Outpatient mastectomies are under fire again

Millions back petition delivered to Congress

In the last several years, seven bills have been introduced in Congress to ban outpatient mastectomies but have not passed. The Breast Cancer Patient Protection Act, introduced in the House and Senate this year, may have new strength thanks to 5 million signatures on a petition delivered by Lifetime Television’s web site and the support of Tami Agassi, who is the sister of tennis star Andre Agassi and a breast cancer survivor.

The legislation would require insurance companies to cover a 48-hour minimum stay for mastectomy patients and a 24-hour stay for women undergoing lymph-node dissections. At press time, the bill had been referred to committees in both houses.

"A mastectomy is not an outpatient procedure in any civilized country in the world, except, perhaps, ours," said Sen. Mary Landrieu (D-LA).1

In 1997, the Department of Health and Human Services sent a policy letter prohibiting Medicare managed care plans from requiring that breast cancer surgeries be performed on an outpatient basis or from limiting hospitals stays. However, insurance companies have not followed suit, according to Rep. Rosa DeLauro (D-CT), one of the sponsors of the legislation.

For their part, many health care providers support mastectomy stays of less than 24 hours for most patients. They point to patient preference as one reason.

"For a significant majority of my patients, who are young — less than 45 years old, same-day mastectomy is an option that is offered to them, and most are pleased with going home prior to the [end of the] 23-hour observation time," says Lee Gravatt Wilke, MD, assistant professor of surgery at Duke University Health System in Durham, NC, and medical officer of the Ameri-can College of Surgeons Oncology Group.

At The Johns Hopkins Breast Center in Baltimore, patients who are not having reconstructive surgery are given the option of staying overnight or going home, but they are asked to make that decision in the recovery room based on how they feel after the surgery.

"In the last eight years, we have only had three patients request to spend the night," says Lillie Shockney, RN, MAS, director of education and outreach. "All three in retrospect said on their surveys that they wish they had gone home, as they felt fine once they re-evaluated themselves when they got to an inpatient bed."

However, providers are quick to point out that outpatient mastectomies are not for every patient. Patients who have comorbid conditions including cardiac dysfunction, pulmonary impairment, or renal insufficiency usually warrant overnight hospitalization for monitoring of their cardiac or respiratory systems, for example, providers say.

For those providers who want to provide outpatients mastectomies, consider these suggestions:

Provide thorough education.

Patients are educated on the procedure, any reconstruction, such as expander or implant placement, and the postoperative pain, wound, and drain care requirements, Wilke says.

"The physicians and nurses work to ensure that the patients who are discharged on the same day or the next morning before 7 a.m., if they had a late surgery start, are very comfortable with this plan," she says.

At Johns Hopkins, the pre-op educational process is conducted by a nurse practitioner who specializes in this type of education, Shockney says. "The educational program is about 90 minutes and includes a review of drain management, wound care, showing photographs of what to expect, details of how she will feel, and what will happen step by step, so that she is empowered with information and can feel confident in her care," she says.

It also includes education on exercises for the arm and sexuality issues, she says. Shockney and the nurse practitioner involve the person caring for the patient after she returns home in the education, she says.

Provide adequate pain control and antiemetics.

At Duke, the majority of the patient’s receive a "paravertebral block" as a component of their anesthesia, Wilke says. "This provides a 12-24 hour window of excellent pain control in the immediate postoperative period," she says.

Johns Hopkins uses propofol for an anesthetic, and uses Decadron (Merck & Co., Whitehouse Station, NJ) and Zofran (GlaxoSmithKline, Boston) intraoperatively, which reduces post-surgical nausea rates, Shockney says.

Include home health nursing.

At Duke, home health nursing follows up with patients in the 48-hour post-op period to ensure proper drain care and pain control, Wilke says.

Johns Hopkins also uses home health nurses, as well as a survivor volunteer who had the same procedure in the past, Shockney says. Volunteers provide one-on-one support emotionally to women from diagnosis through the treatment process, including surgery, she says.

They discuss their own experiences, including their surgery, Shockney says. "Some even come in on the day of surgery to be with the patient," she adds.

Also, a survivor volunteer comes in twice a month on heavy surgery days to help see the patients off to surgery and greet them in the recovery room, Shockney says.

Overall, providers speak highly of outpatient mastectomies. "Through education, accurate patient assessment, and close follow-up, I believe a proportion of the patients receiving mastectomy can be discharged to their own home and environment with family to recover safely," Wilke says.

"Patient safety comes first, and it is the responsibility of the surgeon to accurately assess each patient’s capabilities to recover successfully from an operation," she adds. 

Reference

1. Press release from Rep. Rosa DeLauro (D-CT). Agassi, Landrieu, and Delauro team up to protect breast cancer patients. Sept. 25, 2003. Web: www.house.gov/delauro/press/2003/Breast_Cancer_9_25_03.html.

Sources

For more information on outpatient mastectomy, contact:

  • Lillie Shockney, RN, MAS, Director of Education and Outreach, The Johns Hopkins Breast Center, 601 N. Caroline St., Room 8031A, Baltimore, MD 21287. Telephone: (410) 614-2853. Fax: (410) 614-1947. E-Mail: shockli@jhmi.edu.
  • Lee Gravatt Wilke, MD, Assistant Professor of Surgery, Duke University Health System, Medical Officer, American College of Surgeons Oncology Group. Telephone: (919) 660-2244. Fax: (919) 660-2255. E-mail: wilke031@mc.duke.edu.