Delivering equitable post-mastectomy care requires an understanding of geography, coverage policies, and limited fitter networks that restrict rural breast prosthesis access.

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Equity in Breast Prosthetic Access: Addressing Gaps in Rural Post-Mastectomy Care

Access to a well-fitted external breast prosthesis and mastectomy garments is not a cosmetic luxury. For many breast cancer survivors, especially those who do not choose or cannot obtain reconstruction, these devices are central to physical balance, comfort, body image, and social confidence. North American research suggests that a large majority of women who undergo mastectomy or lumpectomy will use a breast prosthesis at some point in their recovery, and satisfaction is highest when information, choice, and professional fitting are available.

Yet access is far from equitable. Survivors living in rural or remote communities across the United States, Canada, and Mexico often face longer travel distances, fewer certified fitters, patchy insurance literacy, and limited product choice. In fact, while nearly all breast surgeries occur in urban centers (96% vs. 1.55% in rural areas), rural patients often face barriers in accessing follow-up care for fittings.

Quoting the most recent research, a surprising 90% of women who have a mastectomy may use some form of breast prosthesis. The use of external prosthesis is notably lower in rural populations, with studies indicating a usage rate of approximately 25% for rural women compared to roughly 48% in urban,

At the same time, payers formally acknowledge external breast prostheses and post-operative camisoles as medically necessary durable medical equipment—at least on paper. The challenge is translating policy into real, on-the-ground access.

The net effect is that women living outside major cities may be technically “covered” for a prosthesis but functionally underserved.

Why Breast Prostheses and Garments Are Equity Issues

External breast prostheses do more than fill a cup in a bra. Studies from Canada and the United States describe the vital role that mastectomy fitting plays in restoring symmetry, reducing postural strain, and supporting quality of life for women after total mastectomy. Women report feeling more comfortable in clothing, more willing to participate in social and professional life, and better able to “look like themselves” in public spaces.

Qualitative work from Canadian oncology settings shows that women value:

• A prosthesis that looks and feels natural
• Mastectomy bras and camisoles that are comfortable and supportive
• A fitting experience where they feel informed, respected, and not rushed

When those elements are missing, women describe discomfort, limited wear time, and frustration with products that are too heavy, too hot, or poorly matched to their body and lifestyle. Equity in access, therefore, is not simply about whether a prosthesis is technically covered—it is about whether the survivor can realistically obtain a device that works for her.

Rural Realities in North America

Across North America, the United States, Canada, and Mexico, services cluster in large metropolitan centers. Specialty post-mastectomy boutiques, hospital-based fitting programs, and comprehensive cancer centers are far more common in cities than in small towns.

Canadian and Mexican data underscore that satisfaction with external breast prostheses is closely linked to comfort, customization, and the ability to adjust or replace an ill-fitting device—services that are harder to access when the nearest fitter is several hours away.

In Canada, national cancer organizations describe breast prostheses and mastectomy bras as standard post-surgical options but note that access often depends on proximity to certified fitters and specialty retailers. While in Mexico, a case study from Zacatecas, Mexico, published in the Gaceta Mexicana de Oncología (Mexican Journal of Oncology), highlights that dissatisfaction with standardized prostheses—especially regarding shape, weight, and comfort—drives demand for more customized solutions. It acknowledges that, unfortunately, the availability of options and follow-up appointments remains concentrated in urban centers.

For rural survivors, these structural realities translate into very practical barriers:

• Time and travel cost for in-person fittings and refittings
• Limited local inventory in size, skin tone, and style
• Delays in replacing worn or damaged prostheses
• Fewer opportunities to trial lighter-weight or custom options

The net effect is that women living outside major cities, regardless of country, may be technically “covered” for a prosthesis but functionally underserved.

U.S Coverage, Cost, and the Role of Policy

From a policy standpoint, North America recognizes external breast prostheses and mastectomy garments as part of medically necessary post-mastectomy care:

• In the United States, the Women’s Health and Cancer Rights Act (WHCRA) has strongly influenced group health plans that cover mastectomy to also cover breast prostheses. Within the past decade, interpretation by many insurance providers has expanded to also include external breast prosthesis and related post-mastectomy garments.
• Medicare and Medicaid, while not subject to WHCRA requirements, have their DMEPOS contractors continually describe external breast prostheses and postoperative garments as covered, with explicit guidance on indications, coverage parameters, replacement frequency, and required documentation.

Despite this perception of coverage, patient-level experience tells a more complicated story. Survivors are often ill-informed about their benefits. Rural providers and fitters may not be enrolled with all relevant payers. Upfront out-of-pocket costs, even when later reimbursed, can be prohibitive. And benefit designs may be generous for surgery and reconstruction while comparatively modest for external prostheses, bras, compression, and camisole garments.

For women who prefer to remain flat or delay reconstruction, inequities in prosthetic and garment coverage can effectively create a “second tier” of post-mastectomy care.

Information and Fitting Gaps

Satisfaction surveys of external breast prostheses consistently highlight the importance of communication and the fitting experience itself.

A Canadian mixed-methods cohort study of custom breast prostheses found that women who received clear pre-surgical information, had input into prosthesis design, and were supported through adjustments reported higher perceived benefit and satisfaction.

Similarly, Canadian Oncology Nursing Journal research indicates that many women first learn about prostheses from peers rather than clinicians, and that they want more guidance on:

• Timing of initial fittings and temporary camisole garments
• Differences between standard, lightweight, and custom prostheses
• How often can a prosthesis and mastectomy bras reasonably be replaced
• What is covered by public programs or private insurance

When this information is missing, rural survivors are especially disadvantaged. They may have fewer providers to ask, less access to specialty cancer education events, and limited options if a first fitting is uncomfortable or unsatisfactory.

