tributed to a growing population of breast cancer survivors, estimated at 2.1 million women as of 1997. High screening rates have also resulted in more women being diagnosed with ductal carcinoma in situ (DCIS), a type of non-invasive breast cancer (see Chapters 2 and 3). In 2002, there were an estimated 47,700 women diagnosed with DCIS (54,300 with in situ cancer: lobular and ductal) (American Cancer Society, 2001, 2002). These women were not counted as among the 203,500 cases of invasive breast cancer, but because women with DCIS usually receive the same treatment as women with invasive early breast cancer, the rise in DCIS detection has increased the use of breast-cancer-related services and created a new cohort of women worried about their future risk of invasive disease.

Research conducted in the 1980s and early 1990s demonstrating that breast-conserving therapy followed by radiation is an efficacious alternative to mastectomy in most women has contributed to less disfigurement and reduced morbidity among women. This evolution in treatment has also reduced hospital stays and shifted care to outpatient settings. This trend has been accelerated with the dominance of managed care since the 1980s and efforts to reduce health-care costs. Mastectomy and other breast surgical procedures have been increasingly performed in outpatient day-hospital settings. According to one study, cancer-related complete mastectomies were rarely outpatient procedures in 1990, but by 1996, 8 percent of these procedures were outpatient in Connecticut, 13 percent were outpatient in Maryland, and 22 percent were outpatient in Colorado. By 1996, 43 to 72 percent of cancer-related subtotal mastectomies were outpatient procedures in these states, and 78 to 88 percent of lumpectomies were performed on an outpatient basis (Case et al., 2001). The implication of this shift in site of care is that women cared for in outpatient settings no longer have access to the many supportive care personnel that are hospital-based, such as social workers, nurse educators, psychologists, and clergy. The move to outpatient care and shorter hospital stays also has implications for caregivers and families. Much of the assistance with post-surgery recovery and rehabilitation is now assumed by families rather than by nursing personnel.

A greater reliance on pharmacological interventions for women with breast cancer follows findings that adjuvant systemic therapy reduces the risk of distant recurrence by about 40 percent and reduces mortality by 10 to 20 percent. New chemotherapeutic and hormonal agents have been introduced that are active in both early and metastatic breast cancer. These developments, while beneficial, have contributed to increased complexity of breast cancer care. Women treated for breast cancer in the 1960s would have typically been treated surgically with mastectomy in the hospital, with cancer care managed by a surgeon. In contrast, a woman with breast cancer today is likely to encounter a surgeon, radiation oncologist, and medical oncologist during her initial breast cancer treatment. With a number of



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