Breast Cancer Patient Protection Act - Pros and Cons - Research Paper Example

? Breast cancer has been reported to be the second most prevalent cancer affecting mainly women. The treatment procedure for the diseases isprimarily surgery which may either be mastectomy or complete removal of breast, or lumpectomy and lymph node dissection. Mastectomy is often immediately followed by breast reconstruction surgery. US laws have made many provisions for the screening and insurance coverage for women with respect to breast cancer, however the H. R. 111 bill, sponsored by Rep. Rosa L. DeLauro has still not be approved despite six presentations. The bill aims to ensure that insurance coverage be provided for the inpatient hospital stay for a minimum period post mastectomy and for outpatient stay in lumpectomy. Conflicting arguments prevent a consensus on the bill. On one hand it is claimed that post breast surgery the patient need physical care, guidance as well as psychological counseling. On the other hand researchers provide evidence in favor of ambulatory breast surgery. The current paper presents a comprehensive view of the various aspects of H. R. 111 bill and its impact on nurse’s role if enacted. H.R.111 BREAST CANCER PATIENT PROTECTION ACT OF 2009 BACKGROUND BREAST CANCER Cancer involves formation of lump or ‘tumor’ within a specific organ due to uncontrolled division of cells. Breast cancers effects lobules in breasts and have been defined as “the cancer of tissues of the breast, usually the ducts and lobules. It occurs in both male and female breast; although male breast cancer is rare”. (National Cancer Institute, 2011) Breasts are modified skin glands located between the clavicles and sixth to eighth rib on the chest wall, and develop from the mammary ridge in the embryo. The gland tissue or lobules in the breast are responsible for milk production and are connected by ducts to the nipples. Besides the lobules and the ducts, breast also comprises of fatty, connective and lymphatic tissue. Recent studies provide evidence for the presence of more than 20 lobes or segments comprising of major lactiferous ducts involved in conducting milk to the nipples from the lobules. Each lobule, also known as the terminal portion of the duct system; comprises of multiple ductules that form its glandular acini, and the specialized connective tissue enveloping it. The rest of the breast comprises of stromal connective tissues that are histologically distinct. The terminal duct along with its lobular unit; is termed as terminal duct lobular unit (TDLU), and is usually the points of origin of lung cancer. It has been hypothesized that this area possesses stem cells which are responsible for the tumor formation (Kopans, 2007). In situ breast cancer includes cancers restricted to ducts (ductal carcinoma in situ or DCIS), and lobules (lobular carcinoma in situ or LCIS); i.e. the tumor remains within its place of origin. In contrast invasive cancer refers to tumor spread beyond the place of origin, the severity of which is determined by the level of invasiveness. The cancers are diagnosed through needle or surgical biopsy. INCIDENCES OF BREAST CANCER Breasts cancers are the second most prevalent form of cancer next to skin cancer affecting women in US. During the year 2008, 40,480 women and 450 men were reported to have died from breast cancer. In the same year 182,460 and 1990 new cases of invasive breast cancer were reported for women and men respectively. With changes in life style patterns, and reproductive behavior the risks for occurrence of breast cancer are expected to rise. On the basis of data for the occurrence of breast cancer in the period spanning 1995-2007, it has been estimated that during the year 2011 a total of 230,480 new cases of invasive breast cancer and 75,650 additional cases of in situ breast cancer will be diagnosed. Further 39,520 women are expected to suffer death due to breast cancer making it the second major cancer in terms of mortality (next to lung cancer). Women become more vulnerable to breast cancer with advancing age; the threat rising sharply after the age of 40 (American Cancer Society, 2011). BREAST CANCER SURGERY Two surgical procedures followed for local treatment of invasive breast cancer are conservation surgery or lumpectomy and mastectomy. Lumpectomy or breast conserving surgery involves the surgical removal of the malignant tumor along with surrounding healthy tissue. During this process, performed in newly diagnosed cases of breast cancer with early stages of cancer, lymph node dissection or removal of lymph node in the axilla may also be performed. The amount of normal tissue removed in lumpectomy is vaguely defined and varies between 1-50%. The surgery is done in hospital settings and under general anesthesia, though in some cases additional local anesthesia is also used. The surgical procedure requires 1-3hrs. Depending on the condition of the patient and the preferences of the patient as well as the recommendation of the physician the patient may either stay for a day or two; or may get discharged the same day. However lumpectomy involves risks similar to other surgical procedures such as anesthesia after effect and reaction, bleeding or infection due to incision, asymmetry and scarring. Drainage may be required for removal of fluid post surgery. Numbness, enhanced skin sensitivity, etc may also frequently occur with 2-10% also have been reported to develop lymphedema post lymph node dissection. An MRI post lumpectomy has been found to be able to detect presence of any remaining cancerous cells and hence