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Breakthrough study by Kaiser Permanente supports outpatient breast cancer surgery

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Think Pink

This story is part of The Press Democrat's Think Pink series for the month of October. To read more Think Pink stories, click here.

A year ago when her surgeon asked if she wanted to go home a few hours after her right breast was removed, Santa Rosa hairdresser Wendy Woods jumped at the chance.

Woods, 64, a stylist at Icon Hair Salon on Fourth Street, felt fine after a mastectomy in November to treat her breast cancer and saw no need to stay overnight at the hospital. Recently, a salon client facing a similar operation asked her if she’d recommend going home the same day as surgery.

“I told her if you don’t have to stay, don’t,” Woods said. “You’ll be more comfortable at home. I slept all night that first night.”

Woods is among a growing number of breast cancer patients being discharged from the hospital on the same day they have surgery. New home-based recovery programs are increasingly replacing post-surgery hospital stays of one or two days.

After passage of the Women’s Health and Cancer Rights Act of 1998 — which required health insurers to pay for reconstructive surgery for mastectomy patients — it became “progressive” medical practice to let women stay in the hospital two days after certain mastectomy procedures, said Dr. Elizabeth Peralta, a breast surgeon for Sutter Medical Group of the Redwoods.

But in recent years with less-invasive procedures and an increase in the use of nonnarcotic pain and inflammation medication, hospital stays after breast surgery have been greatly reduced to less than 24  hours, Peralta said.

Recently, a medical study across 21 Kaiser Permanente sites in Northern California — including Kaiser Permanente Santa Rosa Medical Center — showed results that reinforced sending mastectomy patients home just hours after surgery.

The study, published this month in the Annals of Surgical Oncology, is the first large evaluation in the nation of a hospital systemwide at-home recovery program for mastectomy patients.

The research documented a dramatic increase in the rate of outpatient breast surgeries across Kaiser medical centers with no significant increase in post-surgery patient issues requiring emergency room visits or hospital readmissions.

“When the patients wake up, they’re surprised they had surgery,” said Dr. Lucinda Romero, one of the authors of the study and a surgeon at Kaiser’s Santa Rosa medical center.

Romero, who primarily performs breast and vascular surgery, said for years she’s been sending patients home the same day as their operations. Romero and other Kaiser physicians helped develop a medical protocol for recovery at home that involved input of surgeons, specialized nurses for breast care and anesthesiologists.

The study period was from 2017 to 2018 and involved 84 surgeons performing 1,380 breast surgeries.

In 2017, only 23% of the 717 mastectomies performed by Kaiser surgeons were outpatient surgeries. A year later, the number of outpatient procedures increased to 61%, or 663 mastectomies, according to the study.

The average length of stay at a Kaiser hospital over the two years was nearly cut in half, from an average of 22.9 hours to 12.6 hours.

Kaiser’s outpatient breast surgery involves setting clear patient expectations for home recovery; teaching patients how to manage pain levels at home with minimal use of opioids; early collaboration with plastic surgeons for reconstructive surgery patients; and regular follow-up with patients after discharge.

Lisa Mindemann, a Kaiser breast care nurse, said the outpatient option for breast surgery patients begins with patient education. Mindemann sees a patient right after the woman gets a test result indicating cancer. She lays out the entire medical journey, including treatment options and potential doctors involved.

Think Pink

This story is part of The Press Democrat's Think Pink series for the month of October. To read more Think Pink stories, click here.

“I present it as these surgeries are primarily done as same-day surgeries, opening that idea and saying it with confidence,” Mindemann said. “We try to keep people out of the hospital. Being in the hospital can cause more complication.”

Deborah Regan, 67, of east Santa Rosa, has never liked the idea of staying overnight at a hospital. Regan, a Los Angeles native who moved to Sonoma County 29 years ago with her husband to raise a family, has been healthy and active all her life and loves the outdoors.

When she gave birth to her three children, each time she went home from the hospital within eight hours.

Two years ago as wildfires burned in Sonoma County, Regan was diagnosed with breast cancer. From November 2017 to March 2018, she received chemotherapy treatments, before having surgery a month later.

Her doctors closely assessed her attitude before surgery. She was largely positive about the operation so they knew she would rather go home in a few hours than be admitted to the hospital.

“They recommended that I do it,” Regan said. “After the surgery, I came home, made some dinner and some friends came over. I know that sounds weird. It wasn’t that horrible.”

Dr. Lisa Tito, a Santa Rosa surgeon specializing in breast surgery, said she started a similar outpatient initiative on a smaller scale eight years ago at Beth Israel Deaconess-Plymouth Hospital in Massachusetts.

Tito, now with St. Joseph Health Medical Group at Santa Rosa Memorial Hospital, said outpatient breast surgery guidelines need to ensure that patients are comfortable and safe at home and can care for their wounds. She said narcotics should be limited in favor of other pain treatments.

Tito said these days all of her breast surgery patients go home soon after the operation. For women who undergo breast reconstruction with an implant, one of the biggest complications is infection, she said.

“So if you’re going to get an infection, I’d rather have you get a bacteria from home than from the hospital,” Tito said.

The strongest argument for outpatient breast surgery is patients have the “psychosocial support of their family,” low complication rates and excellent pain control, she said.

Peralta, the Sutter surgeon, said the majority of her breast surgery patients spend less than 24 hours in the hospital, but 90% do stay overnight.

Woods, the Santa Rosa hairdresser, was diagnosed with breast cancer on Oct. 11, 2018. When she had her mastectomy on Nov. 29, she said Dr. Romero and others in her Kaiser breast care team knew she didn’t want to stay longer than necessary at the hospital.

“I never took narcotics. I never had really any pain,” she said.

Meanwhile, last week at her hair salon, Woods did a cut and color on her longtime friend and client, Cindy Jaque. “It’s good to be back at work,” she said. “My clients are my friends.”

Jaque was not surprised Woods has done so well since her surgery and cancer treatments.

“I have to tell you, her positive attitude is one of the best healing agents there is,” Jaque said.

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