Many Choose More Aggressive Breast Cancer Surgery Despite Breast-sparing Option

According to a new study led by researchers at the University ofMichigan Comprehensive Cancer Center, when women, not their surgeons,have control over the type of surgery they receive, they are morelikely to choose a more aggressive surgery that removes the entirebreast, even though survival rates are the same for surgery thatremoves only the tumor.

With breast-conserving surgery, or lumpectomy, followed byradiation therapy, there's a higher risk of the cancer coming back thanwith mastectomy, surgery that removes the whole breast. But many ofthese recurrences are caught early and treated effectively, so overallsurvival rates are the same for either type of surgery. The studyauthors suggest that's a detail the average person does not understandor care about when faced with a cancer diagnosis.

Study results appear in the August 20issues of the Journal of Clinical Oncology.

Medical practice guidelines encourage surgeons to promotewhenever possible breast-conserving surgery, in which only the tumorand a small amount of normal tissue around it are removed. But morethan one-third of women are still receiving mastectomy.

"The current policy assumes that the high rate of mastectomy,the more invasive treatment, is a result of two things: providers notfollowing guidelines that favor breast-conserving therapy and patientsnot being involved in the treatment decision. What we find is theopposite: Surgeons are strongly promoting lumpectomy, and most womensay they were involved in the decision," says lead study author StevenKatz, M.D., M.P.H., associate professor of general medicine at the U-MMedical School and of health management and policy at the U-M School ofPublic Health.

Katz and his team surveyed 1,844 women in the Los Angeles andDetroit metropolitan areas who had been recently diagnosed with breastcancer. The women were asked whether they made the surgical treatmentdecision, their doctor made the decision or they decided together.Patients were also asked whether their doctor had discussed mastectomy,breast-conserving therapy or both.

Additional questions were aimed at how much control thepatient wanted to have over the decision process and whether she hadany regret about her choice.

The researchers found that 27 percent of women who said theymade the surgical decision received a mastectomy, compared to only 5.3percent of women who said their surgeon made the decision, and 16.8percent of women who said it was a shared decision.

Women who chose mastectomy were more likely to cite a fear ofrecurrence or fears about radiation treatment, which is necessary afterlumpectomy.

In a paper published in June in Health Services Research, theresearchers report that women who said they were involved in thesurgical decision-making process were less likely to have lowsatisfaction with their surgery or regret their decision, suggestingthat how women make their surgery decision is more important than whatdecision they make.

Overall, the researchers found, women were satisfied withtheir choice, with only 11.7 percent of all women reporting lowsatisfaction with the type of surgery they received and 11.4 percentexpressing regret over their decision.

"There are a lot of people who think that mastectomy isovertreatment and that rates are too high. However, our study resultssuggest that women are thinking very rationally about breast cancersurgery from their own perspectives, weighing a lot of differentfactors. When women are diagnosed with breast cancer, they are lookingfor as complete a solution as possible so they can continue on withtheir lives. As long as women are not pressured to have one type ofsurgery over the other, either choice is a viable option," says studyco-author Paula Lantz, Ph.D., associate professor of health managementand policy at the U-M School of Public Health and a member of the U-MComprehensive Cancer Center.

In an editorial accompanying the Journal of Clinical Oncologypaper, Ann Nattinger, M.D., M.P.H., a professor at the Medical Collegeof Wisconsin, writes, "Even if standardized information could beprovided to patients, it seems likely that their interpretation andsynthesis of this information would vary with their social context,leading to variability in the surgical choice. It also requires a highlevel of faith in medical science and clinical trial results to acceptthe idea that the possibility of local recurrence or new cancers in aconserved breast does not translate into any survival decrement."

In addition to Katz and Lantz, study authors for both paperswere Nancy Janz, Ph.D., U-M School of Public Health; Angela Fagerlin,Ph.D., U-M Medical School; Kendra Schwartz, M.D., M.S.P.H., KarmanosCancer Institute; Lihua Liu, Ph.D., University of Southern California;and Barbara Salem, M.S.W., and Indu Lakhani, both from the U-M MedicalSchool. Additional authors on the Journal of Clinical Oncology paperwere Dennis Deapen, Dr.P.H., University of Southern California; andMonica Morrow, M.D., Fox Chase Cancer Center.

Funding was from the National Cancer Institute with additional support from the California Department of Health Services.

For information about breast cancer, visit www.cancer.med.umich.edu/learn/breastinfo.htm or call the Cancer AnswerLine at 800-865-1125.

Reference: Journal of Clinical Oncology, Vol. 23 issue 24
Health Services Research, Vol. 40, issue 3, pp. 754-767