Ambulatory Surgery for Breast Cancer
More women with breast cancer are choosing to have mastectomies over breast-sparing procedures and almost half do not need to stay overnight at the hospital, according to a federal analysis.
The Agency for Healthcare Research and Quality (AHRQ) study shows that treatment trends for breast cancer are evolving with more women opting for outpatient mastectomies versus more conservative surgeries combined with radiation treatment.
Using data from 13 states that represent a quarter of the population, the federal Agency for Healthcare Research and Quality found that the rate of mastectomy increased by 36 percent from 2005 to 2013. During that same period, the overall incidence of breast cancer remained the same, the report says.
According to the study, 45% of mastectomies in 2013 were performed in hospital-affiliated outpatient surgery centers with no overnight stay – an increase of 22% from 10 years ago.
Ambulatory breast cancer surgery continues to steadily gain acceptance for a number of reasons:
- Early discharge has shown to have no adverse effects on patient outcomes and has been attributed to better psychological adjustment for the patient, economic savings, and a more efficient utilization of health care resources
- Minimal care is typically needed post-discharge
- Unplanned conversions to inpatient admission and readmission rates are low
- Wound complications are infrequent and no issues with drain care have been reported
- The period of postoperative observation is short and monitoring is not intensive
- Ambulatory surgery is only suitable for patients without serious comorbidities, where the likelihood of major perioperative events is low
- Optimal management of pain, nausea, and vomiting is essential to ensure a quick recovery and return to normal function
- Regional anesthesia such as the thoracic paravertebral block has been employed to improve pain control during the surgery and in the immediate postoperative period
- The block provides tremendous pain relief and reduces the need for opiates, which also consequently reduces the incidence of nausea and vomiting
- Increasing popularity of total intravenous anesthesia with propofol has also helped reduce the incidence of nausea and vomiting in the postoperative period
- Ambulatory surgery can be safely performed in centers where there is a well-designed workflow to ensure proper patient selection, counseling, and education, and where patients and caregivers have easy access to medical services should problems arise after discharge.
The trend concerns some patient advocates, who say there are less invasive options such as lumpectomy that are just as effective. They also have concerns that other factors, such as financial issues, might be leading some patients to be sent home too soon.
“I’m alarmed and concerned,” said Karuna Jaggar, executive director of the patient advocacy group Breast Cancer Action. “As a patient watchdog group, we would want to know that women are not facing undue pressure,” including the pressure of cost, “to go home before they are ready.”
Rep. Rosa DeLauro, D-Conn., said that she plans to reintroduce next month a version of the 2013 bill that would bar insurers from requiring less than a 48-hour hospital stay, commenting, “Mastectomies are a major operation, and after going through such a physically and emotionally traumatic experience, women should have the ability to continue to stay in the hospital and receive the care they need.”
According to the report, the increasing rate of mastectomies was driven mainly by women having double mastectomies. The overall mastectomy rate rose from 66 per 100,000 to 90 per 100,000 between 2005 and 2013. At the same time, the rate of double mastectomies more than tripled, from 9 per 100,000 women to 30 per 100,000.