STATISTICAL BRIEF #201
(Revised March 2016)*
Claudia A. Steiner, M.D., M.P.H., Audrey J. Weiss, Ph.D., Marguerite L. Barrett, M.S., Kathryn R. Fingar, Ph.D., M.P.H., and P. Hannah Davis, M.S.
Mastectomy (surgical removal of the breast) is a common procedure used in the treatment of breast cancer. Although 97-99 percent of breast cancers occur in only one breast,1 some women choose also to remove the healthy breast—a contralateral prophylactic mastectomy (CPM). Reasons that women elect to undergo CPM include physician advice, fear of a subsequent breast cancer diagnosis, desire for cosmetic symmetry, family history of breast cancer, and genetic susceptibility to breast cancer due to mutations in the BRCA1 and BRCA2 genes.2,3 Some women, such as those with a genetic predisposition to breast cancer, may choose to have prophylactic bilateral mastectomy without occurrence of cancer in either breast.
Research indicates that the proportion of women choosing mastectomy over breast-conserving surgery, such as lumpectomy, increased from 1998 to 2011.4 Much of this increase is attributed to an increase in bilateral mastectomy involving early-stage cancer in one breast and CPM of the other breast.5 Indeed, among women undergoing treatment for early-stage breast cancer, the percentage of those having CPM increased more than fivefold between 1998 and 2011 (from 1.9 to 11.2 percent).6 During this approximate time period, from 2002 through 2012, the incidence of breast cancer overall remained stable at around 130 per 100,000 women.7
At the same time that mastectomies have been increasing, research suggests that mastectomy procedures are shifting to an outpatient setting.8 In 2003, approximately 22 percent of mastectomies across 17 States were performed in a hospital outpatient setting.9 By 2012, about 42 percent of mastectomies were done outpatient.10
This Healthcare Cost and Utilization Project (HCUP) Statistical Brief presents data on bilateral and unilateral mastectomies among adult women in two hospital settings: hospital inpatient and hospital-based ambulatory surgery. The analysis is limited to hospitals within 13 States—representing more than one-fourth of the U.S. population—for which bilateral versus unilateral mastectomies could be identified in both the inpatient and ambulatory surgery settings. Bilateral mastectomies with a cancer diagnosis are likely unilateral mastectomies for cancer with a CPM. Bilateral mastectomies without a cancer diagnosis are likely prophylactic bilateral mastectomies. Unilateral mastectomies without a cancer diagnosis are likely CPMs following a prior unilateral mastectomy with cancer in the other breast.
In this Statistical Brief we provide an overview of characteristics of mastectomies by hospital setting (inpatient and ambulatory surgery) in 2013. We present trends in the overall rates of bilateral and unilateral mastectomies and by hospital setting from 2005 through 2013. The cumulative percentage change over the 9-year time period in the rate of mastectomies based on hospital setting and presence of breast cancer also is provided. Finally, the proportion of all hospital-based mastectomies by type of mastectomy and presence of breast cancer is presented. All differences noted in the text differ by at least 10 percent.
Characteristics of hospitalizations for mastectomy, 2013
Table 1 presents characteristics of bilateral and unilateral mastectomies performed in the hospital inpatient setting compared with the hospital-based ambulatory surgery setting in 2013.
|Table 1. Characteristics of mastectomy hospitalizations by type of mastectomy and hospital setting, in 13 States, 2013|
|Characteristic||Bilateral mastectomy||Unilateral mastectomy|
|Inpatient surgery||Hospital-based ambulatory surgery||Inpatient surgery||Hospital-based ambulatory surgery|
|Total number of cases||6,574||3,332||9,858||10,337|
|Age in years, %|
|Expected primary payer, %|
|Community-level income, %|
|Quartile 1 (lowest)||11.1||17.4||18.8||24.6|
|Quartile 4 (highest)||48.2||29.9||36.8||21.9|
|Hospital stay characteristics|
|Length of stay, mean days||2.2||0.9||2.3||0.8|
|Total hospital charges,c mean $||59,900||44,600||40,400||26,500|
|a Other race/ethnicity includes Asian/Pacific Islander and American Indian/Alaska Native.|
b Two of the 13 States included in this analysis did not report race/ethnicity information.
c We report hospital charges rather than costs because Cost-to-Charge Ratios are not available for ambulatory surgery data.
Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) and State Ambulatory Surgery and Services Databases (SASD) from 13 States, 2013
Figure 1 presents trends in the rate of hospitalization for bilateral and unilateral mastectomies from 2005 through 2013. Hospital inpatient surgeries and hospital-based ambulatory surgeries are combined.
