Current National Health Insurance Coverage Policies for Breast and Ovarian Cancer Prophylactic Surgery Original Article Received: 12 November 1999 Accepted: 21 January 2000 DOI:
Cite this article as: Kuerer, H.M., Hwang, E.S., Anthony, J.P. et al. Ann Surg Oncol (2000) 7: 325. doi:10.1007/s10434-000-0325-1 Abstract Background: The efficacy of prophylactic mastectomy and oophorectomy in reducing breast and ovarian carcinoma has recently been reported in high-risk women. Because cost has become central to medical decision-making, this study was designed to evaluate currently existing coverage policies for these procedures. Methods: A confidential detailed cross-sectional nationwide survey of 481 edical directors from the American Association of Health Plans, Medicare, and Medicaid was conducted. Results: Of the 150 respondents, 65% (n 5 97) had 100,000 or more enrolled members and 35% (n 5 53) had fewer than 100,000 enrolled members. Only 44% of private plans have specific policies for coverage of prophylactic mastectomy for a strong family history of breast cancer and 38% of plans for a BRCA mutation. Only 20% of total responding plans had a policy for coverage of prophylactic oophorectomy under any clinical circumstance. Governmental carriers were significantly less likely to have any policy for prophylactic surgery (range, 2%–12%) compared with nongovernmental plans (range, 24%–44%; P,.001). No significant regional differences for coverage policies were identified (P.05). Conclusions: Significant variations currently exist for health insurance coverage of prophylactic mastectomy and oophorectomy. As genetic testing becomes widespread, more uniform policies should be established to enable appropriate high-risk candidates equal access and coverage for these procedures. Keywords Prophylactic surgery BRCA1 BRCA2 Breast cancer Ovarian cancer Health insurance REFERENCES
Miki Y, Swensen J, Shattuck-Eidens D, et al. A strong candidate for the breast and ovarian cancer susceptibility gene BRCA1. Science 1994;266:66–71.
PubMed Google Scholar
Wooster R, Bignell G, Lancaster J, et al. Identification of the breast cancer susceptibility gene BRCA2. Nature 1995;378:789–92.
CrossRef PubMed Google Scholar
Struewing JP, Abeliovich D, Peretz T, et al. The carrier frequency of the BRCA1 185delAG mutation is approximately 1 percent in Ashkenazi Jewish individuals. Nat Gene 1995;11:198–200.
Ford D, Easton DF, Bishop DT, Narod SA, Goldgar DE. Risks of cancer in BRCA1-mutation carriers: Breast Cancer Linkage Consortium. Lancet 1994;343:692–5.
Easton DF, Ford D, Bishop DT. Breast and ovarian cancer incidence in BRCA1-mutation carriers: Breast Cancer Linkage Consortium. Am J Hum Genet 1995;56:265–71.
Hartmann LC, Schaid DJ, Woods JE, et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med 1999;340:77–84.
CrossRef PubMed Google Scholar
Struewing JP, Watson P, Easton DF, Ponder BA, Lynch HT, Tucker MA. Prophylactic oophorectomy in inherited breast/ovarian cancer families. J Natl Cancer Inst Monogr 1995;17:33–5.
Rebbeck TR, Levin AM, Eisen A, et al. Breast cancer risk after bilateral prophylactic oophorectomy in BRCA1 mutation carriers. J Natl Cancer Inst 1999;91:1475–9.
Kuerer HM, Hwang ES, Esserman LJ. Prophylactic mastectomy in women with a high risk of breast cancer. N Engl J Med 1999;340:1838–9.
Steiner CA, Powe NR, Anderson GF, Das A. The review processused by US health care plans to evaluate new medical technology for coverage. J Gen Intern Med 1996;11:294–302.
Burke W, Daly M, Garber J, et al. Recommendations for follow-up care of individuals with an inherited predisposition to cancer. II. BRCA1 and BRCA2: Cancer Genetics Studies Consortium. JAMA 1997;277:997–1003.
Vasen HF, Haites NE, Evans DG, et al. Current policies for surveillance and management in women at risk of breast and ovarian cancer: a survey among 16 European family cancer clinics: European Familial Breast Cancer Collaborative Group. Eur J Cancer 1998;34:1922–6.