is a recommended procedure (Robinson & Petrek, 1999). Mastectomy can be broadly defined as the surgical removal of breasts for either the treatment or prevention of breast cancer. Mastectomy has been the preferred procedure especially for removal of large tumors, with no requirement of radiation therapy post surgery and with lower risk of recurrence. The modified radical mastectomy performed today involves the removal of breast tissue along with nipple, lymph nodes and an ellipse of skin. In contrast in simple mastectomy, axillary lymph nodes are not removed. Breast reconstruction therapy is also performed in most cases following mastectomy the costs of which along with that of mastectomy, are covered by insurance according to Women’s Health and Cancer Rights Act, 1998. Performed under general anesthesia, the surgery lasts 2-5hrs and the patient may stay for a night after surgery. Post surgery the risks similar to those involved for lumpectomy are relevant for mastectomy too. Though most patients leave hospital after surgery, precaution and extensive care are essential after the procedure. Home care nurse visits are usually required by the patients to guide them in proper care and dealing with surgical drains, changing bandages, keeping records of fluid output and ensuring that no clots are formed. Mild exercises are also recommended to restore strength and motility (Robinson & Petrek, 1999). One of the major aspects of breast surgeries, especially mastectomy is emotional support and psychological counseling. A study conducted by Zemore & Shepel (1989) compared the need of emotional support for 301 women who had undergone mastectomy for breast cancer, against 100 women who had been diagnosed with benign breast lumps (hence not requiring mastectomy). The women were provided emotional adjustment inventories and on the basis of data gathered it could easily be established that perceived emotional support showed positive correlation with adjustment. Though the modern treatments available for breast cancer do not cause as much physical deformity as earlier, yet women do experience distress, fear of recurrence, changes in perceptions related to appearance and sexuality, and also physical toxicities. Hence it is important to consider the psychological aspects and social issues related to breast cancer management procedures. Health care must involve and provide for the psychological support which is essential to aid them in coping with post surgical emotional disturbances (Ganz, 2008). LAWS RELATING TO BREAST CANCER The high occurrence and severity of breast cancer and the burden of the disease affecting the quality of women and their families affected by it has led to several provision and laws covering breast cancer specifically during the last three decades. 24 four states provide breast cancer screening and education programs by statute. Beginning with Illinois, by 2000, all states except Utah enacted laws facilitating reimbursement of expenditure for preventive care such as breast cancer screening. During the 1980s legal provisions in 28 states ensured that the insurance policies cover the expenditures incurred in the procedure for breast reconstruction or prosthetics, post mastectomy. Later legal provision for the reimbursement of mammography expenditures was also provided. By 1993 ten states had enacted laws offering insurance coverage for chemotherapy and/or bone marrow transplant as a treatment procedure for breast cancer. Post 1993, nine states provide legal provisions allowing taxpayers income tax check offs for breast cancer fund contributions. Twenty states in US also have laws providing for the reimbursement for specific length of inpatient stay post mastectomy and/or lumpectomy and lymph node dissection. These states in alphabetical order are Arkansas, California, Florida, Georgia, Illinois, Maine, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Texas and Virginia. In these states insurers are required to provide insurance coverage for a minimum inpatient hospital stay of 72hrs post modified radical mastectomy and a minimum of 48hrs post simple mastectomy. No prior authorizations are required for these provisions. However the length of stay of 48 or 72 hrs is not binding and a shorter stay period can be decided by the patient under consultation with the concerned physician. The law applies to medical and hospital services, health service corporations, health and medical insurance providers, small employers, individual health benefit plans etc (U. S. Department of health and human services, 2000). BILL In the light of the above background it would be easier to comprehend the H. R. 1691presented to the 111th Congress in its first session. The Bill if enacted will be known as, The Breast Cancer Patient Protection Act 2009. The Bill requires that health plans provide coverage for a minimum hospital stay for mastectomies, lumpectomies, and lymph node dissection for the treatment of breast cancer and coverage for secondary consultations. The bill amends the Employee Retirement Income Security Act of 1974 (ERISA), the Public Health Service Act, and the Internal Revenue Code to ensure a group health plan that facilitates medical and surgical benefits so that inpatient (and in the case of a lumpectomy, outpatient) are provided coverage and radiation therapy for breast cancer treatment (govtrack.us). Sponsors Rep DeLauro, Rosa L. [CT-3] (introduced 3/24/2009)   Cosponsors (252) Besides this the following thirteen organizations are lobbying for the bill. America's Health Insurance Plans America's Health Insurance Plans Oncology Nursing