ANNAPOLIS – Baltimore County resident Rosemarie Kaufman believed the worst was behind her.
Diagnosed with breast cancer three years ago, she successfully underwent a lumpectomy. She was trying to move on with her life, but something nagged at her. A mammogram confirmed her worst fears: She had pre-cancerous cells in her other breast. Her physician recommended a double mastectomy.
“I felt horror, shock, disbelief,” she recalled.
For weeks Kaufman wrestled with the decision, and finally agreed to the procedure, but not to reconstructive surgery. Kaufman was told by her doctor that she could have her double mastectomy as an outpatient at Johns Hopkins Medical Center.
“I felt as though doing that would be like a drive-through service,” she recalled.
Kaufman’s sentiment reflects the growing debate in Maryland and across the nation over whether states should mandate insurance coverage for a 48-hour stay for mastectomy patients.
Kaufman was adamant in telling her physician that she wanted to stay overnight. She made the decision based on the fact she already had two drains from her lumpectomy. A double mastectomy, meant tending two more.
“It was comforting to know everything was being taken care of. Having medical professionals help me with my drains for 24 hours was appealing to me rather than putting my husband through that,” said Kaufman, 49. “I think if a woman feels she needs to stay another night, then she definitely should stay.”
Physicians and breast cancer advocates believe length-of-stay-decisions should be left to a woman and her doctor.
Doctors generally agree that most women recover after a one-night stay, but they acknowledge a small minority of women could benefit from a second night.
But not all mastectomies require a two- or even a one-night stay, said Lillie Shockney, director of education and outreach at the Johns Hopkins Breast Center. For the past several years, Hopkins has offered mastectomy on an outpatient basis to women. In 1996, 70 percent of patients undergoing a mastectomy without reconstruction did so as outpatients.
Shockney, who had an outpatient mastectomy at Hopkins, said that women who opted for the outpatient surgery had lower infection rates and gave higher satisfaction ratings in surveys.
One of the reasons behind the outpatient increase and shorter stay is that women are no longer experiencing nausea, vomiting or intense pain because of refined surgery methods, improved anesthesia techniques and better drugs.
“If these changes had not been made, patients would still be spending the night” or more, Shockney said.
They key to success for short stays is education and home nurse visits. Hopkins offers a three-hour education and counseling session for women before the surgery and a shorter session afterward. All patients also receive a minimum of two home health nurse visits to help women with wound and drain care and provide them with a psychological assessment.
“Having someone knowledgeable there and not having to wait for a phone call back or something was wonderful and comforting,” Kaufman.
It is all these aspects that Shockney feels makes the recovery process easier for women, despite the shorter stay in hospitals.
“What I’d like to see is national quality standards for breast cancer treatment. Not all hospitals have the resources we do and that worries me,” she said. “More hospitals should strive to make this experience less traumatic for women.”
Despite Hopkins’ high outpatient caseload, its inpatient mastectomy cases have increased from 2.30 days in 1995 to 2.57 days in 1997. This figure reflects women who have had total mastectomies with reconstruction. Women who go through a mastectomy with reconstruction generally stay one night or longer, depending on the severity of the surgery, Shockney explained.
Shockney stressed that there is no magical recovery process that takes place in a hospital.
“A big part of recovering from breast cancer surgery is the emotional impact it has on you. Being in a hospital setting is not the optimum place to begin that healing,” she said. “You need to be home with your family and friends.”