Return of the Flap; The Empire State Mandate: A Multi-decade Multi-institutional Analysis of the 2010 New York State Legislature's Impact on Postmastectomy Immediate Flap-Based Reconstruction.

Abstract

Immediate postmastectomy breast reconstruction plays an integral role in patient care because of its psychosocial benefits. New York State (NYS) passed the 2010 Breast Cancer Provider Discussion Law with the aim of increasing patient awareness of reconstructive options through mandating plastic surgery referral at the time of cancer diagnosis. Short-term analysis of the years surrounding implementation suggests the law increased access to reconstruction, especially for certain minority groups. However, given the continued presence of disparities in access to autologous reconstruction, we aimed to investigate the longitudinal effects of the bill on access to autologous reconstruction along various sociodemographic cohorts. Retrospective review identified demographic, socioeconomic, and clinical data for patients undergoing mastectomy with immediate reconstruction at Weill Cornell Medicine and Columbia University Irving Medical Center from 2002 to 2019. Primary outcome was receiving implant or autologous-based reconstruction. Subgroup analysis was based on sociodemographic factors. Multivariate logistic regression identified predictors of autologous reconstruction. Interrupted time series modeling analyzed differences in reconstructive trends for subgroups before and after the 2011 implementation of the NYS law. We included 3178 patients; 2418 (76.1%) and 760 (23.9%) patients underwent implant and autologous-based reconstruction, respectively. Multivariate analysis indicated that race, Hispanic status, and income were not predictors of autologous reconstruction. Interrupted time series showed that with each year leading up to 2011 implementation, patients were 19% less likely to receive autologous-based reconstruction. Following implementation, there was a 34% increase in the odds of receiving autologous-based reconstruction with each passing year. Following implementation, Asian American and Pacific Islander patients experienced a 55% greater increase in the rate of flap reconstruction than White patients. Following implementation, the highest-income quartile experienced a 26% greater increase in the rate of autologous-based reconstruction compared with the lowest-income quartile. After implementation, Hispanic patients experienced a 30% greater decrease in the rate of autologous-based reconstruction compared with non-Hispanic patients. Our data indicate the long-term efficacy of the NYS Breast Cancer Provider Discussion Law in increasing access to autologous-based reconstruction, especially for certain minority groups. These findings underscore the importance of this bill and encourage its adoption into other states.