Medical Center

Mastectomy is not being overused in women with breast cancer, as is commonly thought, according to a study published in the October 14 issue of the Journal of the American Medical Association, which found that about 75% of patients surveyed received breast-conserving surgery (BCS) as initial treatment.
“Most surgeons in 2 large diverse urban regions appropriately recommended local therapy options for patients with breast cancer,” said lead author Monica Morrow, MD, chief of the breast service, Department of Surgery, at Memorial Sloan-Kettering Cancer Center in New York City.

Dr. Morrow presented the results at a media briefing held to release new research on surgical care. She told Medscape General Surgery and other media that “more expensive testing, such as [magnetic resonance imaging], is unlikely to have an effect on lowering the mastectomy rate, because surgeons already are successful [in doing so] based on physical exam and mammography.”

She and her coauthors surveyed women 20 to 79 years with ductal carcinoma in situ or stage I or II invasive breast cancer. The aims of the study were to define the mastectomy rate in a population-based group of recently treated women, to determine why women choose mastectomy as initial breast cancer treatment, and to learn how often patients undergo mastectomy after an attempt at lumpectomy. The sample came from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) registries for metropolitan Los Angeles, California, and Detroit, Michigan. Nearly all respondents completed the survey by mail, but some completed the survey over the phone.

Reasons for Patient Choices

Of the 1984 women in the final sample, 1468 (74.4%) had BCS as their initial surgery (including 170 who had a mastectomy after an unsuccessful BCS attempt), and 460 (22.2%) had mastectomy initially. The remaining patients did not report their treatment choice. Failure of BCS with “conversion” to mastectomy was more common in patients with stage II cancer, according to the authors.

Most patients who did not get a second opinion followed their surgeon’s recommendation for initial treatment (97.9% of women if the recommendation was BCS and 88.8% if the recommendation was mastectomy), according to the authors. One third of patients chose initial mastectomy when they did not receive a specific treatment recommendation from their surgeon, Dr. Morrow reported.

Among the 341 women who reported that their surgeon recommended mastectomy, about 67% had a medical contraindication to BCS, which constituted 11% of the total sample. “This is consistent with other findings that relatively few women have contraindications to BCS,” she said.

Approximately 19% of the women (n = 378) sought a second opinion. The second opinion differed from the first opinion for only 43 patients, which Dr. Morrow said indicates that surgeons have adopted consensus thought on indications for BCS and mastectomy. Women were significantly more likely to seek a second opinion if they had more than a high-school education than if they had a high school diploma or less (P < .001) or if the first surgeon recommended mastectomy (P < .001), the authors write.

There were no differences in the first surgeon’s recommendation or in the patient’s choice for initial mastectomy based on the patient’s race/ethnicity or education level. Dr. Morrow said they oversampled blacks and Hispanics to have enough representation of ethnic and racial minorities. They excluded Asians from the study because of enrollment in other studies.

BCS Rate Seems Atypical

The nearly 75% rate of women opting for BCS surprised one surgeon who was not affiliated with the study. “I was surprised it was that high. It shows that the recent perception that we’re going back to a higher mastectomy rate is not true,” Alicia Growney, MD, a breast surgeon at Rush University Medical Center in Chicago, Illinois, told Medscape General Surgery.

Alternatively, the study’s medical centers might not perform advanced procedures, such as nipple-sparing mastectomy, which can result in higher mastectomy rates, she said. Because the survey was conducted in only 2 areas of the United States, Dr. Growney said she would be interested in seeing what the practice patterns are across the country for breast cancer surgery.

Dr. Growney stressed that failure of eligible patients to choose lumpectomy, as recommended by their surgeon, is not the surgeon’s failure to properly educate the patient. “We need to offer all the treatment choices to the patient, and in the end, it’s up to the patient,” she said.

Dr. Morrow and Dr. Growney have disclosed no relevant financial relationships

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