Mastectomy, Lumpectomy, and the Freedom of Choice

October 29, 2004

Two kinds of surgeries are used to treat breast cancer—a radical mastectomy removes the entire breast, while a lumpectomy only removes the tumor and some surrounding tissue and lymph nodes. Although breast-saving lumpectomies have proven just as safe, they have yet to be accepted as the preferable surgery for women with early stage breast cancer.

Recent studies demonstrate that half of the eligible candidates for lumpectomies will undergo mastectomies instead. This is especially true for those living in the Midwest and in Southern states.

Variables: Cost, Doctor, Insurance Coverage

One factor behind the high incidence of radical mastectomies is the relative cost of the procedures. Lumpectomies are more expensive and also must be followed by costly radiation therapy. Not all insurance companies will cover the cost of a lumpectomy and/or the radiation therapy that follows. Medicare, for example, typically favors mastectomies in their reimbursement policy.

Additionally, many older doctors are not trained to perform lumpectomies and may not be informed about the safety and benefits of the procedure. A research article appearing in the American Journal of Surgery reported that breast cancer patients tracked in North Carolina were more likely to have had a lumpectomy if their surgeon was trained after 1981.

Because breast-saving lumpectomies must be followed by radiation therapy, access to radiation treatment is another determinant of whether women can chose to undergo a lumpectomy. Those living in rural areas may be unable to travel to a radiation center, as therapy must be administered almost every day for five to eight weeks.

Some women are not even told that breast-conserving surgery is an option, severely limiting their ability to make informed decisions about their own bodies. Low-income women, those with less education and women without private insurance are at a particular disadvantage.

"Every woman should have the right to be fully informed of the options that affect her body," says Karen Johnson, NOW Executive Vice President. "The limited distribution of information on breast-conserving surgery is unsettling."

Reconstruction Adds to Mastectomy Risk

Breast reconstruction, which often involves saline or silicone gel implants, adds to the danger of mastectomy. The Food and Drug Administration (FDA) reports that seven out of ten reconstruction patients experience at least one serious complication within the first three years of their implant surgery. These complications include pain, hardness, infection and rupture of the implant.

NOW has spoken out on the danger of silicone gel breast implants for all women and is particularly concerned with the use of implants for reconstruction patients, because the risks involved in reconstructive surgery are even greater than those for cosmetic augmentation surgery.

For these reasons, a lumpectomy is a more desirable option in the early stages, as it circumvents the need for breast reconstruction by removing very little of a patient's breast. Those who must or choose to undergo a mastectomy, however, should carefully consider the risks of implants before any decision is made.

Proposed Laws Would Require More Coverage

It is clear that greater patient education is desperately needed both in the area of breast-conserving surgery and on breast reconstruction. The National Cancer Institute has a publication available to download on its web site or by calling 1-800-422-6237.

Doctors must also be held responsible for disclosing accurate and thorough information to their patients before any decisions are made. Patient education, however, is not enough. If health insurance plans continue to favor radical mastectomies, patients will not have the freedom to select the procedure that is right for their situation.

In response to this concern, Sen. Olympia Snowe, R-Maine, introduced legislation last October to hold health insurance companies responsible. The Women's Health and Cancer Rights Act of 2003 (S.1730) would require group health plans to provide basic coverage for mastectomies, lumpectomies and lymph node dissections related to breast cancer treatment. It would also ensure that patients get coverage for a secondary consultation on surgery decisions.

"A woman should be confident in her diagnosis and every cancer patient deserves a second option. S.1730 ensures that," Snowe said in support of her bill last November. "Every woman should be offered treatment options, including inpatient care."

Also introduced last year was Senate bill S.1684, the Breast Cancer Patient Protection Act of 2003. Written by Sen. Mary Landrieu, D-La., this bill would require health plans to provide minimum hospital stays for mastectomies and lymph node surgeries, prohibiting "drive-by" mastectomies without hospitalization. Unfortunately, it does not address lumpectomies.

Like many women's health bills that have come before, both S.1730 and S.1684 are being bottled up in committee by the right-wing majority, unlikely to surface in this Congress. The current Congress and Bush administration have long been hostile towards women's issues, and health care is no exception.

It is doubtful that much progress will ever be made on bills such as these while the current leaders are in power. For this reason, Nov. 2 is a decisive day for women's health.

"Let's make sure that all women are given the full range of health treatment options they deserve," says Johnson. "We can take a major step in that direction by voting on Election Day."