CANCER: Mastectomies, End-Of-Life Care In The Journals
A study in the current Journal of the National Cancer Institute finds that "Medicare breast cancer patients who undergo mastectomies as outpatients face about the same risk of complications as women who spend a night in the hospital after the surgery," the AP/Arizona Daily Star reports (6/3). The NCI researchers looked at data from Medicare fee-for-service patient who underwent mastectomies between 1986 and 1995. They found that for "both inpatient and outpatient mastectomies, the frequency of rehospitalization within seven days and within 30 days after discharge was 1.5% and 4.2%, respectively." While the "odds of rehospitalization" were greater for women in the outpatient category than those with a one-day stay, the overall number "reflects a relatively small number of cases." In fact, the authors estimate that if all 56,337 mastectomies with a one or two-day stay in the data set between 1993 and 1995 were performed in an outpatient setting, "there would be an increase in the percent of patients readmitted from 3.0% to 3.5%, or 282 extra patients." However, the authors also note that the Health Care Financing Administration, insurers and other payers are increasing the pressure to handle more mastectomies as outpatient procedures. This "pressure," they write, "may result in the selection of women who are not optimal candidates for an outpatient procedure, with a potential for more adverse events." The authors state that further research and monitoring is needed to assess whether this hypothesis proves true (Warren et al, 6/3 issue).
Which Is Better?
NCI's Joan Warren, the lead researcher on the study, said the "results on not conclusive about" whether outpatient or inpatient care is best. "We come down pretty squarely in the middle. For women who decide they want an outpatient mastectomy and discuss it with their physician, we show it is a reasonable option." The AP/Daily Star notes that legislation pending in Congress would mandate that insurers cover a minimum of 48 hours of inpatient care for mastectomy patients (6/3).
Terminally Ill Expectations
A study in this week's Journal of the American Medical Association reports that "[m]ost terminally ill cancer patients think they have longer to live than they actually do." The findings are based on the experiences of "917 patients in the final stages of lung or colon cancer" at five teaching hospitals in the U.S. (Talan, Newsday, 6/3). The lead researcher, Dana Farber Cancer Institute's Dr. Jane Weeks, said terminally ill patients' "optimism influenced their preferences about treatment. Patients who thought they had a very high chance of being alive in six months were over twice as likely to favor aggressive life-sustaining therapy rather than comfort care."
Communication Is Key
NPR's Patricia Neighmond reported that patients who opted for more aggressive therapy had survival rates that "were not better than the rates for those who chose comfort care. In fact, they were nearly twice as likely to be readmitted to the hospital, to undergo numerous CPR attempts, or to die while attached to a ventilator." Neighmond noted that "[t]he study didn't examine how or why communication with patients failed." However, Weeks speculated that physicians "are communicating ineffectively, ... delivering what they believe is good information to patients but ... not doing it in a way that patients hear." Weeks also suggested that physicians "are communicating as well as they possibly [can], but the patients aren't processing the information, either because they are too overwhelmed by their circumstances, or because it's just too hard to face what they are hearing" ("All Things Considered," 6/2). Dr. Ezekiel Emanual, head of the department of clinical bioethics at NIH, said it is "simplistic to say that doctors just need to communicate better." He noted, "There are many other things going on in a patient's ability to accept information about dying" (Newsday, 6/3).
NPR's Neighmond reported that an accompanying editorial in JAMA contends that "doctors, either intentionally or not, are often not honest with their patients" ("All Things Considered," 6/2). The editorial concludes: "For now, simply telling patients the truth about their terminal cancer is a significant step in the right direction. The next step should be to study, in actual practice, how much information is given, how much is received, and the effects on decision making for those at the end of life"(Smith/Swisher, 6/3 issue). Click here to see the JAMA study abstract.