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(Drug information on 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, complete" procedures.
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 total cases.
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.