Figure 1. Rate of bilateral and unilateral mastectomies in hospital inpatient and hospital-based ambulatory surgery settings combined, in 13 States, 2005-2013
Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) and State Ambulatory Surgery and Services Databases (SASD) from 13 States, 2005, 2007, 2009, 2011, 2013
Figure 1 is a line graph that shows the number of inpatient stays and ambulatory surgery visits combined per 100,000 adult women for unilateral and bilateral mastectomies in 13 States from 2005 through 2013. The rate of unilateral mastectomies in hospital inpatient and ambulatory surgery settings combined remained relatively constant at 64.4 per 100,000 adult women in 2005 and 69.8 per 100,000 adult women in 2009, and then decreased to 60.6 in 2013. The rate of bilateral mastectomies in hospital inpatient and ambulatory surgery settings rose steadily from 10.0 in 2005 to 29.7 in 2013.
Figure 2. Rate of bilateral and unilateral mastectomies by hospital setting, in 13 States, 2005-2013
Note: Cumulative percentage change was calculated from rates that were not rounded.
Figure 2 is a line graph that shows the number of hospital inpatient stays and ambulatory surgery visits separately for unilateral and bilateral mastectomies per 100,000 adult women in 13 States from 2005 through 2013. The rate of unilateral mastectomies in the inpatient surgery setting remained relatively constant at 46.3 in 2005 and 44.5 in 2009, and then decreased to 29.6 in 2013, for a 36% cumulative decrease. The rate of unilateral mastectomies in the ambulatory surgery setting increased from 18.2 in 2005 to 25.3 in 2009, decreased to 25.1 in 2011, and increased to 31.0 in 2013, for a 71% cumulative increase. The rate of bilateral mastectomies in the inpatient surgery setting increased from 8.1 in 2005 to 19.7 in 2013, for a 143% cumulative increase. The rate of bilateral mastectomies in the ambulatory surgery setting increased from 1.9 in 2005 to 10.0 in 2013, for a 431% cumulative increase.
|Table 2. Rate of hospitalization for bilateral and unilateral mastectomies by hospital setting and presence of breast cancer, in 13 States, 2005 and 2013|
|Hospital setting and presence of breast cancer||Bilateral mastectomy||Unilateral mastectomy|
|Rate per 100,000 adult women||Cumulative percentage change, %||Rate per 100,000 adult women||Cumulative percentage change, %|
|All hospital settings|
|Cancer in situ of breast||1.8||4.8||158.8||8.3||7.3||-11.9|
|Other breast cancer (not in situ)||6.0||20.5||242.2||53.1||49.6||-6.7|
|No cancer diagnosis||2.1||4.4||105.6||3.0||3.7||22.7|
|Cancer in situ of breast||1.6||3.2||96.8||5.9||3.5||-40.8|
|Other breast cancer (not in situ)||5.3||13.7||158.6||38.6||24.5||-36.6|
|No cancer diagnosis||1.2||2.8||138.3||1.8||1.6||-10.0|
|Hospital-based ambulatory surgery|
|Cancer in situ of breast||0.2||1.6||596.3||2.4||3.8||58.2|
|Other breast cancer (not in situ)||0.7||6.8||870.7||14.5||25.1||72.8|
|No cancer diagnosis||0.9||1.6||64.4||1.2||2.1||70.7|
|Note: Cumulative percentage change was calculated from rates that were not rounded. |
Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) and State Ambulatory Surgery and Services Databases (SASD) from 13 States, 2005 and 2013
Figure 3. Proportion of hospital-based mastectomies (inpatient and ambulatory surgery) by type of mastectomy and presence of breast cancer, in 13 States, 2005-2013
Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) and State Ambulatory Surgery and Services Databases (SASD) from 13 States, 2013
Figure 3 is a bar chart that shows the percentage of hospital-based unilateral and bilateral mastectomies, with cancer and with no cancer present, in 13 States from 2005 through 2013. In 2005, 4.0% of hospital-based mastectomies were unilateral, no cancer; 82.6% were unilateral, cancer; 2.9% were bilateral, no cancer; and 10.5% were bilateral, cancer. In 2007, 4.1% of hospital-based mastectomies were unilateral, no cancer; 77.1% were unilateral, cancer; 3.0% were bilateral, no cancer; and 15.8% were bilateral, cancer. In 2009, 3.8% of hospital-based mastectomies were unilateral, no cancer; 72.7% were unilateral, cancer; 3.7% were bilateral, no cancer; and 19.8% were bilateral, cancer. In 2011, 3.9% of hospital-based mastectomies were unilateral, no cancer; 68.4% were unilateral, cancer; 4.1% were bilateral, no cancer; and 23.6% were bilateral, cancer. In 2013, 4.1% of hospital-based mastectomies were unilateral, no cancer; 63.0% were unilateral, cancer; 4.9% were bilateral, no cancer; and 28.0% were bilateral, cancer.
