While breast reconstruction after a mastectomy is covered by insurers in New York, many poor, minority, and less educated women do not seek out the procedure. Now, NY Gov. David A. Paterson has signed into law a bill that is aimed at reversing this trend.
"A disproportionate number of women who are at a socioeconomic disadvantage do not get breast reconstruction surgery after a mastectomy for one of several reasons. Either they are unaware of it as an option, they do not know it is covered by Medicaid and Medicare insurance programs, they do not know where to gain access to the procedures, or it is never mentioned to them by their other doctors," said Evan Garfein, MD, the plastic and reconstructive surgeon at Montefiore Medical Center who authored the Bill.
He hopes that the new law (A10094B/S6993-B/Information and Access to Breast Reconstruction Surgery) will correct this disparity. It requires hospitals in New York to inform breast cancer patients about the availability of, and insurance coverage for, breast reconstruction before they undergo "mastectomy surgery, lymph node dissection or a lumpectomy."
While Congress passed the Women's Health and Cancer Rights Act in 1998, which guaranteed universal coverage for reconstruction after surgery, and New York soon passed comparable provisions into its laws, disparities in access remain.
"Breast reconstruction has been repeatedly shown to improve the quality of life and overall well-being of women who have been treated for breast cancer," said Dr. Garfein. "This new law will ensure that breast cancer patients from all socioeconomic groups are informed about their options regarding breast reconstruction and about where to get the procedure."
Why the Bill is Needed: Letitia Was Never Told About Reconstruction
Letitia M., a 39-year-old single mom of two who lives in the Bronx, was diagnosed with breast cancer in 2006. She had felt a lump in her left breast and her primary care physician confirmed her suspicions of cancer after he referred her for a mammogram and sonogram. Even though she consulted with three different doctors while planning her treatment, none of them mentioned reconstruction as an option.
Letitia first had a lumpectomy and then a full mastectomy. It was only later in the treatment process, while she was receiving radiation therapy at a Manhattan hospital, that she learned about reconstruction. It was at this time that she was referred to Dr. Garfein at Montefiore, who subsequently performed reconstruction – two years after her cancer surgery. When Letitia was asked why she did not undergo reconstruction at the time of her mastectomy, she replied that no one had mentioned that it was an option.
Letitia is doing well and is on the road to recovery. While it is possible that she would have chosen to delay her reconstruction until after her cancer surgery and radiation therapy were complete, the standard of care in 2010 is to at least offer her the option of immediate reconstruction at the time of her mastectomy. The purpose of the Bill is to make sure that no woman ever says, "I didn't get reconstructed because no one mentioned it to me."
One-Third of Women With Breast Cancer Choose Reconstruction
Breast reconstruction is not for everyone. Each year, a quarter of a million women are diagnosed with breast cancer, according to the American Cancer Society. Of those who undergo mastectomy, 30-40 percent, depending on the study, receive breast reconstruction, according to Dr. Garfein.
"This percentage is much lower among poor, minority and less educated women. One reason for this disparity is that their breast surgeons are less likely to discuss it with them and they are less likely to receive treatment at a dedicated cancer center where reconstruction procedures are more readily available," said Dr. Garfein. "We feel strongly that all breast cancer patients, wherever they live and whatever their knowledge level should be informed that reconstruction may be an option and that, if it is, it will be covered."
Discussing Reconstruction Before a Mastectomy is Key
Today, there are many reconstruction options for patients who have breast surgery, including saline and silicone gel implants, and several types of reconstruction using the patient's own tissues from the abdomen, thigh, back or buttocks.
The new law underscores that patients should discuss this range of reconstruction choices before deciding between a mastectomy (the total removal of the cancerous breast) or a lumpectomy (removal of part of the breast), and that the discussion involve both the cancer surgeon, who removes the cancer from the breast, and the plastic surgeon, who would perform the breast reconstruction. The surgical team and the patient can then decide if reconstruction should be performed at all, and if so, whether that should happen at the same time as the cancer surgery (as is now the standard), or at a later date.
Many women who choose not to have reconstruction do so because of personal preferences, their overall health, the stage of their breast cancer, or to avoid the risks of additional surgery. Some women, however, don't receive reconstruction because it wasn't offered to them and they didn't know to ask about it. It is this group that the legislation targets.
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