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Nationally, approximately 200,000 women per year are diagnosed with breast cancer. One in eight will develop the disease in their lifetime, and they have a one-in-33 chance of dying from it. Currently, more than 2 million women in the United States are living with breast cancer.
Despite the fact that breast cancer is the second leading cause of cancer deaths among women, hospital admissions for the disease fell by one-third between 1997 and 2004. The decline has been attributed to a growing trend in outpatient surgery and the increased use of breast-conserving operations.
The Agency for Healthcare Research and Quality reported that in 2004, there were approximately 90,000 hospital stays for breast cancer, down from 125,100 in 1997. The hospitalization rate dropped from 90 per 100,000 women to slightly fewer than 61 per 100,000 women during that period.
The decline in hospital admissions for breast cancer reflects a growing trend in outpatient surgery and the increased use of breast-conserving operations.
Admissions for breast cancer were significantly shorter than those for other non-obstetrical hospital stays. At the same time, the cost for treating breast cancer patients was much higher. The average cost for a breast cancer patient stay was $6,500, and nearly 85 percent of all hospital stays were billed to private insurance and Medicare.
The agency used statistics from the Nationwide Inpatient Sample, a database of hospital inpatient stays that is nationally representative of all non-federal hospitals. The Northeast led the country in hospitalizations for breast cancer, followed by the South and Midwest. The lowest rate of hospitalizations was in the West.
The most common procedures associated with hospital stays were mastectomies and partial mastectomies, also known as lumpectomies. A mastectomy is the surgical removal of the entire breast. It is most often performed in more advanced cases of breast cancer, though some women choose mastectomy even when their cancers are detected early. If the disease is detected when the cancer is small, a woman may have a partial mastectomy, which is the removal of the tumor and some surrounding tissue.
Because of advances in the early diagnosis of breast cancer and new surgical techniques, most partial mastectomies and a number of mastectomies are now performed in an outpatient setting. At least 75 percent of the women who are diagnosed with breast cancer are in the early stages of the disease. Most will be eligible for a partial mastectomy and radiation.
There is usually a one- to two-night stay following a mastectomy. Most partial mastectomy patients can go home the same day if there are no complications.
The development of a technique called sentinel lymph node biopsy has helped reduce the extent of many surgeries. The procedure involves injecting a tracer into the skin of the breast. The tracer travels to the axillary lymph nodes via the lymphatic vessels. The first lymph nodes that drain the breast are the first ones that take up the tracer and also the most likely to involve cancer. The lymph nodes containing the tracer are removed and evaluated.
If cancer is found, an axillary dissection (removal of the remaining lymph nodes under the arm) is performed. If no cancer is found in the sentinel lymph nodes, no others have to be removed. As a result, there is a lesser chance of postoperative complications such as swelling or pain.
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Inpatient stays have decreased following many types of surgery. In the past, patients were admitted on the day prior to surgery and stayed several days afterward. While shorter stays following surgery have largely been driven by insurance companies, it is not necessarily improper management. Surgery for breast cancer often does not require a hospital stay, and patients generally do very well.
“Complications are rare, which is another reason the surgery can usually be done on an outpatient basis.”
It has not been our practice at UK to send patients who have had mastectomies or axillary dissections home the same day. We prefer to monitor them for any immediate complications. These procedures also require placement of drains at the time of surgery to prevent collection of fluid within the wound, something that can be very uncomfortable for the patient. During the hospital stay, patients learn to manage these drains.
Partial mastectomy At UK, we do more partial mastectomies than mastectomies. As long as you achieve negative margins on your tissue biopsy and add radiation therapy to the breast, the local recurrence rate is only about 10 percent. That is acceptable to most women.
As long as the patient does not require an axillary dissection, she can go home following a partial mastectomy. There is not much care required following the procedure. The incisions are closed with sutures that dissolve.
The most common complications following surgery for breast cancer are infection and bleeding. Complications are rare, however, which is another reason the surgery can usually be done on an outpatient basis. Most breast surgery at UK is done in the Center for Advanced Surgery, an ambulatory surgery center. We can admit for 23 hours if necessary.
"Seek a second opinion if you are diagnosed with breast cancer. There are so many treatment choices that it is easy to be confused"
In certain cases, partial mastectomy cannot be offered — for example, when the patient has cancer involving more than one quadrant of the breast or known breast cancer with indeterminate calcifications throughout the breast.
When a mastectomy is performed, most surgeons will keep the patient in the hospital over night. If the patient has immediate reconstruction with her own tissue, she will stay for several days because it is a more extensive procedure.
Other treatment options and techniquesOne of our newer techniques is called a nipple-sparing mastectomy. It is a good option for patients desiring immediate reconstruction who are undergoing prophylactic (preventive) mastectomy or whose cancers are not centrally located. All breast tissue underlying the nipple-areola complex is removed, and the skin is left in place. During the surgery, a sample of the patient’s tissue beneath the nipple is tested. If atypical cells are found, the nipple should be removed.
Patients with a strong family history of breast cancer may choose to have genetic testing. We have a genetic counselor who can coordinate testing to see if the patient has a genetic mutation. If a woman has a BRCA gene mutation, there is a 50- to 80-percent chance she will develop breast cancer. Many of these women opt to undergo prophylactic mastectomies, which decrease the chance of developing breast cancer by 90 percent.
It is a very good idea to seek a second opinion if you are diagnosed with breast cancer. There are so many treatment choices that it is easy to be confused. You really need to sit down with a specialist who knows your case inside and out, can discuss your options with you and can help you make the choice with which you can be at peace.
Dr. Wright is a surgical oncologist and co-director of the Comprehensive Breast Care Center at the UK Markey Cancer Center. She is also assistant professor of surgery at the UK College of Medicine.
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