The volumes and rates in this Statistical Brief are based upon data from the Healthcare Cost and Utilization Project (HCUP) 2013 State Inpatient Databases (SID) and State Ambulatory Surgery and Services Databases (SASD). This report evaluates inpatient and outpatient procedure data from 13 States that contributed to the 2013 SID and 2013 SASD: Connecticut, Indiana, Kansas, Maryland, Minnesota, Nebraska, New Jersey, New York, Ohio, South Carolina, Tennessee, Vermont, and Wisconsin. Historical data were drawn from the same 13 States in the 2005, 2007, 2009, and 2011 SID and SASD. Analysis was limited to hospitals within the 13 States that had cases in the inpatient and ambulatory surgery settings in each data year and for which bilateral versus unilateral mastectomies could be identified. In particular, States were included only if they provided complete outpatient procedure coding that would allow the identification of bilateral versus unilateral mastectomies, by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes, by Current Procedural Terminology (CPT®) procedure codes that included CPT modifiers, or by both.
Supplemental sources included population denominator data for use with HCUP databases, derived from information available from the Nielsen Company.11
Diagnoses, procedures, ICD-9-CM, CPT®
The principal diagnosis is that condition established after study to be chiefly responsible for the patient's admission to the hospital. Secondary diagnoses are concomitant conditions that coexist at the time of admission or develop during the stay. All-listed diagnoses include the principal diagnosis plus these additional secondary conditions.
All-listed procedures include all procedures performed during the hospital inpatient stay or outpatient visit, whether for definitive treatment or for diagnostic or exploratory purposes. The first-listed procedure is the procedure that is listed first on the discharge record. Inpatient data define this as the "principal procedure" — the procedure that is performed for definitive treatment rather than for diagnostic or exploratory purposes (i.e., the procedure that was necessary to take care of a complication).
Procedures on inpatient hospitalization records are coded using the ICD-9-CM; procedures on ambulatory surgery and services records can be coded using either ICD-9-CM or the CPT.
ICD-9-CM assigns numeric codes to diagnoses and procedures. There are approximately 14,000 ICD-9-CM diagnosis codes and 4,000 ICD-9-CM procedure codes. CPT assigns numeric codes to procedures. There are approximately 9,600 CPT procedure codes.
Hospital discharge and ambulatory surgery visit records with mastectomy procedures were defined based on all-listed procedure codes as identified using the ICD-9-CM and CPT procedure codes in Table 3.
Table 3. ICD-9-CM and CPT procedure codes for defining mastectomy procedures
|Type of mastectomy||ICD-9-CM procedure codes||CPT procedure codes|
Presence of breast cancer was defined using the ICD-9-CM diagnosis codes in Table 4. If codes for both cancer in situ and cancer not in situ were indicated on the same record, the record was categorized as cancer not in situ.
Table 4. ICD-9-CM diagnosis codes for defining breast cancer
|Presence of breast cancer||ICD-9-CM diagnosis code|
|Cancer in situ of breast||
|Other breast cancer (not in situ)||
Two additional ICD-9-CM V codes were considered for this Statistical Brief: V5041 (prophylactic breast removal) and V8401 (genetic susceptibility to malignant neoplasm of breast). The proportion of mastectomies without a cancer diagnosis that included one or both of these V codes increased substantially between 2005 and 2013, for bilateral and unilateral mastectomies as well as inpatient and outpatient mastectomies. We did not include the V codes as part of our primary analysis because it is unclear whether this increase represented an actual shift in the characteristics of patients who underwent a mastectomy or a medical practice change to more complete reporting of the nature of mastectomy procedures.
Types of hospitals included in HCUP State Inpatient Databases
This analysis used State Inpatient Databases (SID) limited to data from community hospitals, which are defined as short-term, non-Federal, general, and other hospitals, excluding hospital units of other institutions (e.g., prisons). Community hospitals include obstetrics and gynecology, otolaryngology, orthopedic, cancer, pediatric, public, and academic medical hospitals. Excluded for this analysis are long-term care facilities such as rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals. However, if a patient received long-term care, rehabilitation, or treatment for psychiatric or chemical dependency conditions in a community hospital, the discharge record for that stay was included in the analysis. The analysis was limited to hospitals that had at least one mastectomy procedure performed in both the SID and the SASD in each data year.
