PURPOSE: In 2010, New York State (NYS) passed the Breast Cancer Provider Discussion Law mandating that breast cancer surgeons discuss insurance coverage of reconstruction and refer to a plastic surgeon, two significant factors found to affect reconstructive rates. Previously, we examined the impact of this law using the NYS Statewide Planning and Research Cooperative System (SPARCS) database, a comprehensive all payer patient data record that was established in 1979 to document patient characteristics, outcomes, and use of the NYS healthcare system. Our results demonstrated an increase in reconstruction rates across all groups and a reversal of previously documented racial and economic disparities. Herein, we analyzed data from four of the largest public New York City (NYC) Health and Hospital Corporation (HHC) hospitals to determine if the same increase in reconstruction rates is reflected in a diverse urban populace with high percentage of publicly insured patients, and whether discussion of breast reconstruction was affected by enactment of the law.
METHODS: This study was approved by the Columbia University Medical Center and Biomedical Research Alliance of New York (BRANY) IRBs. We analyzed breast cancer-related surgery data from four NYC HHC hospitals: Bellevue Hospital Center, Jacobi Medical Center, Lincoln Hospital, and Metropolitan Hospital Center. Using these datasets, we examined breast reconstruction rates four years before (2007–2010) and three years after (2011–2013) the law came into effect. We further evaluated documentation of reconstructive discussion and referral and other variations in hospital care by subgroup.
RESULTS: All four hospitals reported that their breast surgeons were made aware of the law shortly after passage. We analyzed 603 patients who underwent mastectomies with a 50.9% reconstruction rate before law enactment and 50.0% after. Hospital-based subgroup analysis at Lincoln and Bellevue demonstrated 398 patients who underwent mastectomies with a 47.52% reconstruction rate before the law and a 57.65% after (OR 1.503, p-value = 0.0434). Jacobi patients were analyzed separately due to a reported breast surgeon preference shift favoring lumpectomies over mastectomies post-law enactment. 173 patients were analyzed demonstrating a 56.58% reconstruction rate before the law and a 38.14% rate after (OR 0.473, p-value = 0.0164). At Jacobi, discussion rate before the law was 71.05% and 94.85% after (OR 7.496, p-value < 0.0001).
CONCLUSION: Our results suggest that enactment of the law was correlated with a slight increase in reconstruction rates after mastectomy at Lincoln and Bellevue and an increase in discussion rates at Jacobi. Decrease in reconstruction rates at Jacobi may be explained by reported breast surgeon preference for lumpectomies. The relatively modest increase in discussion and reconstruction rates seen in this urban populace as compared to the SPARCS database may suggest that there can be a saturation point wherein patients who are made aware of options still choose not to see a plastic surgeon or undergo reconstruction. Limitations to this study are its retrospective design and potential under-reporting of patient outcomes by data collection methods. Further study is ongoing to determine the patient, provider, and healthcare environment factors that impact breast reconstruction.