An estimated 178,700 new cases of invasive breast cancer will be
diagnosed among women in the United States during 1998, 1,500 fewer
than the American Cancer Society estimated for 1997. As such, breast
cancer continues to account for close to 30% of all new cancers among
US women and remains their most frequent cancer diagnosis. Further,
breast cancer is second only to lung cancer in terms of female deaths
from cancer in this country.[1-4]
Between 1982 and 1987, breast cancer incidence rates increased
approximately 4% each year. These increases coincided with the
growing utilization of screening mammography, which became widespread
around 1983.[1,5] After a modest decline between 1987 and 1989, the
incidence rates now appear to have plateaued around 110 per 100,000
population (Figure 1). Modest
decreases in age-adjusted breast cancer mortality have been evident
since the end of the 1980s, with a record low of 21.0 per 100,000
population reported in 1995, the latest year for which these data are
available. Between 1991 and 1995, breast cancer death rates
declined over 6%--9.3% among women under age 65 and 2.8% among those
65 and over.
Early detection through the increased use of screening mammography,
as well as advances in treatment (adjuvant chemotherapy and hormone
therapy), are generally credited for the declining breast cancer
mortality. Mammography utilization continues to increase among US
women. According to the National Health Interview Survey, the
proportion of women reporting a mammogram within 24 months of the
interview has doubled, on average, between 1987 and 1994. For
women 50 years old or older, the rate increased from 27.4% to 60.6%;
for women ages 40 to 49, the proportion rose from 31.9% in 1987 to
61.3% in 1994.
Risk of breast cancer increases with age (more than two-thirds of
cases occur in women over 50) and is elevated by three- to fourfold
in women with a premenopausal first degree relative with breast
cancer.[1,2,4,11] Other putative risk factors include:
Late age of first birth or having no children;
Reaching menarche before age 12;
Menopause after age 53;
Higher educational and socioeconomic status;
Biopsy-confirmed diagnosis of atypical hyperplasia;
Radiation to the breast area during childhood; and
Recent oral contraceptive use or post- menopausal estrogen use.[1,11,12]
Also, the recently identified breast cancer susceptibility genes, BRCA1
and BRCA2, have been reported to account for only about 5% of
breast cancer case development.[1,3]
In 1998, 43,500 women are projected to die from breast cancer in the
United States, 400 fewer than in 1997.[1,2] Breast cancer mortality
differs both among countries and areas within countries. Such
variations have led researchers to implicate dietary factors,
particularly diets high in fat, in the development of the disease;
such a relationship has not been firmly established, however. A
number of additional environmental factors, such as exposure to
pesticides and other chemicals, alcohol consumption, weight gain, and
physical inactivity, may also be associated with an increased risk of
breast cancer.[1,11] Even if all of these factors proved to be
causal, the majority of women who develop the disease do not fall
into one of the high-risk categories.
Survival rates among breast cancer patients continue to increase,
attributed, in large part, to the efficacy and utilization of
screening tests (mammography) that has resulted from increased
clinical support for and public awareness of the importance of early
detection. As with many other malignancies, generally the earlier
breast cancer is found, the better the results and the less extensive
the treatment. Over the years, the surgical treatment for breast
cancer has become more conservative, no longer automatically
resulting in the complete removal of the breast and adjacent tissues
and muscles (radical mastectomy). In the 1970s, the less debilitating
and disfiguring "modified radical mastectomy" began
replacing the more radical surgery which had been in use since the
early 1900s.[14-16] In 1990, breast-conserving surgery (lumpectomy or
partial mastectomy) plus radiation therapy was recommended by the
National Institutes of Health Consensus Development Conference as the
treatment of choice for most women with early invasive breast
cancer.[17-19] While this procedure is being increasingly performed
and accepted, the majority of women with stage II breast cancer still
undergo a mastectomy, however. In 1995, 5 years after the
breast-conserving surgery recommendation, 83% of the 103,000
mastectomies performed in US nonfederal, short-stay hospitals were
modified radical mastectomies and 11% were coded as "unilateral,
The frequency of this disease and the number of breast surgeries
performed each year prompted MetLife researchers to investigate the
charges associated with the primary treatment of the two most common
breast cancer surgeries, ie, the modified radical and the partial
mastectomy. Study patients were defined by DRG codes 257 to 260, 274,
and 275 for female breast cancer and CPT-4 codes 19160 to 19162 for
partial mastectomies and 19240 for modified radical mastectomies.
These cases were restricted to women 30 years of age and older with
sufficient regional/state hospital and physician charge information
and length of stay data; high outliers were eliminated. Although data
are presented for all states, results are highlighted and discussed
for the 20 states in which 20 or more modified radical mastectomies
were performed and the 13 states with 10 or more partial mastectomies
reported. Respectively, these cases accounted for 78% and 72% of the
Metropolitan Life Study
The study group was extracted from a 1996 database of more than
542,000 hospital admissions claims covered by MetraHealth group
health contracts. Of the total admissions, 312,260 were among women.
Approximately l% of these hospitalizations were for breast
cancer--58% of which were treated surgically. In agreement with
national data, the vast majority (68%) of these women were treated
with a modified radical mastectomy.
