The Privilege of Advocacy (2011)

In 2010, New York State passed legislation sponsored by Assemblywoman Naomi Rivera and State Senator Ruth Hassel-Thompson that mandates hospitals and physicians inform women of the option of breast reconstruction after mastectomy. Authoring this legislation was surprisingly educational and simple. It can easily be replicated in the other 49 states with the help of readers of this Journal. From the pioneering days of breast reconstruction with silicone implants in the 1960s to the autologous era beginning with Hartrampf in the 1980s, to the more elaborate and nuanced techniques of today, plastic surgeons have successfully developed a set of operations that provide women with a wide variety of options for reconstructing the postmastectomy defect.1 Today, among the dozen accepted techniques, most women can find a procedure that will be deemed a success, in their eyes and in their surgeon's eyes. Among women undergoing mastectomy, a minority undergo reconstruction. Some women choose not to undergo reconstruction. Some are not candidates because of advanced disease, comorbid conditions, or advanced age. Some do not know that reconstruction exists as an option and are never educated otherwise. Some women think reconstruction is viewed as cosmetic by their insurance companies and are unable to afford it. Some would choose it but are not referred to a plastic surgeon. The first two factors are beyond our control. The last three are not. There are two issues to address: the overall low rate of reconstruction and the much lower rate of reconstruction among poor and minority women in the United States. In 1998, Senator D'Amato of New York authored federal legislation entitled the Women's Health and Cancer Rights Act to address both issues. Among other things, it guaranteed universal coverage for women undergoing breast reconstruction for postmastectomy or postlumpectomy defects. In the first decade following passage of this bill, several large studies examined the disparities in rates of reconstruction among various socioeconomic and racial groups. Guaranteeing universal coverage for reconstruction should have had a major impact on the overall rate of reconstruction and on the existent disparity. Unfortunately, it did not. Several investigators have analyzed why the elimination of financial barriers has played little role in making breast reconstruction more accessible. In 2004, Tseng et al. found that African American women were 34 percent as likely to undergo immediate reconstruction as white women.2 In 2005, Joslyn reported the low overall rate of immediate reconstruction among the studied cohort (approximately 20 percent of women undergoing mastectomy) and the 40 percent decrease, after multivariate analysis, in the likelihood that black women will undergo immediate or early reconstruction compared with white women.3 Alderman et al. also used the National Cancer Institute's Surveillance, Epidemiology and End Results database to examine the use of immediate and early breast reconstruction. They found a 15 percent immediate/early reconstruction rate overall, a widely disparate rate based on geographic region, and significant disparities based both on age and on race.4 Greenberg et al. noted that the single greatest predictor of whether a woman underwent breast reconstruction was the mentioning of reconstruction by the breast surgeon in the initial consultation.5 In an effort to further understand why such significant disparities persist, Alderman et al. explored referral patterns from breast surgeons to plastic surgeons. They found that only 24 percent of breast surgeons in metropolitan Detroit and Los Angeles referred more than 75 percent of their patients to a plastic surgeon to discuss reconstruction.6 The persistence of the disparity in the rates of reconstruction among poor, minority, undereducated women in the post–Women's Health and Cancer Rights Act era is unacceptable. The beneficial effects of breast reconstruction on patient well-being have been proven.7 The Women's Health and Cancer Rights Act guarantees financial coverage. Several techniques are available to most board-certified plastic surgeons, making success likely for the majority of women and surgeons. Although there are many reasons why a particular woman may choose not to undergo reconstruction, lack of access to a plastic surgeon should not be one of them. Referral to a plastic surgeon ought to be viewed in the same light as referral to a radiation oncologist, breast surgeon, or medical oncologist. Plastic surgeons must demand input at this level, as we offer patients a perspective they will not get from other cancer doctors. Hospitals must make access to a plastic surgeon logistically possible for the patient and economically and operationally possible for the plastic surgeon. In 2011, reconstruction is undoubtedly part of the standard-of-care for breast cancer and, as such, hospitals that treat breast cancer must offer the full complement of services that constitute this standard. Our responsibility, as a profession, is to make every effort to treat women diagnosed with breast cancer in a timely fashion. Plastic surgeons are not formally taught to be politicians, public advocates, lobbyists, or legislators. However, we should not underestimate our influence in these nonsurgical realms. Nor should we overestimate the difficulty of enacting change on a macro scale. When presented with the problem of disparity and access, Gifford Miller, past Speaker of the New York City Council, suggested that, in addition to community outreach and educating our patients and colleagues, we simply make informing women of the availability of breast reconstruction a New York State law. From this suggestion, the leadership at Montefiore Medical Center (specifically, Don Ashkenase, the Special Advisor to the President and Chief Executive Officer), coordinated meetings in Albany with legislators who helped draft the bill. Meetings with state senators and assemblymen were simple and straightforward. In one of the most difficult legislative environments in New York State history, the bill passed both the Assembly and the Senate unanimously and expediently. It was signed into law in August of 2010 by Governor Paterson. Plastic surgeons must demand a seat at the table where decisions on breast cancer care are made. This includes the conference table at the hospital and the round table at the state capital. The literature suggests that many of patients who do not undergo reconstruction are never told about reconstruction or referred to a plastic surgeon. One could argue, then, that the disparity is not our responsibility, as a specialty. Of course, it is (at least partly) our responsibility. The American Society of Plastic Surgeons is currently playing an active role in fostering the spread of legislation such as that recently signed in New York. It is our privilege to help, and it is easier than one might think.