The New York State Senate

testing  for  susceptibility genes like BRCA, targeted chemotherapeutics
like Herceptin, and microsurgical reconstructive techniques  have  given
women more hope, more options, and a better chance of not only surviving
but recovering from this disease.

Breast  cancer  care, at the highest level, is delivered by a multi-spe-
cialty group of physicians and surgeons that include a  medical  oncolo-
gist,  a  breast  surgeon,  a radiation oncologist, and a reconstructive
surgeon. Despite the advances and the progress, there remains a  signif-
icant  disparity  in  the  care  provided  to  women with breast cancer,
particularly with respect to access to reconstructive surgery.

Reconstruction of the breast after cancer surgery has  not  always  been
the  standard-of-care.  With  the development of improved reconstructive
techniques during the last two decades, we entered a new era  in  breast
cancer  care.  Reconstruction  has  repeatedly been shown to improve the
quality of life and overall well-being of women who  have  been  treated
for breast cancer. However, it is not for everyone; there are some women
who  undergo surgery for breast cancer who either do not want or are not
candidates for reconstruction.

In the 1990s, studies showed a great disparity among women who  received
reconstruction  and  those  who  did  not. This disparity related to the
patient's socioeconomic and educational status as well as to the  breast
surgeon's  practice  setting. When breast reconstruction was viewed as a
cosmetic procedure, insurance companies were not compelled  to  pay  for

it.  Poor  women  often  could  not  afford to pay out-of-pocket for the
procedure. To address this disparity, Congress passed the Women's Health
and Cancer Rights Act in 1998.  This  legislation  guaranteed  universal
coverage for reconstruction after surgery for breast cancer and compara-
ble provisions were added to New York State Insurance Law to ensure that
coverage was extended here in New York.

Despite  these  laws,  however,  disparities in access to reconstructive
surgery remain. Several important national studies conducted  under  the
leadership  of  Amy  Adelman  at  the University of Michigan and Caprice
Greenberg at Dana Farber analyzed why many women did not receive  recon-
struction.  The  two  dominant  causes  were their failure to understand
their options and breast surgeons' failures to refer their patients to a
reconstructive surgeon. According to a recent report by  Greenberg,  the
greatest  predictor  of reconstruction was a documented discussion about
reconstruction between the breast surgeon  and  patient.  This  critical
discussion is not taking place often enough.

Statistics on the type of treatment women receive for breast cancer care
at  a  particular  hospital  or  in a particular region are not publicly
available. The best surrogate is to compare the  patient  population  of
interest  with a similar one from a studied database.  The Surveillance,
Epidemiology, and  End  Results  (SEER)  cancer  registry,  run  by  the
National  Cancer Institute (NCI), provides this opportunity. Analysis of
treatment  received  by  women  in  different  settings  provides  stark
contrasts.  The  SEER  database  looks  at women treated in a variety of
geographic settings, with attention paid to factors  such  as  level  of
education,  socioeconomic  status, type of medical center (cancer center
vs community  hospital),  and  a  variety  of  other  factors.  Multiple
analyses show that poor, uneducated women are far less likely to receive
reconstruction. Their breast surgeons are less likely to discuss it with
them.  They  are  less likely to receive treatment at a dedicated cancer
center. They are more likely to receive a lumpectomy and radiation  than
to  undergo  a  mastectomy  followed by reconstruction. Greenberg et al.
reported the disturbing fact that  women  with  Medicare  had  a  recon-
struction rate of 11% compared with women with managed care or indemnity
insurance  who  received  reconstruction  approximately 54% of the time.
Nationally, across multiple socioeconomic groups and different treatment
environments, only 33% of women undergoing  surgery  for  breast  cancer
will receive reconstruction.

The  bill  is,  designed  to educate women regarding the availability of
reconstructive surgery and enhance access  to  these  services.  When  a
Woman  is  diagnosed  with  breast cancer, she will be given information
that clearly explains her rights to coverage and  her  options  as  they
relate to reconstruction. This is akin to the informed consent a patient
must  sign  before  undergoing any operation. The bill will also require
that the patient receive information relating to the option of  referral
to  a  reconstructive.surgeon at the time of diagnosis or shortly there-
after if she chooses. Because important decisions on cancer  care,  such
as  the  choice  between having a mastectomy or a lumpectomy, are influ-
enced, in large part, by the patient's understanding  of  reconstructive

options, the reconstructive surgeon must be part of this discussion from
the very beginning.

LEGISLATIVE HISTORY: None.

FISCAL IMPLICATIONS: None.

