Insurance Influences Type of Surgery Women Get for Early-Stage Breast Cancer

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Lumpectomy (also called breast-conserving surgery) followed by radiation is likely to be equally as effective as mastectomy for women diagnosed with early-stage breast cancer.

Studies have shown that women with small breast cancers (smaller than 4 cm) treated with lumpectomy plus radiation therapy were just as likely to be alive and disease-free 20 years later as women who had mastectomies. Based on these studies, the U.S. National Institutes of Health released a statement in 1991 saying that lumpectomy plus radiation was preferred over mastectomy to treat early-stage breast cancer.

A new study has found that women who have insurance through Medicaid were more likely to have a mastectomy to treat early-stage breast cancer compared to women who have private insurance.

The study was published online on April 24, 2013 by JAMA Surgery. Read the abstract of “Effect of Insurance Payer Status on the Surgical Treatment of Early Stage Breast Cancer.”

To see if the type of insurance a woman had affected the type of breast cancer surgery she had, the researchers looked at the records of 1,539 women who had surgery for early-stage breast cancer at a facility in Ohio from 1996 to 2009. Stage I, stage II, and stage IIIA breast cancer is considered early-stage cancer.

Overall, 42% of the women had a mastectomy and 58% had a lumpectomy. When the researchers looked at the surgeries by insurance type, they found:

  • 60% of women with Medicaid insurance had mastectomy
  • 39% of women with private insurance had mastectomy

Overall, women diagnosed with cancers that were smaller than 2 cm were more likely to have lumpectomy (71% had lumpectomy) and women diagnosed with cancers that were 2 cm to 4 cm in size were more likely to have mastectomy (81% had mastectomy).

Still, women with private insurance diagnosed with cancers that were smaller than 2 cm were more likely to have mastectomy compared to women with Medicaid insurance diagnosed with cancers that were smaller than 2 cm:

  • 47% of women with cancers smaller than 2 cm with private insurance had mastectomy
  • 11% of women with cancers smaller than 2 cm with Medicaid insurance had mastectomy

According to the researchers, this difference could be due to either the preference of the women or their surgeons. Surgeons are reimbursed about 40% less for lumpectomy compared to mastectomy. The researchers said that the level of reimbursement does affect the type of surgery recommended for early-stage breast cancer.

If you’ve been diagnosed with early-stage breast cancer, it makes sense to ask your doctor about all of your surgical options and about what makes the most sense for you and your unique situation. You’ll consider a number of factors, including:

  • your preferences
  • any other health problems you have
  • all the characteristics of the cancer
  • how close you are to treatment facilities

While all the breast cancers in this study were considered early-stage, women who had insurance through Medicaid were diagnosed with larger tumors than women who had private insurance (3.3 cm compared to 2.1 cm).

Women who had insurance through Medicaid also were less likely to be diagnosed with stage I disease:

  • 30% of women with Medicaid insurance had stage I disease
  • 47% of women with private insurance had stage I disease

These results echo earlier studies that found that woman with Medicaid insurance were more likely to be diagnosed with more advanced-stage disease. This could be because women with Medicaid insurance are less likely to get screening mammograms, so breast cancers are diagnosed later, at a more advanced stage. It’s not clear why women on Medicaid are less likely to get screening mammograms; some research suggests that it’s harder for women on Medicaid to schedule a mammogram appointment.

ALL women – no matter their age, ethnicity, economic status, or insurance status – deserve the best breast health care possible. Differences that affect cancer outcomes, such as screening, access to care, and quality and consistency of care, should be eliminated.

Screening is a good place to start. Breast cancer that is diagnosed early is typically easier to treat and offers the best survival chances. Regular screening for breast cancer, including annual mammograms and breast exams by a medical professional, is important for everyone. Paying for healthcare can be difficult, especially if you have limited income and no or inadequate health insurance or are covered only by Medicare. But if you're older than 40, skipping regular mammograms is NOT an option. Stick with the screening plan you and your doctor decide is best for you. If scheduling problems or cost concerns are stopping you from getting a mammogram, talk to your doctor, a hospital social worker, or a staff member at a mammogram center. Ask about free mammogram programs and healthcare services in your area. It's YOUR health and YOUR future and you deserve the best care possible.

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