CanSORT: Mastectomy not overused as initial surgical treatment

Despite concern that mastectomy is overused, more than 75% of women who responded to a recent survey reported undergoing breast-conserving surgery as initial surgical therapy.

“Most surgeons in two large diverse areas appropriately recommended surgical options for breast cancer treatments, and we did not observe differences in recommendations on the basis of race or ethnicity,” Monica Morrow, MD, of Memorial Sloan-Kettering Cancer Center in New York, said during a press briefing today.

Morrow and colleagues from the Cancer Surveillance and Outcomes Research Team (CanSORT) evaluated data from a survey of 1,984 women aged 20 to 79 years identified from the SEER registries for Los Angeles and Detroit. Women had intraductal, stage I or stage II cancer. The women were diagnosed between June 2005 and February 2007.

Researchers reported that 1,468 women (75.4%) had breast-conserving surgery as initial surgical therapy, while 460 women had initial mastectomy. Nearly 12% of women who underwent breast-conserving surgery had an unsuccessful surgery and underwent mastectomy as a result. Morrow said there was no difference in the recommended or received treatments based on race/ethnicity, education or SEER site.

Sixty-seven percent of women who underwent mastectomy as initial surgery reported a contraindication to breast-conserving surgery, such as prior radiotherapy or more than one cancer in the breast, according to Morrow. “This was 11% of the total patient population, which is consistent with the findings of other studies that relatively few women have contraindications to breast-conserving surgery,” Morrow said.

About 13% of the total population had an initial mastectomy, which was reported to be due to surgeon recommendation, and 8.8% of the entire group underwent mastectomy based on their own preference.

Second opinions

Nineteen percent of patients sought a second opinion — 33.4% had originally been advised to undergo mastectomy, 15.6% were originally advised to undergo breast-conserving surgery, and 21.2% had not received an initial recommendation for either surgery (P<.001).

“Overall, discordant second opinions were relatively infrequent — only 43 patients or 12% of those who sought a second opinion received a discordant opinion from the second surgeon, suggesting that surgeons have adopted standard contraindications to breast-conserving surgery,” Morrow said.

Among women who underwent breast-conserving surgery, 62% did not require additional surgery, 26% required re-excision of additional breast tissue and 11.9% required mastectomy. Morrow said that 8% of those who were converted to mastectomy underwent only a single attempt at breast conservation, suggesting that re-excision might have allowed them to continue with breast conservation.

“If we are interested in decreasing the mastectomy rate … more extensive and expensive preoperative evaluations with additional imaging modalities such as MRI are unlikely to have an impact on the mastectomy rate because we are quite successful at selecting patients with standard tools of physical exams and mammography,” Morrow said.

Morrow recommended improved approaches to patient education on the equivalent survival rates between the two surgical techniques and on the low rates of in-breast recurrence with current breast-conservation techniques. – by Tina DiMarcantonio

Morrow M. JAMA. 2009;302:1551-1556.