EFFECTIVE DATE:  January 1, 2011.

chemotherapeutics  like  Herceptin,  and  microsurgical reconstructive
techniques have given women more hope,  more  options,  and  a  better
chance of not only surviving but recovering from this disease.

Breast   cancer  care,  at  the  highest  level,  is  delivered  by  a
multi-specialty group  of  physicians  and  surgeons  that  include  a
medical  oncologist,  a  breast surgeon, a radiation oncologist, and a
reconstructive surgeon. Despite the advances and the  progress,  there
remains  a  significant  disparity  in the care provided to women with
breast cancer, particularly with respect to access  to  reconstructive
surgery.

Reconstruction  of the breast after cancer surgery has not always been
the standard-of-care. With the development of improved  reconstructive
techniques during the last two decades, we entered a new era in breast
cancer  care.  Reconstruction has repeatedly been shown to improve the
quality of life and overall well-being of women who have been  treated
for  breast  cancer.  However,  it is not for everyone; there are some
women who undergo surgery for breast cancer who either do not want  or
are not candidates for reconstruction.

In  the  1990s,  studies  showed  a  great  disparity  among women who
received reconstruction and those who did not. This disparity  related
to  the  patient's  socioeconomic and educational status as well as to
the breast surgeon's practice setting. When breast reconstruction  was
viewed as a cosmetic procedure, insurance companies were not compelled
to  pay for it. Poor women often could not afford to pay out-of-pocket
for the procedure. To address  this  disparity,  Congress  passed  the
Women's  Health  and  Cancer  Rights  Act  in  1998.  This legislation
guaranteed universal coverage for  reconstruction  after  surgery  for


breast  cancer  and comparable provisions were added to New York State
Insurance Law to ensure that coverage was extended here in New York.

Despite  these  laws, however, disparities in access to reconstructive
surgery remain. Several important national studies conducted under the
leadership of Amy Adelman at the University of  Michigan  and  Caprice
Greenberg  at  Dana  Farber  analyzed  why  many women did not receive
reconstruction.  The  two  dominant  causes  were  their  failure   to
understand  their options and breast surgeons' failures to refer their
patients to a reconstructive surgeon. According to a recent report  by
Greenberg,  the  greatest predictor of reconstruction was a documented
discussion  about  reconstruction  between  the  breast  surgeon   and
patient. This critical discussion is not taking place often enough.

Statistics  on  the  type of treatment women receive for breast cancer
care at a particular hospital  or  in  a  particular  region  are  not
publicly  available.  The  best  surrogate  is  to compare the patient
population of interest with a similar one  from  a  studied  database.
The   Surveillance,   Epidemiology,  and  End  Results  (SEER)  cancer
registry, run by the National Cancer Institute  (NCI),  provides  this
opportunity.  Analysis  of  treatment  received  by women in different
settings provides stark contrasts. The SEER database  looks  at  women
treated  in  a  variety of geographic settings, with attention paid to
factors such as level of  education,  socioeconomic  status,  type  of
medical center (cancer center vs community hospital), and a variety of
other  factors. Multiple analyses show that poor, uneducated women are
far less likely to receive reconstruction. Their breast  surgeons  are
less  likely  to discuss it with them. They are less likely to receive
treatment at a dedicated  cancer  center.  They  are  more  likely  to
receive  a  lumpectomy  and  radiation  than  to  undergo a mastectomy
followed by reconstruction. Greenberg et al. reported  the  disturbing
fact  that  women  with  Medicare  had  a  reconstruction  rate of 11%
compared with women with  managed  care  or  indemnity  insurance  who
received  reconstruction  approximately  54% of the time.  Nationally,
across  multiple  socioeconomic   groups   and   different   treatment
environments,  only  33% of women undergoing surgery for breast cancer
will receive reconstruction.

The bill is, designed to educate women regarding the  availability  of
reconstructive  surgery  and  enhance access to these services. When a
Woman is diagnosed with breast cancer, she will be  given  information
that  clearly  explains her rights to coverage and her options as they
relate to reconstruction. This is  akin  to  the  informed  consent  a
patient  must sign before undergoing any operation. The bill will also
require that the patient receive information relating to the option of
referral to a reconstructive.surgeon  at  the  time  of  diagnosis  or
shortly  thereafter  if  she  chooses.  Because important decisions on
cancer care, such as the choice  between  having  a  mastectomy  or  a
lumpectomy,   are   influenced,   in  large  part,  by  the  patient's
understanding of reconstructive options,  the  reconstructive  surgeon
must be part of this discussion from the very beginning.

LEGISLATIVE HISTORY: None.

FISCAL IMPLICATIONS: None.

EFFECTIVE DATE: January 1, 2011.