Current National Health Insurance Coverage Policies for Breast and Ovarian Cancer Prophylactic Surgery

Kuerer, Henry Mark; Hwang, E. Shelley; Anthony, James P.; Dudley, R. Adams; Crawford, Beth; Aubry, Wade M.; Esserman, Laura J.

doi:10.1007/s10434-000-0325-1

Cited by 27 publications

(15 citation statements)

References 29 publications

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“…Of those who did have specific coverage policies, private plans were more likely to pay for prophylactic surgery compared with governmental plans such as Medicare/Medicaid. 45 …”

Section: Prophylactic Mastectomymentioning

confidence: 97%

Educational Review: Role of the Surgeon in Hereditary Breast Cancer

et al. 2001

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Up to 10% of the breast cancers detected in the United States are related to an inherited germline mutation, usually in the BRCA1 or BRCA2 genes, and the majority of these patients will at some point require surgical evaluation and/or treatment. Women who harbor a genetic predisposition for breast cancer face an increased risk for early onset disease, bilateral tumors, and other non-breast malignancies, such as ovarian cancer. These issues raise questions regarding the appropriate surveillance regimen, and the potential efficacy of risk reduction strategies that should be considered. Once a breast cancer diagnosis has been established, the prognosis appears to be similar to stage-controlled sporadic breast cancer, despite an increased prevalence of adverse primary tumor features. However, the role of breast conservation therapy for these patients and the optimal means of addressing the substantially increased risk for contralateral tumors is not yet defined. The reported literature in this area, including a discussion of the value of genetic counseling and genetic testing, is reviewed.

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“…Of those who did have specific coverage policies, private plans were more likely to pay for prophylactic surgery compared with governmental plans such as Medicare/Medicaid. 45 …”

Section: Prophylactic Mastectomymentioning

confidence: 97%

Educational Review: Role of the Surgeon in Hereditary Breast Cancer

et al. 2001

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“…Only 20% of total responding plans had a policy for coverage of prophylactic oophorectomy under any clinical circumstance. Governmental carriers were significantly less likely to have any policy for prophylactic surgery (range, 2–12%) compared with nongovernmental plans (range, 24–44%; p < 0.001) (24).…”

Section: Operative Interventionmentioning

confidence: 98%

Prophylactic Surgery to Reduce Breast Cancer Risk: A Brief Literature Review

Anderson

2001

Breast Journal

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Prophylactic mastectomy reduces the likelihood of developing breast cancer among women at heightened risk for breast cancer, but at significant personal cost. Women at increased breast cancer risk on the basis of hormonal history, family history and/or genetic mutation carrier status may consider bilateral prophylactic mastectomy with or without reconstruction to reduce their cancer risk and/or decrease their chances of cancer mortality. Women having received mastectomy as treatment for breast cancer may request contralateral mastectomy to decrease the chances of developing a second breast primary. The potential oncologic value of these procedures must be weighed carefully on a case-by-case basis against the operation's physical and psychological morbidity. The purpose of this literature review is to provide a practice-oriented summary of recent clinical studies attempting to address the relative risks and benefits of preventive surgery for breast cancer. Data are included regarding the psychological factors surrounding patient selection and quality of life outcomes, which become the cornerstone of patient satisfaction and acceptance. Taken together, these data support the Society of Surgical Oncology position statement regarding the proper application of prophylactic surgery for breast cancer.

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“…A 2000 study showed that explicit coverage for a prophylactic surgery among private health plans ranged from 24 to 43% depending on the type of surgery and the clinical circumstance. 65 Fourteen per cent of plans had an explicit policy of non-coverage for prophylactic mastectomy based on a strong family history and 10% non-coverage based on the identification of a BRCA mutation. 66 These numbers were similar for a prophylactic oophorectomy—15 and 10%, respectively.…”

Section: The State Of Insurance Coverage Pre-acamentioning

confidence: 99%

Prevention for those who can pay: insurance reimbursement of genetic-based preventive interventions in the liminal state between health and disease

Prince

2015

J Law and the BioSci

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Clinical use of genetic testing to predict adult onset conditions allows individuals to minimize or circumvent disease when preventive medical interventions are available. Recent policy recommendations and changes expand patient access to information about asymptomatic genetic conditions and create mechanisms for expanded insurance coverage for genetic tests. The American College of Medical Genetics and Genomics (ACMG) recommends that laboratories provide incidental findings of medically actionable genetic variants after whole genome sequencing. The Patient Protection and Affordable Care Act (ACA) established mechanisms to mandate coverage for genetic tests, such as BRCA. The ACA and ACMG, however, do not address insurance coverage for preventive interventions. These policies equate access to testing as access to prevention, without exploring the accessibility and affordability of interventions. In reality, insurance coverage for preventive interventions in asymptomatic adults is variable given the US health insurance system’s focus on treatment. Health disparities will be exacerbated if only privileged segments of society can access preventive interventions, such as prophylactic surgeries, screenings, or medication. To ensure equitable access to interventions, federal or state legislatures should mandate insurance coverage for both predictive genetic testing and recommended follow-up interventions included in a list established by an expert panel or regulatory body.

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Current National Health Insurance Coverage Policies for Breast and Ovarian Cancer Prophylactic Surgery

Abstract: Significant variations currently exist for health insurance coverage of prophylactic mastectomy and oophorectomy. As genetic testing becomes widespread, more uniform policies should be established to enable appropriate high-risk candidates equal access and coverage for these procedures.

Cited by 27 publications

References 29 publications

Educational Review: Role of the Surgeon in Hereditary Breast Cancer

Educational Review: Role of the Surgeon in Hereditary Breast Cancer

Prophylactic Surgery to Reduce Breast Cancer Risk: A Brief Literature Review

Prevention for those who can pay: insurance reimbursement of genetic-based preventive interventions in the liminal state between health and disease

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