Types of hospitals included in HCUP State Ambulatory Surgery and Services Databases
This analysis used State Ambulatory Surgery and Services Databases (SASD) limited to data from hospital-owned ambulatory surgery facilities. Although some SASD include data from facilities not owned by a hospital, those facilities were excluded from this analysis. The designation of a facility as hospital-owned is specific to its financial relationship with a hospital that provides inpatient care and is not related to its physical location. Ambulatory surgery performed in hospital-owned facilities may be performed within the hospital, in a facility attached to the hospital, or in a facility physically separated from the hospital. The analysis was further limited to ambulatory surgeries performed at facilities owned by community hospitals. Community hospitals are defined as short-term, non-Federal, general, and other specialty hospitals, excluding hospital units of other institutions (e.g., prisons). The analysis was limited to hospitals that had at least one mastectomy procedure performed in both the SID and the SASD in each data year.
Unit of analysis
The unit of analysis is the hospital discharge (i.e., the hospital stay) for an inpatient stay or ambulatory surgery visit, not a person or patient. This means that a person who is admitted to the hospital to have surgery multiple times in 1 year will be counted each time as a separate discharge from the hospital or visit.
Charges represent what the hospital billed for the discharge. Hospital charges reflect the amount the hospital charged for the entire hospital stay and do not include professional (physician) fees. We report hospital charges rather than costs because Cost-to-Charge Ratios are not available for ambulatory surgery data. For the purposes of this Statistical Brief, charges are rounded to the nearest hundred dollars.
Median community-level income
Median community-level income is the median household income of the patient's ZIP Code of residence. Income levels are separated into population-based quartiles with cut-offs determined using ZIP Code demographic data obtained from the Nielsen Company. The income quartile is missing for patients who are homeless or foreign.
Payer is the expected payer for the hospital stay. To make coding uniform across all HCUP data sources, payer combines detailed categories into general groups:
Reporting of race and ethnicity
Data on Hispanic ethnicity are collected differently among the States and also can differ from the Census methodology of collecting information on race (White, Black, Asian/Pacific Islander, American Indian/Alaska Native, Other (including mixed race)) separately from ethnicity (Hispanic, non-Hispanic). State data organizations often collect Hispanic ethnicity as one of several categories that include race. Therefore, for multistate analyses, HCUP creates the combined categorization of race and ethnicity for data from States that report ethnicity separately. When a State data organization collects Hispanic ethnicity separately from race, HCUP uses Hispanic ethnicity to override any other race category to create a Hispanic category for the uniformly coded race/ethnicity data element, while also retaining the original race and ethnicity data. All of the States included in the analyses for this Statistical Brief report Hispanic ethnicity. This Statistical Brief reports race/ethnicity for the following categories: Hispanic, non-Hispanic White, non-Hispanic Black, non-Hispanic Other (includes Asian/Pacific Islander, American Indian/Alaska Native, and Other).
The Healthcare Cost and Utilization Project (HCUP, pronounced "H-Cup") is a family of healthcare databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ). HCUP databases bring together the data collection efforts of State data organizations, hospital associations, and private data organizations (HCUP Partners) and the Federal government to create a national information resource of encounter-level healthcare data. HCUP includes the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information beginning in 1988. These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to healthcare programs, and outcomes of treatments at the national, State, and local market levels.
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About Statistical Briefs
HCUP Statistical Briefs are descriptive summary reports presenting statistics on hospital inpatient and emergency department use and costs, quality of care, access to care, medical conditions, procedures, patient populations, and other topics. The reports use HCUP administrative healthcare data.
About the SID
The HCUP State Inpatient Databases (SID) are hospital inpatient databases from data organizations participating in HCUP. The SID contain the universe of the inpatient discharge abstracts in the participating HCUP States, translated into a uniform format to facilitate multistate comparisons and analyses. Together, the SID encompass more than 95 percent of all U.S. community hospital discharges. The SID can be used to investigate questions unique to one State, to compare data from two or more States, to conduct market-area variation analyses, and to identify State-specific trends in inpatient care utilization, access, charges, and outcomes.
