Did you know that a woman with breast cancer living in or near Neenah, WI, is four, times more likely than one living in or near Ormond Beach, FL, to have a mastectomy instead of a breast-sparing lumpectomy;
That’s just one statistic showing that when it comes to health care, geography is often destiny. Depending on the way medicine is practiced in your community, your doctor might recommend invasive surgery — or medication. No matter what the treatment, the consequences are the same: You may not get the care you need or want, says Jolene Underwood of Women Care Shelter.
Here, what women need to know about how five common medical procedures differ across zip codes:
The upper Midwest is the mastectomy capital, according to the 1998 Dartmouth Atlas of Health Care, which has been documenting geographic differences in medical treatment for the past four years. Rates of this invasive procedure are higher there-even for early breast cancer — than they are on the East and West coasts or in the South, where more women get lumpecyomies. But there are differences even within the Midwest: A cancer patient in Iowa City, IA, is more than twice as likely to have breast-sparing surgery as one living in Mason City IA.
“Rates of lumpectomy are always higher near a major city, where there are teaching hospitals doing clinical trials,” explains Mitchell Posner, M.D., chief of surgical oncology at the University of Chicago. “There are more rural areas in the Midwest, and acceptance of new information is slower in these places. Doctors there aren’t used to going through clinical trials.” In addition, rural areas have a larger population of general surgeon “Lumpectomy takes more effort than mastectomy, and a general surgeon may not be as comfortable with the nuances of performing a lumpectomy,” says Alexandra S. Heerdt, M.D., a breast surgeon at Memorial Sloan-Kettering Cancer Center in New York City.
But Barry L. Rogers, M.D., chief of surgery at Ripon Memorial Hospital in Ripon, WI, an area with a high mastectomy rate, says there just isn’t a lot of presstire from patients to do lumpectomies. “Because this is primarily a rural area, it’s difficult for patients-especially elderly ones — to travel for the five weeks of almost dally radiation [that usually follows a lumpectomy],” he explains. Also, these women may not feel as strongly about preserving a breast as those in other parts of the country. “I have very few patients who are interested in reconstruction after breast-cancer surgery,” says Dr. Rogers.
If mastectomy saved more lives than lumpectomy, one could argue that women in the upper Midwest are better served than those on the coasts or in the South. But studies have shown that the chance of surviving early-stage breast cancer — about 75 percent of all cases, in which a tumor is smaller than five centimeters and has little or no spread to the lymph nodes — is the same no matter which treatment a woman receives. There are, however, instances which mastectomy is recommended: when there are multiple tumors in one breast, when a tumor is very large, or when a patient can’t undergo radiation.
A Southern woman is nearly twice as likely to have a hysterectomy as one living in the Northeast, according to the Centers for Disease Control and Prevention in Atlanta. Seven out of every 1,000 women in the South have their uteruses removed. Only about five per thousand in the Midwest and West undergo the operation; about four do so in the Northeast. Also, women are apt to have a hysterectomy at a younger age in the South-an aver-of age of 42, compared to about 44 in the Midwest and West, and almost 48 in the Northeast
That may be partly because doctors in other parts of the country are more likely to experiment with high-tech alternatives, like lasers, to control abnormal uterine bleeding. “Doctors on the coasts tend to pick Lip this new technology faster, and want to do everything with it,” says Sharon Phelan, M.D., an associate professor of obstetrics and gynecology at the University of Alabama School of Medicine in Birmingham. “I think doctors here are saving that they’re going to treat patients the traditional way until these new methods are proven.”
Another possibility: “Women weren’t accepted as health-care providers in the South until fairly recently, and men may be quicker to do hystecectomies,” says Dr. Phelan. Indeed, only about 26 percent of obstetrician-gynecologists in the South are women, compared to about 30 percent in the West, 32 percent in the Midwest, and 34 percent in the Northeast. Research conducted in North Carolina showed that male gynecologists perform hysterectomies at a higher rate than female gynecologists. But age also seems to play a role: In the study, young gynecologists did fewer operations than those who were in practice longer.
Over time, doctors ‘practice styles seem to be reflected in patient preferences. “Out West, women resist hysterectomy if their problems can be managed with drugs or a less drastic procedure,” says Dr. Phelan, who has also practiced in Albuquerque, NM. “But here, I’ve had women come to me demanding the procedure. I’ll ask them why, and they’ll say it’s because they’re fifty and they’re due. All their friends have had their uteruses removed.”
The South’s high hysterectomy rate may also be explained by pockets of poverty. The region has the highest number of people living in poverty in the nation-14 million, compared with about 9 million in the West, and 6.5 million in the Northeast and Midwest, according to the 1996 census. Studies have shown that women with few resources are more apt to have the surgery than those who are more affluent. They’re less likely to get regular gynecologic care, so by the time they seek treatment for health problems, hysterectomy is often the only option.
