Plastic Surgery Research Council

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The Impact of the 2010 NY State Breast Cancer Provider Discussion Law on Type of Breast Reconstruction: An Analysis of 42,137 Patients From the NY SPARCS Database
Rose H. Fu, MD, MS1, Lu Li, MS2, Onur Baser, MS1, Paul Kurlansky, MD, FACS1, Yoshiko Toyoda, BA1, Alexandra Lin, BA1, Christine Rohde, MD, MPH, FACS1.
1Columbia University Medical Center, New York City, NY, USA, 2StatinMed, Plano, TX, USA.

PURPOSE:
The percentage of women undergoing breast reconstruction increased significantly in New York State (NYS) after its passage of the NYS Breast Cancer Provider Discussion Law, which mandates cancer surgeon provider discussion of breast reconstruction in order to improve patient awareness of post-mastectomy reconstructive options. We previously demonstrated that there was improvement in racial, economic, and age disparities in breast reconstruction after law enactment. However, while examining patient factors, we did not analyze what procedure breast reconstruction patients ultimately chose. The majority of patients who receive breast reconstruction choose implant-based reconstruction (IBR) as opposed to autologous flap reconstruction (AFR). Since increasing reconstruction rates may impact rates of specific procedures unequally, this study examines the law's potential impact on the type of breast reconstructive modality chosen. METHODS:We used the NYS Planning and Research Cooperative System (SPARCS) database to examine different breast reconstruction modalities three years before (2008-2010) and four years after (2011-2014) law enactment, stratifying by implant-based versus autologous reconstruction. We assessed for statistical significance using the chi-squared test and a p-value <0.05 was considered significant. All statistical analysis was carried out using SAS® version 9.4
RESULTS:
We examined 42,137 patients. There was a decline in the absolute volume of mastectomies from 6479 in 2008 to 4488 in 2014, with an increase in percentage of women seeking reconstruction from 49% in 2008 to 60% in 2014. In all years studied, the percentage of women undergoing IBR was significantly higher than those seeking AFR (p<0.01). However, when comparing data pre and post-law enactment, rates of IBR decreased significantly whereas rates of AFR increased significantly (IBR: from 79.17% of all reconstructions to 70.35%, p<0.01, AFR: from 20.83% to 29.65%, p<0.01). When examining types of autologous procedures, perforator flaps experienced a general increase from before to after law-enactment—with a 16% jump from 29.39% to 43.71% in deep inferior epigastric perforator flaps (p<0.01), while all muscle flaps (latissimus, pedicled and free transverse rectus abdominus myocutaneous flap) declined in frequency. CONCLUSION: The aim of the Breast Cancer Provider Discussion Law is to improve breast reconstruction rates through provider-driven patient education. Our data shows significant increases in overall breast reconstruction. In those who opt for reconstruction, there is an increasing trend towards autologous reconstruction with a corresponding decline in implant-based reconstruction. Implant-based reconstruction continued to be the more common procedure, but the significant increase in autologous reconstruction, which was mostly concentrated in muscle-sparing perforator flaps, may reflect increasing familiarity among surgeons with the procedure, rather than a singular contribution of the law. However, as reconstruction rates increase with wider discussion from oncologic surgeons who essentially serve as “gatekeepers”, we can potentially expect increasing rates of autologous reconstruction.


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