Over at TIE, I wrote a post a couple months ago highlighting a study showing that breast conservation surgery (BCS) was a better option for many women than more aggressive surgeries like contralateral prophylastic mastectomy (CPM). From the accompanying editorial:
CPM is unlikely to be associated with any significant survival advantage for the general population of patients with unilateral breast cancer. These investigators analyzed survival for nearly 200,000 California Cancer Registry patients with unilateral nonmetastatic breast cancer managed with BCS in 55% of cases, bilateral mastectomy/CPM in 6%, and unilateral mastectomy in 39%. With median follow-up of 89.1 months, 10-year survival for these 3 groups was 83.2%, 81.2%, and 79.9%, respectively. Although the unilateral mastectomy cases experienced a statistically significant survival disadvantage compared with BCS, the absolute difference was less than 4%. These findings support the rationale for encouraging BCS whenever feasible.
In fact, this, and other papers report that BCS has become a "standard of excellence " in breast cancer care. Unfortunately, trends are going in the wrong direction. "Nationwide Trends in Mastectomy for Early-Stage Breast Cancer":
IMPORTANCE Accredited breast centers in the United States are measured on performance of breast conservation surgery (BCS) in the majority of women with early-stage breast cancer. Prior research in regional and limited national cohorts suggests a recent shift toward increasing performance of mastectomy in patients eligible for BCS.OBJECTIVE To examine whether mastectomy rates in patients eligible for BCS are increasing over time nationwide, and are associated with coincident increases in breast reconstruction and bilateral mastectomy for unilateral disease.
DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective cohort study of temporal trends in performance of mastectomy for early-stage breast cancer using multivariable logistic regression modeling to adjust for pertinent covariates and interactions. We studied more than 1.2 million adult women treated at centers accredited by the American Cancer Society and the American College of Surgeons Commission on Cancer from January 1, 1998, to December 31, 2011, using the National Cancer Data Base.
EXPOSURES Year of breast cancer diagnosis.
MAIN OUTCOMES AND MEASURES Proportion of women with early-stage breast cancer who underwent mastectomy. Secondary outcome measures include temporal trends in breast reconstruction and bilateral mastectomy for unilateral disease.
This was a cohort study using the National Cancer Data Base to look at temporal trends in mastectomy, breast reconstruction, and contralateral prophylactic mastectomy. Again, given what we know, we'd hope that mastectomy rates would have decreased in favor of BCS.
That's not what happened. In fact, the odds of having a mastectomy increased more than one third in the last eight years of the cohort. The rates of increase were highest in women with clinically node-negative disease and in situ disease, women who'd be more likely to benefit from BCS, and not mastectomy.
Breast reconstruction increased from 12% in 1998 to 36% in 2011. The rate of contralateral prophylactic mastectomy increased from just 2% in 1998 to more than 11% in 2011.
Why? It's not because they were more likely to achieve better outcomes. Research shows that getting more invasive surgery doesn't appear to improve mortality or survival. It costs more money. It's a harder recovery. It can lead to more sequelae and problems down the road. There can even be more psychological effects.
One answer can be found in the discussion of the paper (emphasis mine):
Previous work on decision making in patients with early-stage breast cancer demonstrated greater discordance between patient goals and ultimate surgical treatment in women who underwent mastectomy than in those who underwent BCS. Furthermore, less than 50% of women reported being asked by their physicians whether they preferred BCS or mastectomy, and more than 80% of women reported that their physicians made a specific recommendation for either BCS or mastectomy. This suggests that physicians may strongly influence whether a woman with early-stage breast cancer undergoes BCS or mastectomy.
Less than half of women report being presented with the option of BCS. More than 80% report that their doctor basically told them what to do. And research shows us that what women want, and what their treatment provides, often doesn't match. We can do better than this. We have to improve our communication skills with patients, and make sure that what we do for them aligns with outcomes they value.