Fisher B, Costantino JP, Wickerham DL, et al. Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst 1998;90:1371–88.
CrossRef PubMed Google Scholar
Narod SA, Risch H, Moslehi R, et al. Oral contraceptives and the risk of hereditary ovarian cancer: Hereditary Ovarian Cancer Clinical Study Group. N Engl J Med 1998;339:424–8.
Niederhuber JE. Genetic testing for cancer: the surgeon’s critical role. J Am Coll Surg 1999;188:74–93.
Hughes KS, Papa MZ, Whitney T, McLellan R. Prophylactic mastectomy and inherited predisposition to breast carcinoma. Cancer 1999;86:1682–96.
Holleb AI, Montgomery R, Farrow JH. The hazard of incomplete simple mastectomy. Surg Gynecol Obstet 1965;121:819–22.
Ziegler LD, Kroll SS. Primary breast cancer after prophylactic mastectomy. Am J Clin Oncol 1991;14:451–4.
Pennisi VR, Capozzi A. Subcutaneous mastectomy data: a final statistical analysis of 1500 patients. Aesthetic Plast Surg 1989;13:15–21.
Toth BA, Lappert P. Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning. Plast Reconstr Surg 1991;87:1048–53.
Schusterman MA, Kroll SS, Miller MJ, et al. The free transverse rectus abdominis musculocutaneous flap for breast reconstruction: one center’s experience with 211 consecutive cases. Ann Plast Surg 1994;32:234–41.
Singletary SE, Kroll SS. Skin-sparing mastectomy with immediate breast reconstruction. Adv Surg 1996;30:39–52.
Gershenwald JE, Hunt KK, Kroll SS, et al. Synchronous elective contralateral mastectomy and immediate bilateral breast reconstruction in women with early-stage breast cancer. Ann Surg Oncol 1998;5:529–38.
NIH consensus conference. Ovarian cancer: screening, treatment, and follow-up: NIH Consensus Development Panel on Ovarian Cancer. JAMA 1995;273:491–7.
Partridge EE, Barnes MN. Epithelial ovarian cancer: prevention, diagnosis, and treatment. CA Cancer J Clin 1999;49:297–320.
Tobacman JK, Greene MH, Tucker MA, Costa J, Kase R, Fraumeni JF Jr. Intra-abdominal carcinomatosis after prophylactic oophorectomy in ovarian-cancer-prone families. Lancet 1982;2:795–7.
Piver MS, Jishi MF, Tsukada Y, Nava G. Primary peritoneal carcinoma after prophylactic oophorectomy in women with a family history of ovarian cancer: a report of the Gilda Radner Familial Ovarian Cancer Registry. Cancer 1993;71:2751–5.
Schrag D, Kuntz KM, Garber JE, Weeks JC. Decision analysis: effects of prophylactic mastectomy and oophorectomy on life expectancy among women with BRCA1 or BRCA2 mutations. N Engl J Med 1997;336:1465–71.
Grann VR, Panageas KS, Whang W, Antman KH, Neugut AI. Decision analysis of prophylactic mastectomy and oophorectomy in BRCA1-positive or BRCA2-positive patients. J Clin Oncol 1998;16:979–85.
Rosen PP, Groshen S, Kinne DW, Hellman S. Contralateral breast carcinoma: an assessment of risk and prognosis in stage I (T1N0M0) and stage II (T1N1M0) patients with 20-year followup. Surgery 1989;106:904–10.
Leis HP Jr. Selective, elective, prophylactic contralateral mastectomy. Cancer 1971;28:956–61.
Page DL, Dupont WD, Rogers LW, Rados MS. Atypical hyperplastic lesions of the female breast: a long-term follow-up study. Cancer 1985;55:2698–708.
Frank TS, Manley SA, Olopade OI, et al. Sequence analysis of BRCA1 and BRCA2: correlation of mutations with family history and ovarian cancer risk. J Clin Oncol 1998;16:2417–25.
Society of Surgical Oncology. SSO develops position statement on prophylactic mastectomies. Soc Surg Oncol News 1993;1:10.
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