Mastectomy Selected More often than Lumpectomy
Concerned about cancer recurrence, women with breast cancer often choose a mastectomy over a less-drastic lumpectomy when they have control over the decision, according to a study reported in the Journal of Clinical Oncology.
October is national Breast Cancer Awareness Month.
This, despite the fact that survival odds - though not recurrence rates - are the same with the two procedures.
In recent years, medical practice guidelines have recommended that a lumpectomy, in which just part of the breast is removed, should be performed, if possible, in lieu of a mastectomy - removal of the entire breast.
But there has been concern among health experts that the mastectomy rate has remained high, says study lead author Dr. Steven Katz, associate professor of medicine and health management and policy at the University of Michigan Medical School in Ann Arbor.
"The issue is that surgeons have been blamed for being too aggressive with recommendations" for mastectomies, he says.
However, Dr. Katz's study suggests that it is often patients, not their surgeons, who are opting for the mastectomies.
"Some policy-makers have said that women are not adequately informed [about options for breast-cancer surgery], leading to legislative efforts in 20 states mandating women be informed of surgical options," he explains.
The study findings, Dr. Katz says, suggest that surgeons are following policy recommendations and recommending the less-invasive treatment and that women are informed and usually involved in the decision-making process.
"But the most interesting finding is, the more involvement [by women] reported, the more likely they receive a mastectomy," he says.
Dr. Katz and his colleagues surveyed 1,844 women in the Los Angeles and Detroit areas who had recently learned they had breast cancer. They were asked if they made the decision about surgical treatment, if their physician did, or if both did and which options were discussed.
They found that among Caucasian women, who made up more than 70 percent of the sample, 27 percent who said they made the decision chose a mastectomy. This compared to just 5.3 percent of women who said their surgeon made the treatment choice, and 16.8 percent who said the decision was shared.
The study also found that African-American women seemed to have more difficulty reaching a decision - they sought more opinions from more surgeons and made decisions later.
But because the prognosis is similar for both mastectomy and lumpectomy, these differences in the decision-making process may not be significant, the study finds.
Overall, 30.2 percent of the women underwent mastectomy as their initial treatment. Forty-one percent of those patients said they made that surgical decision, while 37.1 percent said it was a shared decision and 21.9 percent said the surgeon made the decision - with or without their input.
Those who chose mastectomy were likely to say they did so due to a fear of cancer recurrence or concerns about radiation treatment, which follows lumpectomy.
Women who chose mastectomy, Dr. Katz notes, "view the mastectomy as a more complete treatment and it reduces their concern about the return of the cancer."
While survival rates between the two options is not different, the risk of recurrence is substantially higher in lumpectomy patients than in mastectomy patients.
"For all women with early stage disease - that is noninvasive and early stage invasive - their risk of recurrence is 15 to 20 percent over 10 years in the local breast, the one with cancer, versus 1 percent in those with mastectomy," Dr. Katz says.
Dr. Ann Nattinger, chief of the Division of General Internal Medicine at the Medical College of Wisconsin, wrote an accompanying editorial in the journal.
In an interview, she says, "Methodologically this is a well-done study. It's well analyzed." In addition, "it is the first study that has looked systemically at how the decision was made," she adds.
The message for women, Dr. Nattinger says, is "they should make sure they are making a decision consistent with their own values."
They should also consider getting several opinions about treatment from different physicians, she says.
Dr. Katz adds that women should weigh their choices deliberately. While it is not wise to delay cancer treatments, women with breast cancer often have more time to make their therapy decisions than they think they do, he says.
Involve a patient advocate, a family member, or friend to help sort out the options, Dr. Katz advises.
Always consult your physician for more information.
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Mastectomy Selected More often than Lumpectomy
Patients Deciding Treatment Route
Weigh Choices Carefully, Expert Says
Mammogram Improves Prognosis, Study Shows
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Women whose breast cancer is detected by a screening mammogram have a better prognosis than those whose cancer is found symptomatically, even if the cancer has spread to the lymph nodes, according to a report in the Journal of the National Cancer Institute.
"Everyone knows finding cancer mammographically gives you longer survival due to lead time," says senior study author Donald A. Berry, chairman of the department of biostatistics and applied mathematics at the University of Texas M.D. Anderson Cancer Center.
October is national Breast Cancer Awareness Month.
Lead time refers to the time between when the tumor is detected by mammography and when the tumor would have been detected in the absence of screening - such as finding the lump by feeling it.
Mammogram-detected tumors, Dr. Berry says, "tend to be found sooner than those found symptomatically."
What is new in this study, he says, is that the researchers considered women with the same characteristics, including age, tumor size, and involvement of the lymph nodes, and found there is still an advantage with finding the cancer by mammogram vs. other detection methods, he says.
"It's the second paper to report this," Dr. Berry notes. "One other Finnish study reported this, too."
For the study, Dr. Berry's team evaluated data from three large randomized breast cancer screening trials. They included the Health Insurance Plan of New York, which assigned 62,000 women to screening or a control group, and two Canadian studies that evaluated nearly 45,000 women who were screened and nearly the same number in control groups who were not.
The researchers then focused on the women in the studies who were eventually diagnosed with breast cancer.
They compensated for the stage of cancer to eliminate "lead-time bias" and found women whose cancers were discovered after a previous negative mammogram (by methods other than a mammogram) had a 53 percent higher risk of death than those whose cancer was detected by the regular screening mammograms.
Those in the control group (in which no mammogram was used) had a 36 percent higher risk of breast cancer death compared to those who were screened by mammograms.
The difference in survival is due to a "length bias," because screening detects more slow-growing tumors, Dr. Berry explains
Dr. Herman Kattlove, medical editor for the American Cancer Society, says the study findings are of interest to researchers and women alike.
"A woman who is screened every year and finds a lump in between [screenings] has a different cancer than one whose cancer is detected on a mammogram," he says
"They may be biologically different cancers, and probably more aggressive," Dr. Kattlove says. "The message for women is, continue getting mammograms. It still will save lives."
Women should also know that if they find a lump between mammograms, it is crucial to see a physician as soon as possible, Dr. Kattlove notes, because the cancer may be more aggressive.
Adds Dr. Berry: "The message is not that screening is good or screening is bad. We didn't address that question. But there is a distinct survival advantage if women get mammograms."
"A woman who has had her tumor detected mammographically can breathe an extra sigh of relief because her tumor is, on average, less lethal than her sister's tumors detected symptomatically," he says.
Always consult your physician for more information.
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