Recent research has suggested that more women are choosing to have mastectomy to treat early-stage breast cancer when lumpectomy followed by radiation therapy is a good option. This study wanted to know why this trend was happening and whether mastectomy was appropriate for most of the women opting for it.
Lumpectomy followed by radiation therapy is a good option for many women diagnosed with early-stage breast cancer. Still, there are medical and personal reasons that may make mastectomy a better choice.
Medical reasons include:
Personal reasons include:
In this study, the researchers looked at the medical records of nearly 2,000 women diagnosed with early-stage breast cancer who had surgery. About 75% of the women had lumpectomy as the initial surgery and 25% had mastectomy. For medical reasons, some women who initially had lumpectomy had mastectomy later. Overall, about 33% of the women ended up having mastectomy. The researchers found that women who chose mastectomy instead of lumpectomy to treat early-stage breast cancer had good reasons for their choice.
The researchers found:
About 20% of the women got a second opinion on which surgery was best for them. If a woman's doctor initially recommended mastectomy, she was more likely to get a second opinion. Most of the time (88%) the second opinion agreed with the initial recommendation.
It seems that doctors are doing a good job of identifying and recommending a breast cancer surgery that makes sense based on a woman's specific situation. Most of the recommendations for mastectomy were considered appropriate by the researchers -- only 6.2% of the mastectomy recommendations were considered questionable.
If you've been diagnosed with early-stage breast cancer, you and your doctor will discuss a surgical approach that makes the most sense for you and your unique situation. Ask your doctor about the cancer characteristics that are influencing the surgery recommendation. Your surgery decision also should reflect your personal beliefs and preferences. Accurate information about the cancer, as well as a clear understanding of what you want, are essential to developing a treatment plan that makes the most sense for you.
Mastectomy may not be as overused as commonly thought, according to a population-based survey showing that doctors recommend and attempt local resection in most early stage breast cancer cases.
While one-third of patients surveyed ultimately had a mastectomy, physicians initially attempted breast conserving surgery on 75% of women overall, Monica Morrow, MD, of Memorial Sloan-Kettering Cancer Center, and colleagues reported in the Oct. 14 Journal of the American Medical Association.
Only 6.2% of women who did not report a clinical contraindication to lumpectomy got a recommendation for mastectomy from their surgeon, the researchers found.
Since patient preference appears to be an important factor in a decision for mastectomy, either against a surgeon's recommendations or when the surgeon makes no definite recommendation, targeting physicians alone in an attempt to reduce mastectomy rates is unlikely to be effective, the investigators concluded.
"Focusing on improved patient selection for breast conserving surgery, either through the increased use of second opinions or more detailed imaging evaluations, are not likely to have a major effect," they wrote. "Our findings suggest that a combined approach of education for patients and health care professionals targeting specific areas may improve decision making."
There's no question that a shift toward mastectomy has occurred, particularly in the past two years, commented W. Fraser Symmans, MD, of the MD Anderson Cancer Center in Houston.
Randomized trials have shown equivalent survival for lumpectomy and mastectomy, "so in early stage breast cancer women have a choice," commented Lori J. Pierce, MD, of the University of Michigan in Ann Arbor.
Why the shift has occurred and whether it's appropriate has been a matter of debate, both noted.
There can be good reasons for mastectomy, such as planned prophylactic mastectomy of the contralateral breast for particularly high risk women, Symmans said.
"A mastectomy from 20 years ago isn't the same a mastectomy from today," he added. "The dramatic improvements in reconstruction have probably factored into this."
However, "the negative here would be to have a woman undergo mastectomy simply because she isn't fully informed of all of the options" or because of additional lesions on MRI that would have been controlled by radiation, Pierce said.
In an attempt to answer some of these questions about mastectomy rates, Morrow's group surveyed 1,984 women aged 20 to 79 years with intraductal or stage I and II breast cancer diagnosed between June 2005 and February 2007 who were included in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registries for Los Angeles and Detroit.
Among these women, breast conserving surgery dominated, accounting for 66.6% of surgeries. Another 8.8% received mastectomy after at least one unsuccessful attempt at lumpectomy.
A further 13.4% said they had an initial mastectomy based on their surgeon's recommendation, while 8.8% received initial mastectomy despite their surgeon's recommendation for breast conserving surgery or lack of recommendation of one procedure over another.
About one in five women sought a second opinion, with an even higher rate among the 17.2% of survey respondents whose initial surgeon had recommended a mastectomy (33.4%, P<0.001).
Overall, the initial surgeon most frequently recommended breast conserving surgery (66.2%), though 16.7% did not recommend one procedure over another.
When mastectomy was recommended by the first surgeon, 67.4% reported a contraindication to breast conserving surgery (11.3% of the total sample).
Second opinions usually agreed with the first (87.9%), and only 1.9% of the women opted for mastectomy when both surgeons recommended against it.
Those who did go against their initial surgeon's recommendation were more likely to have an unsuccessful lumpectomy that had to be converted to mastectomy in the end (46.5% versus 11.9% overall).
Morrow and colleagues said the findings indicate hat surgeons have already largely adopted mastectomy when appropriate contraindications to breast conserving surgery exist, and that they accurately determine candidates for breast conserving surgery.
They cautioned that the study relied on patient recall, without confirmation of what surgeons actually discussed and recommended for surgery. And as with any survey, nonresponse and missing data might have biased some of the results, the investigators added.
The study was funded by grants from the National Cancer Institute to the University of Michigan. The researchers reported no conflicts of interest.
Symmans reported conflicts of interest with Agendia, Genentech, Invitrogen, Nuvera Biosciences, Amgen, Cell Therapeutics, and Isis Pharmaceuticals. Pierce reported having received research funding from the National Institutes of Health and the Breast Cancer Research Foundation.
Primary source: Journal of the American Medical Association Source reference: Morrow M, et al "Surgeon Recommendations and Receipt of Mastectomy for Treatment of Breast Cancer" JAMA 2009; 302: 1551-1556.
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