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 The researchers don’t suggest that either choice is wrong or right.
But they point to a recent 34 percent rise in the likelihood a woman
will opt for total breast removal as a trend that needs further
study to make sure women are being well informed about their risks.
“We don’t know what’s going to be happening in the future, but it’s
important for patients, providers and policymakers to know that this
is our current trajectory,” said Dr. Kristy Kummerow, the study’s
lead author from Vanderbilt University Medical Center in Nashville.
The complete removal of the breast – known as mastectomy – was
common before research in the 1980s found that lumpectomy, which is
the removal of just the tumor, provides equal outcomes, especially
for early cancers.
Kummerow and her coauthors write in JAMA Surgery that rates of
lumpectomy, or breast conserving therapy, rose over the years, but
then began declining again.
For the study, they used data on 1.2 million women who had surgery
for early-stage breast cancer between 1998 through 2011. The figures
came from the National Cancer Data Base, which captures about 70
percent of newly diagnosed U.S. cancers.
The percentage of women who were eligible for lumpectomy but chose
mastectomy increased from about 34 percent in 1998 to about 38
percent in 2011. The odds of women choosing mastectomy rose by about
34 percent between 2003 and 2011.
Rates of breast reconstruction increased from 12 percent in 1998 to
36 percent in 2011. Rates of removal of both breasts when only one
was found to have cancer rose from 2 percent in 1998 to about 11
percent in 2011.
“It’s hard to say what’s going to happen,” Kummerow said. “If the
trajectories are going to continue or if it’s going to flatten out.”
The increase in mastectomy rates is largely attributable to cases
where a woman has both breasts removed after cancer is found in one
breast and cases of mastectomy with breast reconstruction, the
researchers found.
The U.S. requires insurers to pay for reconstruction after
mastectomy.
The study team notes that tests for genetic mutations that increase
breast cancer risk are not likely driving the trend toward more
mastectomies.
Previous research suggests that doctor recommendations, patient
concerns, use of breast MRIs and desire by the patient for breast
symmetry are tied to the decision, they write. Women without genetic
risk factors also tend to overestimate the risk of cancer occurring
in their second breast.
In an accompanying editorial, Drs. Bonnie Sun and Michael Zenilman
from Johns Hopkins Medicine in Baltimore write that doctors must
make sure treatment decisions are not based on misconceptions.
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“At least in my personal experience, there is this predisposition
out of fear and talking to friends that bigger treatment is better,”
said Dr. Richard Bleicher, a surgical oncologist at Fox Chase Cancer
Center in Philadelphia.
Bleicher, who wasn’t involved in the new study, told Reuters Health
that many women with early-stage cancer move away from mastectomy
when he compares it to lumpectomy.
He said mastectomy requires a more extensive and longer operation
than lumpectomy. The risk of complications with mastectomy is also
higher. It may reduce the risk of cancer reoccurrences, but outcomes
are equal to lumpectomy.
Earlier this year, a study also published in JAMA Surgery found 94
percent of women who chose lumpectomy between 1998 and 2008 had not
died of breast cancer after 10 years, compared to 90 percent of
women who chose mastectomy (see Reuters Health article of January
16, 2014 here: http://reut.rs/1F3ZVz0).
“The bottom line is there is no difference at all for survival if
you have mastectomy or breast conservation therapy,” Zenilman told
Reuters Health. “What we have already noticed is the rates of
mastectomy have been increasing over the last 15 years. This study
basically confirms that this is happening.”
It’s important to keep track of breast cancer patients’ decisions,
because the National Accreditation Panel for Breast Centers says
lumpectomies must be performed in at least half of patients with
early-stage breast cancers, according to the researchers.
At this point, the researchers write, 62 percent of women are still
choosing lumpectomy at those accredited centers.
Kummerow said it’s important to know that women may also make
decisions to have mastectomy for reasons that aren’t captured by
these data. For example, tumor size relative to breast size and
family history may be taken into account.
“Ultimately it ends up being something that you and your provider
decide on together,” Bleicher said.
SOURCE: http://bit.ly/1wYWaoc and http://bit.ly/1HlLhoM JAMA
Surgery, online November 19, 2014.
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