NEW YORK, Oct 13, 2009 (ASCRIBE NEWS via COMTEX) -- There is concern that
mastectomy is over-utilized in the United States, which raises questions about
the role of surgeons and patient preference in treatment selection for breast
cancer. New data from an observational study found that breast-conserving
surgery was presented and provided in the majority of patients evaluated.
Surgeon recommendations, patient decisions, and failure of breast-conserving
surgery were all found to be contributing factors to the mastectomy rate. The
findings are published in the Oct. 14 issue of the Journal of the American
Medical Association (JAMA), a theme issue on surgical care.
The study was lead by Monica Morrow MD, Chief of the Breast Service in the
Department of Surgery at Memorial Sloan-Kettering Cancer Center, along with
Steven Katz MD, MPH, and colleagues at the University of Michigan Comprehensive
Cancer Center. Dr. Morrow and colleagues were interested in investigating the
factors responsible for the overall mastectomy rate in the United States and why
women undergo mastectomy for the initial treatment of breast cancer.
The findings suggest that surgeons are appropriately recommending
breast-conserving surgery and that patient preferences play an important role in
shaping the pattern of surgical treatment for breast cancer, especially in the
absence of a surgeon recommendation favoring one procedure over another. This is
consistent with previous studies performed by these investigators that have
shown that when both procedures are medically appropriate, increased patient
involvement in breast surgery decisions is associated with greater probability
of mastectomy. In this study, one-third of patients appear to choose mastectomy
as initial treatment when not given a specific recommendation for mastectomy by
their surgeons. Researchers speculate that patients may prefer mastectomy for
"peace of mind" or to avoid radiation and are often strongly influenced by
concerns about disease recurrence and fear.
"Women need to understand that although it intuitively seems obvious that a
bigger surgery is a better surgery - it may not be the case here. There are some
patients for whom mastectomy is the best medical treatment, but when it is not
indicated, women need to make sure that if they are choosing mastectomy as a
matter of preference that they understand that it is not going to improve the
likelihood of breast cancer survival. The risk of cancer recurring in the breast
after a lumpectomy is basically no different than the risk of cancer recurring
in the scar tissue of a mastectomy," said Dr. Morrow.
Concerns about the excessive use of mastectomy for patients with breast cancer
have been raised for decades despite a marked increase in breast-conserving
surgery in recent years. According to a 2008 study (by the Mayo Clinic),
mastectomy rates were 45 percent in 1997, dropped to 30 percent in 2003, but
then increased to 43 percent in 2006.
In this new study, Dr. Morrow and colleagues found that of 1984 women aged 20 to
79 years with stage 1 and 2 breast cancer that was diagnosed between June, 2005
and February, 2007: 67 percent of women reported that their first surgeon
recommended breast-conserving surgery and that they had successful procedures;
13 percent had mastectomies after initial surgical recommendation; 8.8 percent
had mastectomies when there was no clear surgical recommendation for either
procedure; and finally, an additional 8.8 percent reported having unsuccessful
breast-conserving surgery that required revision with mastectomy. The results
are based on data reported to the metropolitan Los Angeles and Detroit
Surveillance, Epidemiology and End Results (SEER) registries.
"Our results and those from other studies we performed suggest that surgeons
face special challenges in how they discuss treatment options and elicit the
treatment preferences of their patients with breast cancer. Our results
reinforce that both patient preferences and surgeon recommendations are powerful
determinants of treatment," said Dr. Katz, who is a professor of internal
medicine and health management and policy at the University of Michigan.
"This study suggests that breast-conserving surgery has been appropriately
adopted by surgeons and for most women - if they are given a specific reason why
they are not a good candidate for breast-conserving surgery, a second opinion is
not likely to change that," said Dr. Morrow.
Funding for this study was provided by grants from the National Cancer Institute
and the American Cancer Society to the University of Michigan. Dr. Katz was
supported by an Established Investigator Award in Cancer Prevention, Control,
Behavioral, and Population Sciences Research from the NCI.
Memorial Sloan-Kettering Cancer Center is the world's oldest and largest private
institution devoted to prevention, patient care, research, and education in
cancer. Our scientists and clinicians generate innovative approaches to better
understand, diagnose, and treat cancer. Our specialists are leaders in
biomedical research and in translating the latest research to advance the
standard of cancer care worldwide. For more information, go to
http://www.mskcc.org .
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