Perspective on Women's Health: Editors' 1997-1998 Year in Review

, Boston University School of Medicine, Boston Medical Center; , Louisiana State University School of Medicine.

Disclosures

Medscape General Medicine. 1998;1(3) 

In This Article

Abstract and Introduction

Abstract

Heart disease, breast cancer, and hormone therapy were top clinical concerns in women's health in 1997. One of the major reports on heart disease confirmed that women are no different from men in terms of early infarct-related artery patency rates, reocclusion after thrombolytic therapy, and ventricular functional response to injury/reperfusion; nevertheless, women have 3 times the mortality of men in the first 30 days after an acute myocardial infarction. Research brought only modest gains in the understanding of breast cancer etiology in 1997, but engendered major debate on whether women younger than 50 years should have mammograms every 1 to 2 years. A National Institutes of Health consensus conference said no, but the National Cancer Institute's National Cancer Advisory Board said yes. Evidence of estrogen benefits and risks mounted: One report added to the data suggesting that estrogen may retard age-related memory loss, while another study reported that the risk of breast cancer significantly increased with long-term use of estrogens. The interest in selective estrogen receptor modulators (SERMs), also called "designer estrogens," grew. Efforts to develop pharmacologic treatment for obesity suffered a setback in 1997 when a team reported that 1 in 3 patients who used d-fenfluramine developed abnormal valvular thickening, with the most severe cases needing valve replacement. One of the most promising events in colorectal cancer, the third most common cancer in women, was the set of screening guidelines issued by the Agency for Health Care Policy and Research. The year ended with major ethical debates about multiple gestation and cloning.

Introduction

As we begin 1998, it is apparent that the past year has brought us clarity on some issues in women's health and added to the confusion on others. In 1997, as we did in 1996 and will likely do in 1998, we looked at heart disease and breast cancer as top issues in women's health.

Managed care remained a continuing concern, especially in relation to early hospital discharge. In 1997, "drive-through" deliveries were curbed by national legislation that requires insurers to reimburse for up to 48 hours of hospitalization postpartum. Also in 1997, another "drive-through" health care practice captured our attention: outpatient mastectomies.

Little research on this practice has been reported, though in the fall, 2 Kaiser Permanente Medical Center surgeons in Los Angeles, California, reported their follow-up of 50 women who were discharged the same day that they had undergone an axillary lymph node dissection (ALND) with or without a simple mastectomy (SM), or a modified radical mastectomy (MRM). The surgeons concluded that "breast cancer surgery, from ALND to SM or MRM, can be safely and comfortably performed on an outpatient basis."[1] Nevertheless, 2 bills to permit women the option of hospital recovery were introduced in the US Congress[2]: The Breast Cancer Patient Protection Act of 1997 (H.R. 135) proposes a required 48-hour minimum hospital stay for patients undergoing mastectomies and a minimum of 24 hours in the hospital for lymph node removal for the treatment of breast cancer. The Women's Health and Cancer Rights Act of 1997 (S. 249) would allow a woman and her physician to determine her length of stay following a mastectomy and lymph node dissection, provide coverage for reconstructive surgery, and require insurers to pay full costs for second opinions whenever any cancer has been diagnosed by the patient's primary physician.

Such legislative proposals demonstrate the continued concern about the quality of care provided through managed care. However, the fact that HMOs continue to have double-digit growth in enrollment speaks to the notion that employers who subsidize health care for most patients continue to want cheaper care, even if there is still an argument about what is better. This speaks to the need to study the outcomes of practice carefully, and to document situations when longer stays do improve care.

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