Strategies to Improve Equity in Rural Prosthetic Access

While some structural issues lie beyond the control of individual clinicians, several practical strategies can move care closer to equity. It is at this stage that Certified Post-Mastectomy Fitters are vital

1. Build Rural-Responsive Referral Pathways

Oncology teams, nurse navigators, and those serving rural regions can:

• Maintain updated referral lists of certified fitters and mobile fitting services as reputable options that understand post-mastectomy needs.
• Incorporate external prosthesis and garment referrals into survivorship care plans, not as an optional add-on but as a standard element of post-surgical recovery.
• Partner with regional cancer programs to host periodic “fitting days” in rural clinics or community centers, bringing expert fitters closer to where women live.

2. Blend In-Person and Remote Fitting Models

Technology cannot replace the need for hands-on prosthesis fitting. But it can reduce the back-and-forth burden on rural breast cancer survivors by:

• Using telehealth for pre-fit or post-fit education and benefit explanation before a single in-person session
• Offering virtual follow-up to troubleshoot issues with weight, strap pressure, or garment comfort
• Coordinating shipments for a more efficient visit, eliminating the need for repeated trips

Design innovation from North and Central American research—such as lighter, more biomimetic, and customizable prostheses—can be aligned with these hybrid models to address the comfort and weight concerns many women raise.

Equity in breast prosthetic access is not a side issue in post-mastectomy care; it is a core survivorship concern.

3. Use Policy as a Tool for Access

When policy knowledge is paired with survivor-centered advocacy, existing laws and guidelines become levers for access instead of bureaucratic obstacles. Clinicians and fitters who understand coverage frameworks can actively reduce inequity by:

• Verifying benefits proactively and helping rural survivors navigate prior authorization, documentation, and supplier enrollment requirements
• Educating patients about replacement intervals and encouraging them to schedule refitting before a prosthesis or garment becomes visibly worn
• Advocating with insurers and public programs for policies that recognize rural realities—such as covering travel costs for fitting visits or supporting tele-fitting where appropriate

4. Center Survivor Voice in Service Design

Prosthesis demographic research consistently shows that women are experts in identifying what does and does not work in daily life. Rural survivors in particular can inform:

• Preferred appointment times that fit around family or caregiving schedules
• The most important features of mastectomy garments (e.g., moisture management in hot climates, front closures, pockets for forms and drains)
• Communication channels that actually reach them—local radio, community health workers, or social media groups, rather than only hospital websites

Embedding survivor advisory input into prosthesis programs helps ensure that innovations and outreach efforts address real barriers.

Ultimately, quality in breast prosthetic access is not a side issue in post-mastectomy care; it is a core survivorship concern.

A growing corpus of evidence confirms that high-quality external prostheses and mastectomy garments support body image, comfort, and long-term function. At the same time, rural survivors continue to face disproportionate barriers in reaching fitters, understanding coverage, and accessing products that truly fit their bodies and lives.

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References

1. Fitch, M. I., McAndrew, A., Harris, A., Anderson, J., Kubon, T., & McClennen, J. (2012). Perspectives of women about external breast prostheses. Canadian Oncology Nursing Journal, 22(3), 162–174.
2. Kubon, T. M., McClennen, J., Fitch, M. I., et al. (2012). A mixed-methods cohort study to determine perceived patient benefit in providing custom breast prostheses. Current Oncology, 19(2), e43–e52.
3. Glaus, S. W., & Carlson, G. W. (2009). Long-term role of external breast prostheses after total mastectomy. The Breast Journal, 15(4), 385–393.
4. Burnes-Rudecino, S., Rodríguez-Juárez, P., Baltazar, R., & De la Rosa, J. I. (2025). Satisfaction in external breast prostheses: a case study in Zacatecas, Mexico. Gaceta Mexicana de Oncología, 24(2), 76–84.
5. Cruz, P., Hernández, F. J., Zuñiga, M. L., Rodríguez, J. M., Figueroa, R., Vertiz, A., & Pineda, Z. (2018). A biomimetic approach for designing a full external breast prosthesis: post-mastectomy. Applied Sciences, 8(3), 357.
6. Canadian Cancer Society. (n.d.). Breast prostheses. Information page on types of prostheses and access options for post-mastectomy patients in Canada.
7. Commonwealth Care Alliance. (2021). External Breast Prostheses Medical Necessity Guideline (MNG 74). Policy document summarizing clinical indications and coverage for external breast prostheses under a U.S. health plan.
8. DeCoster RC, Bautista RF Jr, Burns JC, et al. Rural-Urban Differences in Breast Reconstruction Utilization Following Oncologic Resection. J Rural Health. 2020;36(3):347-354. doi:10.1111/jrh.12396
9. Noridian Medicare / CMS. (2021). External Breast Prostheses – Policy Article and Webinar Q&A (including L8015 external breast prosthesis garment). U.S. Medicare guidance on coverage, coding, and use of external breast prostheses and post-operative garments.
10. Facing Our Risk of Cancer Empowered (FORCE). (n.d.). Women’s Health and Cancer Rights Act: Breast prostheses coverage. Consumer-facing summary of WHCRA provisions related to post-mastectomy prostheses and garments in the United States.
11. Ramu D, Ramesh RS, Manjunath S, et al. Pattern of External Breast Prosthesis Use by Post Mastectomy Breast Cancer Patients in India: Descriptive Study from Tertiary Care Centre. Indian J Surg Oncol. 2015;6(4):374-377. doi:10.1007/s13193-015-0456-2