Cut-and-go breast surgery

BOSTON — BOSTON -- From time to time, when I hear yet another decision from the health-care honchos of America, a small sentence forms above my head like a balloon in a cartoon: Who Are These People?

Do HMOs deliberately recruit their policy-makers from some small subset of Americans who have no -- repeat, no -- experience with illness? Do managed-care headhunters actively search for folks whose primary people-skill is the skill to block out people while focusing on numbers?


I burst this balloon publicly after reports that the same managed-care folks that brought us drive-thru deliveries topped that public-relations disaster with a new feat: drive-thru mastectomies.

We have now numerous accounts from women with breast cancer who were required to have this radical surgery performed on an outpatient basis. Amputate and out.


The news has come primarily from Connecticut, which is to medical insurance what California is to lifestyle: the breeding ground of national trends. But the percentage of outpatient mastectomies in the country at large has risen from 1.6 percent in 1991 to 7.6 percent in 1995.

Now, anyone who has had a mastectomy herself or been with a mother, sister, daughter, wife, friend who needed this radical surgery found another balloon forming overhead: What Are These People Thinking Of?

Maternity at least is a natural event in the life of a healthy woman. A breast amputation is not. A woman goes into surgery anxious about life and death as well as mutilation. She comes out of anesthesia with a wound, pain, tubes and, often, psychological trauma.

Some may indeed choose to go home straight from the recovery room. But the average breast-cancer patient is 63 years old at onset. Many of these women being released into what is euphemistically called "self-care" live alone or with a husband who may be traumatized as well.

Policy-makers who tried to rationalize the amputate-and-out policy without using the word "money" said that women can do quite well, nay, better, at home than in the hospital where they are at risk of infection. A consultant went so far as to tell the Wall Street Journal that "women feel quite empowered by being able to do their own care."

This controversy did indeed empower more than a few women. At least it fueled their outrage.

When reports started drifting in, Cindy Pearson, executive director of the National Women's Health Network, exploded her own little balloon: "What part of a man's body would they amputate in same-day surgery?"

Fran Visco, president of the National Breast Cancer Coalition, said in more measured tones, "What this asks a woman to do is to become her own medical caretaker at the time when she needs a caretaker very badly. She needs someone who can explain, help her to adjust, to grieve. It doesn't show a tremendous amount of humanity."


In a belated show of some humanity, the American Association of Health Plans invited any "media-trained physician" to a press conference Thursday. The members disputed the notion that outpatient mastectomy is the norm or even the trend. The association president, Karen Ignagni, suggested in a phone interview that the horror stories were misunderstandings between patient and provider.

A policy statement

Nevertheless, in this trust-me press conference, the group released a policy statement saying: "Health plans do not and should not require outpatient care for removal of a breast."

Alas, suspicion does indeed cast a shadow over the relationship between patients in need of care and providers in pursuit of profit. Too often the suspicion is justified. In many cases, the star patient sets the medical standard. Doctors are forced to haggle for every extra day or treatment for their other patients.

But you do not have to be too suspicious to, uh, suspect that the HMOs are only reacting because of the uproar. Not to mention the prospect of legislation.

Last winter, the furor over drive-thru deliveries produced a law that guarantees an American woman as much hospital time to deliver a baby as Fed Ex has to deliver a package: one overnight. Now Connecticut congresswoman and cancer survivor Rosa DeLauro has introduced a law to guarantee any mastectomy patient two nights in the hospital.


Do I see another balloon forming: Is This Any Way To Run a Health Care System? There is indeed something bizarre about protecting access to health care one body part at a time. Remember universal health care? This is dissected health care.

But until trust recovers its health, cut the cards, book your mammogram, and go for the legislation.

Ellen Goodman is a syndicated columnist.

Pub Date: 11/19/96