Society American College of Ob/Gynecologists American Hospital Assn American Hospital Assn Aetna Inc Aetna Inc American Society of Clinical Oncology Cigna Corp Oncology Nursing Society Cepheid Amer Congress Obstetricians & Gynecology American Society of Clinical Oncology Blue Cross/Blue Shield General Federation of Women's Clubs Humana Inc Susan G Komen For The Cure Political/Legislative Aspects context Rosa DeLauro, a congresswoman from Connecticut presented H. R. 135, the Breast Cancer Protection Act of 1997, in January 1997. The bill presented in 105th Congress aimed to amend the Public Health Service Act and Employee Retirement Income Security Act of 1974. The bill proposed that legal provisions be made to ensure that both group and individual health insurance coverage be provided for a minimum hospital stay for mastectomies, lumpectomy and lymph node dissections. The minimum period of stay was proposed to be not less than 48hrs. The bill was referred to various committees and could not proceed beyond being introduced to the Congress till the end of 105th Congress. Subsequently Rep. DeLauro proceeded to present the same bill five times as H. R. 116 (to 106th Congress) in January 1999, as H. R. 536 (to 107th Congress) in February 2001, as H. R. 1886 (to 108th Congress) in April 2003, as H. R. 1849 (to 109th Congress) in April 2005, as H. R. 119 (to 110th Congress) in January 2007. In each of these incidences the bill passed on from one referral committee to another and could never be brought to vote. H. R. 758 which was a revised Breast Cancer Patient Protection Act of 2007, was finally taken up by the House in September 2008, post 21 months of introduction. However the bill was not approved. The sixth presentation of the bill by Rep DeLauro as H. R. 1691 (the Breast Cancer Protection Act of 2009) was made in March 2009. The same was introduced by Senator Olympia Snowe of Maine in the senate as S. 688. The bill still remains under consideration (snope.com). Sociocultural Aspects Significant geographic variations have been documented for the choice of outpatient vs. inaptient breast surgery though no specific reason could be attributed to it. No correlation between the economic status or race of patient with the choice of surgery could also be derived (Warren et al., 1998). Ethical Aspects Considering the burden of disease and its growing incidence it is important to ensure uniform laws in all states. Since twenty states in US, as mentioned before already have enacted law fulfilling the conditions of the bill, the positive impact of the law is easily observed in these states. It has been observed that screening and treatment procedures as well as statistics vary in different states and can be correlated with the nature of laws followed in the particular state (govtrack.us). The enactment of the bill is also essential considering the evidences that breast cancer patient have frequently reported adverse outcomes and complications such as infection and pain as a consequence of premature discharge from the hospital post surgical procedure for breast cancer. Surgical procedure of any form can be followed by nausea, pan, vomiting, ileus and stress induced catabolism. These issues may need postoperative fatigue, post surgical intensive care, hence treatment in absence of which recovery may be delayed or further complications may arise. With the increasing life expectancy of women in general and women that have been treated for breast cancer in particular, it is also important that these women may be better prepared to cope with later stresses in life. Hence it is imperative that good perioperative care be provided to them. Thus for the ultimate goal of medical benefit and health considerations, it is ethically important that health care providers ensure the recovery and education for self care of patients prior to discharge. Economic Aspects The health plans and provisions have a significant impact on the commerce of the states. United States’ annual expenditure on health care services is $2 million, approximately half of which is tax payer’s money. In terms of Gross Domestic Product (GDP), 15% of GDP comprises health care. However approximately 15% of Americans lack a medical insurance and with are deprived of the basic medical care (Sage, 2007). Despite the surgical procedures and their psychological impacts, drive in surgery or ambulatory surgery for breasts cancer patients has been recommended by many researchers. A study conducted by Margolese & Lasry (2000), compared the levels of pain, fear, emotional adjustment, anxiety, overall health, social relations and quality of life of 55 outpatient and 35 inpatients with similar sociodemographic characteristics. It was reported that same day discharge patients or outpatients were not at a relative disadvantage to inpatients. In fact they recovered faster and exhibited better emotional adjustment. There have also been evidences supporting the claim that patients undergoing outpatient breast surgery, with changes in anesthetic techniques and due to higher levels of alertness post surgery, recover faster than the inpatients. In the light of the above two arguments, it is justifiable to oppose the need of a post operative inpatient hospital stay insurance coverage since researches provide evidence that the same is not essentially required. Further, it does definitely involve cost containment. In fact in early 1980s it was calculated that medical reimbursements were favorable for outpatient surgery compared to inpatient; since the former was made on a cost basis while the latter was based on