Of course, hysterectomy can be helpful to some women-at least in the short-term. In one recent study, women who had the operation reported greater relief from fibroids and pelvic pain than those treated with drugs. But researchers didn’t take into account important long-term effects, which can range from incontinence to a decrease in sexual responsiveness. There are alternatives, such as medication and less invasive operations in which fibroids are removed but the uterus is left intact.
The South also leads the nation in cesarean births. For every 100 babies born alive, nearly 24 are delivered by C-section, compared with 22 in the Northeast, and 20 in the Midwest and West. That may be partly because of the South’s high incidence of hypertensive disease during pregnancy, like toxemia, says Robert Cefalo, M.D., director of maternal/fetal medicine at the University of North Carolina at Chapel Hill. “The disease may be so severe that women must deliver early, and can’t do it vaginally,” he explains. The reason for the high rate is unknown.
Another factor Doctors elsewhere are encouraging women to have vaginal deliveries after a first C-section. In 1993, the rate of vaginal birth after cesarean was about 27 per 100 babies born in the Northeast and Midwest, 25 in the West, and 20 in the South. “There’s been a push for a trial of labor after a cesarean that got adopted much faster in other parts of the country than in the South,” notes Dr. Phelan.
While many women choose C-section over vaginal delivery, most who opt to deliver vaginally — even after they’ve had a C-section — do so successfully. Women should keep in mind that a C-section isn’t risk-free: complications include anemia and infection, as with all surgery, and en-dometriosis, related to the C-section itself
If you have heart disease and you live in Little Rock, AR, you’re twice as likely to undergo bypass surgery as you would if you were living in neighboring Jackson, MS. (There, you might be prescribed medication or undergo a nonsurgical procedure such as angloplasty, in which clogged arteries are opened with a tiny balloon.) Bypass surgery is especially popular in Alabama, New Mexico, and Michigan. It’s less frequently performed in the Northeast, the Mountain states, Hawaii, and Alaska.
In areas with a high rate of bypass surgery, there’s a large number of hospital beds, operating rooms, and, naturally, surgeons. There are also a lot of angiograms, a high-tech diagnostic procedure. “In these areas, doctors use angiograms to look for the disease, find it, and treat it with bypass surgery,” notes John E. Wennberg, M.D., principal investigator of the Dartmouth Atlas. “In low-rate areas, people aren’t getting as many angiograms. They’re being treated with drugs.”
Who’s getting better care? Studies show that in patients with one or two blocked arteries but no damage to the heart, medication is just as effective as open-heart surgery and angloplasty, says Richard Stein, M.D., chief of cardiac prevention and rehabilitation at Lenox Hill Hospital in New York City. Bypass surgery and angioplasty improve survival rates only if patients don’t respond well to medication or have more than two blocked arteries and damage to the heart.
Residents of Provo, UT, are three times more likely than those of Kingsport, TN, to have surgery for back problems, such as herniated disks, in which a spinal disk presses on tender nerves. Back surgery is popular in the Northwest, the Mountain states, and the South. It’s more unusual in the Northeast and parts of the Midwest.
Not surprisingly, areas with a high surgery rate tend to have more spine surgeons. But practice style may also account for the differences: “Some doctors believe surgery is preferable, so they recommend it more frequently,” explains Robert Keller, M.D., an orthopedic surgeon and executive director of the Maine Medical Assessment Foundation, a Manchester-based research organization that examines variations in medical practice. “Once a pattern is established, it tends to stay in place. These doctors practice for years, and they don’t think they operate any more frequently than others.”
Unless someone has progressive nerve damage or bowel or bladder impairment, hemiated-disk surgery is probably unnecessary 75 percent of the time, says Mark Brown, M.D., chair of the department of orthopedics and rehabilitation at the University of Miami School of Medicine in Florida. Those with back pain should try to stay mobile and take painkillers and anti-inflammatories.
HOW CAN YOU TELL WHETHER THE treatment your doctor is recommending is right for you, or just the way medicine is practiced in your community? Some helpful strategies:
* Ask your doctor why she’s recommending a particular treatment, and what the alternatives are.
* Get a second opinion, but choose that doctor carefully. If a specialist is recommending surgery and you’re leery, ask your primary-care doctor for the name of someone who will take a more conservative approach.
* Take advantage of the Information Age. Surf the Internet, and look for articles from medical journals comparing one treatment to another. (Some recommended Web sites are www.jwatch.olg; www.ama-assn.org; and www.nejm.org.) The Foundation for Informed Medical Decision Making offers information on breast cancer, heart disease, and back pain. A videotape costs $49.95; call 603-650-1828.
* If the treatment you want is not available in your community, you may have to leave town to get it. Your primary-care doctor may be able to help with referrals, but chances are, you’ll have to do a lot of the groundwork yourself. Go to the library or do an online search to find out the names of experts in the field; contact them for referrals.