The data were merged by Corporate Health Strategies, Inc., and
physician, hospital, and length of stay information linked per
individual admission. The median age of the women undergoing a
modified radical mastectomy was 60 years and their modal age was 62.
In contrast, 59 years was both the median and modal age for the women
who had a partial mastectomy.
Modified Radical Mastectomies
The average total charge for a modified radical mastectomy among
1,049 women over age 29 years was $10,000 in 1996 (Table
1). Although two-thirds of the nine geographic areas reported
total charges higher than this average, the excesses ranged from only
14% to 2% above the US norm (Figure 2).
The West South Central and the Pacific areas were the highest, each
more than 10% above the US average. However, these area averages were
44% and 38%, respectively, above the lowest charges, which were
reported in the New England and the East North Central states. The
charges varied more between states, differing by as much as 95%. Four
states, New York, California, Virginia, and Florida, each reported
total charges 20% or more above the norm and five states, Ohio,
Connecticut, Wisconsin, Washington and Michigan, had charges between
22% and 35% below the norm.
Hospital and Physician Charges
Close to two-thirds of the total charge to insurance for a modified
radical mastectomy was accounted for by the hospital component of the
bill ($6,500). Virginia, Florida, and California each had hospital
charges at least 30% above this average, and Connecticut, Washington,
and Michigan were at the other end of the spectrum, with charges
ranging from 32% to 37% below.
The physicians charges averaged $3,500 across the country,
ranging from $6,200 in New York to almost two-thirds lower in
Minnesota, $2,300. The New York doctors charges were 77% above
the US average and 50% higher than the state with the second highest
charge, Georgia, $4,140. The physicians charge in Michigan
($2,410) was the second lowest, 31% below the average and just $110
more than the lowest charge in Minnesota.
Patients with a modified radical mastectomy were in the hospital, on
average, for 2.39 days. Among study states, these hospital stays
ranged from just over 3 days in New York to 1.66 and 1.69 days in
Arizona and Washington, respectively. Per diem charges averaged
$4,180 with those in Arizona and California the highest, each more
than 40% above the norm. The lowest per diem charge was reported in
Michigan ($2,560), almost 40% lower than the US average.
The average total charge for a partial mastectomy among the 347 study
insured patients in 1996 was $8,760 (Table
2). As with the modified radical surgeries, the average total of
hospital and physician charges for a partial mastectomy was the
highest in the West South Central area of the country (38% above the
average), driven by the high charge in Texas (Figure
2). The only other geographical area to report total charges
above the average was the Middle Atlantic, with charges 14% above the
norm. The lowest total charge was recorded in the Mountain area,
$6,720, more than $2,000 and 23% below the US average. All eight
states within this geographic area had total charges considerably
below the norm, none coming within $600 of the US norm.
Between study states, the average total charges differed by 112%. The
charge in Texas was by far the highest ($12,890), almost 50% above
the US average and more than twice that in Ohio ($6,080). Curiously,
two of the three Middle Atlantic states (New York and Pennsylvania)
had the second and third highest total charges, ranging between 22%
and 27% above the norm, while neighboring New Jersey averaged total
charges 10% below the norm. Along with Ohio, total charges in
Colorado and Washington were also low--under $7,000, 20% and 22%
lower than the average, respectively.
Hospital and Physician Charges
Just over 60% of the total charge for a partial mastectomy was
attributed to the hospital portion of the bill (ancillary fees and
room and board charges). This proportion ranged from 70% in both
Indiana and Colorado to 46% in New York. The two highest hospital
charges were reported in Texas, 57% above the norm, and Pennsylvania,
41% above. These high charges contrast with those in Ohio, 31% below
the US average of $5,430 and Washington, 22% below the average.
Physicians charges averaged $3,330 across the country, with
more than a twofold difference between study states. The charges in
New York and Texas were the highest, 71% and 32% above the average US
charge, respectively, and at least twice that reported in either
Indiana or Colorado. These two low charges were each around 37% below
the US norm. The average length of the hospital stay for a partial
mastectomy was 1.84 days. Women in New Jersey remained in the
hospital, on average, close to one day longer (2.78 days), whereas
those in Oregon and Massachusetts were discharged in 1.40 days and
1.45 days, respectively Cost per diem averaged $4,760 across the
country, with the charge in Pennsylvania more than $2,000 higher and
42% above the US norm. Neighboring New Jersey, on the other hand, had
the lowest per diem charge, $2,830, or 41% below the average.
As increasing numbers of screening mammographies are performed, as
more early-stage breast cancers are discovered, as the efficacy of
breast-conserving surgeries continue to be affirmed and used, and as
sentinel node biopsy (a new, less extensive surgical procedure to
examine lymph nodes) is perfected and becomes part of the standard
treatment for early-stage breast cancer, performing breast surgery on
an outpatient basis becomes more acceptable and, some are arguing,
even probable.[21-23] Should breast-conserving surgeries be further
perfected and become the treatment standard for early stage breast
cancer, the cosmetic outcome and quality of life should concomitantly
improve. Increased survival in patients with breast cancer will
continue to be associated with early detection and advances in our
understanding of the biology of the disease.
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