diagnoses and procedure during hospitalization. Thus the average beneficiary liability for outpatient mastectomy was $72 to $153 more than inpatient deductible (Warren et al., 1998). IMPACT ON NURSING PRACTICE Post surgery for breast cancer treatment a patient undergoes psychological as well as physical distress resulting in a complex situation that is often incomprehensible and definitely difficult to cope for the patients. Besides the post surgery physical disability and care; the victim is unable to adjust to her social and personal chores. Thus breast surgery procedures need to be followed by rehabilitation aids and education for the patients. H. R. 1691, a bill which if passed would ensure a reimbursement of an inpatient stay of at least 48hrs post breast surgery would mean that patients would prefer to stay the period in the care of health care providers. In this context the role of nurses would become significant in providing the multiprofessional care, emotional support and education to these patients. During the rehabilitation process, nurses would be required to provide information regarding physical post surgical care, orientation about the stages of recovery process and the various complications that could be associated with each of these stages; and additional care of the arm on the side of the surgery. The nurses would be needed to educate them regarding the exercises that are essential to enable the mobility and functionality of the arm and shoulder. Besides this nurses would be required to inform the patients regarding other treatments such as radiotherapy especially in case of lumpectomy. Considering the vulnerability and distress of the patients that have undergone breast surgery, the nurses’ need to be better prepared to aid in the care, support, counseling of these patients so as to play a significant role in their rehabilitation and perform their duties as health care providers (Mamede et al., 2000). Global Perspective Insurance coverage provided in other countries varies with respect to specificity. For example in United Kingdom, universal single payer model is followed, i.e. health care is facilitated by the government without any cost sharing at the time of service, but paid in form of taxes such as sales, income and social security taxes. Evidence based clinical guidelines are provided by National Institute of Health and clinical excellence (NICE), an independent organization responsible for providing guidelines for and ensuring the well being of all citizens. In France too the government provides permanent and qualified residents statutory, non-profit health insurance plans the caisses d'assurance maladie. These plans are based on the employment of the citizens with no choice for the citizens regarding the nature of plan (Leduc, 2009). Among the Asian countries such as Japan, the egalitarian health care system renders the need of specific laws unnecessary. Further, in Japan the entire health care is provided with surgeons, with no role of oncologists, radiologists etc. Most Japanese surgeons are capable of detecting small tumors by ultrasound and removing them on the spot. In India several different plans are available with their own specifications and there is lack of a uniform and specific law. Though a specific and uniform insurance coverage law is essential for countries worldwide, in consideration of sociocultural conditions of different countries and their unique legal system, it is difficult to provide a generalized account of the implications of enactment or even requirement of a law similar to H. R. 111 bill. REFERENCES 1. American Cancer Society, (2011). Breast cancer: facts and figures 2011-2012. Atlanta, Georgia: American Cancer Society, Inc. 2. Ganz, P. A. (2008). Psychological and social aspects of breast cancer. Oncology , 642-6. 3. govtrack.us. (n.d.). Text of H.R. 1691 [111th]: Breast Cancer Patient Protection Act of 2009. Retrieved 2011, from govtrack.us: http://www.govtrack.us/congress/billtext.xpd?bill=h111-1691 4. Kopans, D. B. (2007). Breast Imaging. PA, USA: Lippincott Williams and Wilkins. 5. LeDuc, R. G., Perrin, W. F., & Dizon, A. E. (1999). Phylogenetic relationships among the delphinid cetaceans based on full cytochrome b sequences. Marine mammal science , 619-48. 6. Mamede, M. V., Clapis, M. J., Panobianco, M. S., Biffi, R. G., & Bueno, L. V. (2000). Post-mastectomy orientations: nursing role . Revista Brasileira de Cancerologia . 7. Margolese, R. G., & Lasry, J. C. (2000). Ambulatory surgery for breast cancer patients. Ann Surg Oncol , 181-7. 8. National Cancer Institute, (2011). Breast cancer. Retrieved Oct 2011, from National Cancer Institute: http://www.cancer.gov/cancertopics/types/breast 9. Robinson, R. Y., & Petrek, J. A. (1999). A Step-by-Step Guide to Dealing With Your Breast Cancer. NY: Carol Publishing group. 10. Sage, W. M. (2007). Relational duties, regulatory duties, and the widening gap between individual health law and collective health policy. Georgetown Law Journal . 11. snopes.com. (2009). Breast cancer patient protection act. Retrieved 2011, from snopes.com: http://www.snopes.com/politics/medical/mastectomy.asp 12. U. S. Department of health and human services (2000). State laws relatig to breast cancer. Atlanta, Geogia: CDC. 13. Warren, J. L., Riley, G. F., Potosky, A. L., Klabunde, C. N., Richter, E., & Ballard-Barbash, R. (1998). Trends and outcomes of outpatient mastectomy in elderly women. J Natl Cnacer Inst , 833-40. 14. Zemore, R., & Shepel, L. F. (1989). Effects of breast cancer and mastectomy on emotional support and adjustment. Soc Sci Med , 19-27. Read More