Mastectomy not being overused for breast cancer treatment, study suggests

Monica Morrow, M.D., of Memorial Sloan-Kettering Cancer Center, New York, presented the findings of the study at a JAMA media briefing in Chicago.

"Concerns about excessive use of mastectomy for patients with breast cancer have been raised for more than 2 decades. Rates of breast-conserving surgery (BCS) have been used by some as a quality measure. Despite a marked increase in BCS, concerns persist that women with breast cancer are being overtreated with mastectomy," according to background information in the article.

Dr. Morrow and colleagues conducted a study to determine the reasons women undergo initial mastectomy for treatment of breast cancer and the frequency of mastectomy after BCS is attempted. The study consisted of a survey of women age 20 to 79 years with intraductal or stage I and II breast cancer diagnosed between June 2005 and February 2007 and reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results registries for the metropolitan areas of Los Angeles and Detroit. The final survey sample included 1,984 female patients (502 Latinas, 529 blacks, and 953 non-Hispanic white or other).

The researchers found that of the patient population, 75.4 percent had BCS as an initial surgical therapy; 23 percent had initial mastectomy; 13.4 percent received initial mastectomy based on surgeon recommendation; 8.8 percent received initial mastectomy when the first surgeon did not recommend one procedure over another or recommended BCS; and 8.8 percent received mastectomy after unsuccessful attempts at BCS.

Of the 1,984 patients, 19.1 percent sought a second opinion about surgical options prior to treatment. "This was more common for women with a higher education level and for those advised to undergo mastectomy (33.4 percent) vs. those advised to have BCS (15.6 percent) or those who did not receive a recommendation for one procedure over another (21.2 percent)," the authors write.

They also found that 11.9 percent of patients who received an initial BCS recommendation received a second opinion for mastectomy; 12.1 percent of the patients who consulted a second surgeon received a discordant opinion. Among the 1,459 women for whom BCS was attempted, additional surgery was required in 37.9 percent of patients. Mastectomy was most common in patients with stage II cancer.

"The results of this study suggest that most surgeons in 2 large, diverse urban regions appropriately recommended local therapy options for patients with breast cancer. The majority of women who received a surgeon recommendation for initial mastectomy reported a clinical contraindication to breast conservation," the authors write.

"Our results also suggest that patient preferences may play an important role in shaping the pattern of surgical treatment for breast cancer. One-third of patients appear to choose mastectomy as initial treatment when not given a specific recommendation for BCS or mastectomy by their surgeon, accounting for about one-quarter of total mastectomy use. Patients may prefer mastectomy for peace of mind or to avoid radiation."

"In conclusion, findings of this survey of women with breast cancer demonstrate that the etiology [cause] of current mastectomy rates is multifactorial, but that BCS is recommended by surgeons and attempted in a majority of patients," the researchers write. "Our findings suggest that a combined approach of education for patients and health care professionals targeting specific areas may improve decision making."