IB, Schoen C, Neuman P, Strollo MK, Rogers WH, Chang H et al (2007) Physician-patient communication about prescription medication nonadherence: a 50-state study of America’s seniors. J Gen Intern Med 22(1):6–12

    Article  Google Scholar 

  26. 26.

    Hunter WG, Hesson A, Davis JK et al (2016) Patient-physician discussions about costs: definitions and impact on cost conversation incidence estimates. BMC Health Serv Res 31(16):108

    Article  Google Scholar 

  27. 27.

    Smedley BD, Stith AY, Colburn L, Evans CH 2001 Medicine (US) I of increasing racial and ethnic diversity among physicians: an intervention to address health disparities? The right thing to do, the smart thing to do: enhancing diversity in the health professions: summary of the symposium on diversity in health professions in honor of Herbert W. Nickens, M.D., National Academies Press (US) Available from http://www.ncbi.nlm.nih.gov/books/NBK223632/. Accessed 6 May 2020

  28. 28.

    Saha S, Taggart SH, Komaromy M, Bindman AB (2000) Do patients choose physicians of their own race? Health Aff Proj Hope 19(4):76–83

    CAS  Article  Google Scholar 

  29. 29.

    Buetow S, Elwyn G (2008) The window-mirror: a new model of the patient-physician relationship. Open Med 2(1):e20-25

    PubMed  PubMed Central  Google Scholar 

  30. 30.

    Haider AH, Dankwa-Mullan I, Maragh-Bass AC et al (2016) Setting a national agenda for surgical disparities research: recommendations from the national institutes of health and American college of surgeons summit. JAMA Surg 51(6):554–563

    Article  Google Scholar 

  31. 31.

    Al-Qurayshi Z, Robins R, Hauch A, Randolph GW, Kandil E (2016) Association of surgeon volume with outcomes and cost savings following thyroidectomy: a national forecast. JAMA Otolaryngol Neck Surg 142(1):32–39

    Article  Google Scholar 

  32. 32.

    Alexander GC, Casalino LP, Meltzer DO (2003) Patient-physician communication about out-of-pocket costs. JAMA 290(7):953–958

    Article  Google Scholar 

  33. 33.

    Fuchs VR (2013) The gross domestic product and health care spending. N Engl J Med 369(2):107–109

    CAS  Article  Google Scholar 

  34. 34.

    Fuchs VR (2009) Eliminating “waste” in health care. JAMA 302(22):2481–2482

    Article  Google Scholar 

  35. 35.

    Fuchs VR (1978) The supply of surgeons and the demand for operations. J Hum Resour 13(Suppl):35–56

    Article  Google Scholar 

  36. 36.

    Lee ZH, Reavey PI, Rodriguez ED, Chiu ES, Caplan AL (2019) Ethical issues in aesthetic and reconstructive surgical innovation: perspectives of plastic surgeons. Plast Reconstr Surg 143(1):346–351

    CAS  Article  Google Scholar 

  37. 37.

    Kung TA, Pannucci CJ, Chamberlain JL, Cederna PS (2012) Migraine surgery practice patterns and attitudes. Plast Reconstr Surg 129(3):623–628

    CAS  Article  Google Scholar 

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We acknowledge Erica Goodoff, ELS (D) of Editing Services, and Research Medical Library at MD Anderson Cancer Center for contributions to editing.


This research was supported by funds from the University Cancer Foundation via the Sister Institution Network Fund (SINF) at The University of Texas MD Anderson Cancer Center.

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Correspondence to Anaeze C. Offodile II.

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The senior author (ACO) has received research funding from Blue Cross Blue Shield Affordability Cures Consortium and National Academy of Medicine unrelated to the submitted work. He is also an advisory board member of the Patient Advocate Foundation.

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Sheckter, C.C., Aliu, O., Bailey, C. et al. Exploring provider- and practice-level drivers of cost-consciousness in breast cancer reconstruction—secondary analysis of a survey of the American Society of Plastic Surgeons. Breast Cancer Res Treat (2021). https://doi.org/10.1007/s10549-020-06085-4

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  • Breast reconstruction
  • Cost conversation
  • Financial toxicity
  • Cancer