Breast Cancer Surgery Trends and Outcomes:
Results from a National Department of Veterans
Affairs Study
Denise M Hynes,
PhD, RN
, Frances Weaver,
PhD
, Monica Morrow,
MD
, Frank Folk,
MD
,
David J Winchester,
MD
, Meri Mallard,
RN
, Dolores Ippolito,
MPH
, Bharat Thakkar,
MS
,
William Henderson,
PhD
, Shukri Khuri,
MD
, Jennifer Daley,
MD
BACKGROUND:
This study examined trends and outcomes for breast cancer surgery performed at Department
of Veterans Affairs (VA) hospitals.
STUDY DESIGN:
We examined breast cancer operations performed in VA hospitals from October 1991 to
September 1997. Data from the VA National Surgical Quality Improvement Program, surgical
pathology reports, discharge data, and outpatient data were used. Surgical outcomes included
postoperative length of stay, 30-day morbidity rates, 1-year surgery-related readmission rates,
and mortality. An expert panel of breast cancer clinicians identified surgery-related hospital
readmissions. Hierarchical regression analysis was used to identify patient, provider, and hos-
pital characteristics associated with postoperative length of stay, and 30-day morbidity.
RESULTS:
From October 1991 to September 1997 1,333 breast operations were performed, ranging from
1 to 38 on average per hospital; 478 operations were for breast cancer. Among breast cancer
surgery patients, 25% were men. Thirty-day morbidity rates, 1-year hospital readmission rates,
and mortality were very low for both men and women. Postoperative length of stay averaged 6.8
days. Lower income, longer operation times, and older age increased the likelihood of 30-day
morbidity. Lower functional status, older age, longer operation time, and lower average annual
volume of procedures increased postoperative length of stay. Documentation of the extent of
disease and surgical margin in pathology reports was poor in medical records.
CONCLUSIONS:
Hospital stays were longer, and morbidity and readmission rates for patients having breast
cancer operations at VA hospitals were comparable to those reported for private sector hospitals.
( J Am Coll Surg 2004;198:707–716. © 2004 by the American College of Surgeons)
The number of women seeking care at Department of
Veterans Affairs (VA) Medical Centers, including pri-
mary breast cancer operations, has increased. Despite
epidemiologic evidence that women veterans may be at
greater risk for some cancers
1-4
and that primary breast
cancer treatment has increased at VA hospitals over the
last 10 years,
5
little research has focused on the care that
breast cancer patients receive at VA hospitals. Notwith-
standing this increase in use, the number of women
treated in VA hospitals is very small in comparison to the
number of men treated. Previous research has shown a
positive correlation between surgical volume and out-
comes in general,
6
and in a recent review, for cancer
specifically.
7
Yet, it is not known how this volume-
outcomes relationship applies to primary breast cancer
surgery at VA hospitals. In general, women veterans us-
ing VA hospitals have been shown to have poorer health
status than their male counterparts,
8
but it is not known
whether women who receive primary breast cancer op-
erations at VA hospitals are similar to their male coun-
terparts, or whether they have similar extent of disease or
The research reported here was supported by the Department of Veterans
Affairs, Veterans Health Administration, Health Services Research and De-
velopment Service, as project GEN 97-016. Dr Hynes was the co-principal
investigator at Hines, IL. The views expressed in this article are those of the
authors and do not necessarily represent the views of the Department of
Veterans Affairs.
Received December 30, 2003; Accepted January 30, 2004.
From the Midwest Center for Health Services and Policy Research (Hynes,
Weaver, Ippolito, Thakkar), the VA Information Resource Center (Hynes,
Weaver), the Cooperative Studies Program Coordinating Center (Hynes,
Thakkar, Henderson), Edward Hines Jr Veterans Administration Hospital
(Folk), Hines, IL; Loyola University Chicago, Maywood, IL (Hynes); the
Institute for Health Services Research and Policy Studies, Northwestern Uni-
versity (Weaver) and Evanston Northwestern Healthcare (Winchester), Evan-
ston, IL; Feinberg School of Medicine, Northwestern University, Chicago, IL
(Morrow, Winchester); Durham VA Medical Center, Durham, NC (Mal-
lard); University of Colorado Health Sciences Center, Denver, CO (Hender-
son); Boston VA Healthcare System (Khuri) and Harvard Medical School
(Khuri), Boston, MA; and Tenet Health System Dallas, TX and Dartmouth
Medical School, Hanover, NH (Daley).
Correspondence address: Denise M Hynes, PhD, VA Information ResourceCen-
ter, Edward Hines Jr Veterans Administration Hospital, PO Box 5000 (151V),
Fifth and Roosevelt Rds, Building 1 Room C305, Hines, IL 60141-5000.
707
© 2004 by the American College of Surgeons ISSN 1072-7515/04/$30.00
Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2004.01.027