About the SASD
The HCUP State Ambulatory Surgery and Services Databases (SASD) include encounter-level data for ambulatory surgeries and may also include various types of outpatient services such as observation stays, lithotripsy, radiation therapy, imaging, chemotherapy, and labor and delivery. The specific types of ambulatory surgery and outpatient services included in each SASD vary by State and data year. All SASD include data from hospital-owned ambulatory surgery facilities. In addition, some States include data from facilities not owned by a hospital. The designation of a facility as hospital-owned is specific to its financial relationship with a hospital that provides inpatient care and is not related to its physical location. Hospital-owned ambulatory surgery and other outpatient care facilities may be contained within the hospital, physically attached to the hospital, or located in a different geographic area. This analysis was restricted to hospital-owned ambulatory surgery.
For More Information
For more information about HCUP, visit http://www.hcup-us.ahrq.gov/.
For additional HCUP statistics, visit HCUPnet, our interactive query system, at http://hcupnet.ahrq.gov/.
For information on other hospitalizations in the United States, refer to the following HCUP Statistical Briefs located at http://www.hcup-us.ahrq.gov/reports/statbriefs/statbriefs.jsp:
Agency for Healthcare Research and Quality. Overview of the State Inpatient Databases (SID). Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality. Updated November 2014. http://www.hcup-us.ahrq.gov/sidoverview.jsp. Accessed January 7, 2015.
Agency for Healthcare Research and Quality. Overview of the State Ambulatory Surgery and Services Databases (SASD). Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality. Updated November 2014. http://www.hcup-us.ahrq.gov/sasdoverview.jsp. Accessed January 7, 2015.
Steiner CA (AHRQ), Weiss AJ (Truven Health Analytics), Barrett ML (M.L. Barrett, Inc.), Fingar KR (Truven Health Analytics), Davis PH (AHRQ). Trends in Bilateral and Unilateral Mastectomies in Hospital Inpatient and Ambulatory Settings, 2005-2013. HCUP Statistical Brief #201. February 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb201-Mastectomies-Inpatient-Outpatient.pdf.
The authors would like to acknowledge the contributions of Minya Sheng of Truven Health Analytics and Anne Casto of Ohio State University.
***AHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of healthcare in the United States. We also invite you to tell us how you are using this Statistical Brief and other HCUP data and tools, and to share suggestions on how HCUP products might be enhanced to further meet your needs. Please e-mail us at email@example.com or send a letter to the address below:
Virginia Mackay-Smith, Acting Director
Center for Delivery, Organization, and Markets
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
*This Statistical Brief was revised to include 5 CPT mastectomy procedure codes that were valid in 2005. This affected the mastectomy counts that were contributed by 3 of the 13 States included in this Brief, resulting in an overall increase in the rates reported in 2005.
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2 Yi M, Meric-Bernstam F, Middleton LP, Arun BK, Bedrosian I, Babiera GV, et al. Predictors of contralateral breast cancer in patients with unilateral breast cancer undergoing contralateral prophylactic mastectomy. Cancer. 2009 Mar 1;115(5):962-71.
3 Kurian AW, Lichtensztajn DY, Keegan THM, Nelson DO, Clarke CA, Gomez SL. Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011. JAMA. 2014;312(9):902-14.
4 Kummerow KL, Du L, Penson DF, Shyr Y, Hooks MA. Nationwide trends in mastectomy for early-stage breast cancer. JAMA Surg. 2015 Jan;150(1):9-16.
7 National Cancer Institute. SEER Stat Fact Sheets: Breast Cancer. http://seer.cancer.gov/statfacts/html/breast.html. Accessed July 14, 2015.
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9 Russo CA, VanLandeghem K, Davis PH, Elixhauser A. Hospital and Ambulatory Surgery Care for Women's Cancers. HCUP Highlight #2. AHRQ Pub. No. 06-0038. Rockville, MD: Department of Health and Human Services, Agency for Healthcare Research and Quality. September 2006. http://archive.ahrq.gov/data/hcup/highlight2/high2.htm#Outpatient. Accessed July 15, 2015.
10 Wier LM, Steiner CA, Owens PL. Surgeries in Hospital-Owned Outpatient Facilities, 2012. HCUP Statistical Brief #188. February 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb188-Surgeries-Hospital-Outpatient-Facilities-2012.pdf. Accessed July 30, 2015.
11 Barrett M, Lopez-Gonzalez L, Coffey R, Levit K. Population Denominator Data for Use with the HCUP Databases (Updated with 2013 Population Data). HCUP Methods Series Report #2014-02. August 18, 2014. U.S. Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/reports/methods/2014-02.pdf. Accessed January 7, 2015.
|Internet Citation: Statistical Brief #201. Healthcare Cost and Utilization Project (HCUP). March 2016. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/reports/statbriefs/sb201-Mastectomies-Inpatient-Outpatient.jsp.|
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