More women with breast cancer are choosing to have mastectomies over breast-sparing procedures. And nearly half of them don't spend a single night in the hospital but go home the same day, according to a federal analysis.
It's the latest study to show that treatment for breast cancer is shifting after years in which women, particularly those with early-stage breast cancer, were encouraged to have less invasive surgery — and patient advocates opposed outpatient or "drive-by" mastectomies.
The trend concerns some patient advocates, who say for many women, less invasive options such as lumpectomy are just as effective. The advocates also fear that financial issues might be leading some patients to be sent home too soon.
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.
"Even with some of the other papers that are out there, I was surprised by the rapid growth [found in the latest report]," said Claudia Steiner, a senior research physician at AHRQ and lead author of the statistical brief, which was released Monday.
Studies have shown that more conservative surgeries coupled with radiation treatment are as effective as mastectomy and had fewer complications, especially for women with early-stage breast cancer.
Another big change seen in the data: 45 percent of mastectomies in 2013 were performed in hospital-affiliated outpatient surgery centers with no overnight stay. That's up from 22 percent a decade earlier.
This report didn't look at whether women who have surgery in a hospital, with a median stay of just over two days, fare better or worse than those who had outpatient surgery. Nor did it speculate on the factors behind the increase in outpatient surgeries, which could include patient choice or insurance reimbursement issues. Or it could be part of the increasing shift of all types of surgeries to ambulatory surgical centers.
"We know that more procedures in general are moving out of the hospital setting," said Lisa McGiffert, director of the Safe Patient Project at Consumers Union. "But the reality is we don't know if outpatient clinics are safer than the hospital because we don't have much information on quality in the outpatient setting." McGiffert had not yet seen the AHRQ study results.
She noted that some outpatient surgery clinics are highly specialized and do the same procedures over and over, and that can lead to improved quality.
About a decade ago, concern about shorter hospital stays following mastectomies prompted about 20 states to pass legislation barring insurers from forcing women to leave the hospital less than 48 hours after surgery. Similar national legislation was introduced a number of times but failed as recently as 2013.
Karuna Jaggar, executive director of the patient advocacy group Breast Cancer Action, was surprised by the finding, saying she had not heard from members about increases in outpatient surgeries.
If the shift is occurring, "I'm alarmed and concerned," said Jaggar. "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.
"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," DeLauro said in an emailed statement.
The increasing rate of mastectomies was driven mainly by women having double mastectomies, the AHRQ analysis found. 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.
Many of those women had cancer in only one breast but chose to have the other one removed as well, with younger women more likely to do so, the data found. Other studies have found a similar trend.
While most women choosing a double mastectomy had a cancer diagnosis, the study found the rate of bilateral mastectomies performed as a preventive measure without any diagnosis of breast cancer more than doubled, although the actual number of women remained small. In 2005, about 2 women per 100,000 without a cancer diagnosis chose the surgery, while that rate rose to 4.4 women per 100,000 in 2013.
The 13 states in the AHRQ study included Connecticut, Indiana, Kansas, Maryland, Minnesota, Nebraska, New Jersey, New York, Ohio, South Carolina, Tennessee, Vermont and Wisconsin.