Given a choice, not all women prefer breast conservation surgery

Data from a prospective, observational study demonstrate that well-informed women eligible for both surgeries may prefer mastectomy.

Women eligible for mastectomy or breast conservation surgery who receive information about their options, the importance of personal values in the decision-making process and balanced testimonials prior to their surgical consultations may prefer mastectomy.

Researchers conducted a prospective, observational cohort study to determine whether well-informed women with newly diagnosed breast cancer would choose to undergo mastectomy instead of breast conservation surgery and to discover the reasons behind the decision.

Women completed a standard questionnaire and viewed a 55-minute video decision aid as part of the center’s standard practice. They completed a second questionnaire after viewing the video. After their surgery was scheduled, women completed a telephone questionnaire that inquired about decision quality. Using medical record review, postoperative cancer stage was recorded after surgery to consider possible clinical contraindications to breast conservation surgery.

One-hundred twenty-five women completed all three questionnaires. Thirty-five percent chose mastectomy; married and younger patients were positively associated with the decision to undergo mastectomy (P≤.05). Women with stage II and III cancers were also more likely to choose mastectomy (P<.01).

At each questionnaire time point, the percentage of women indicating their preference for mastectomy increased: 22% at baseline, 31% after viewing the decision aid and 35% after scheduling their surgery. Prior to viewing the decision aid, 43% of women were unsure about either option. After viewing the decision aid, 38% of women were unsure. After consulting with the surgeon, however, uncertainty diminished; of those unsure after the decision aid (n=47), 33 chose breast conservation surgery and 14 chose mastectomy.

Seventy-eight women reported a definite preference prior to viewing the decision aid; however, 15 changed their choice after their consultation. Twelve patients switched from mastectomy to breast conservation therapy. Three women switched from breast conservation surgery to mastectomy. Knowledge scores did not differ between women choosing breast conservation surgery (93%) and mastectomy (92%), according to the researchers.

Mastectomy was more likely to be chosen with each point increase in importance for the questionnaire item “remove breast for peace of mind” (OR=2.2). “Avoid radiation” was also related to the decision to have a mastectomy (OR=1.5). Women were less likely to have mastectomy with each point increase for “keep your breast” (OR=0.7).

At baseline, decisional conflict scores were high, but they decreased after the decision aid and again after the surgical consultation. Decisional conflict scores were generally lower (by one to four points) among women who chose mastectomy, though the difference was not significant.

In an accompanying editorial, Alyssa D. Throckmorton, MD, department of surgery at the University of California at San Francisco, and Laura J. Esserman, MD, MBA, Carol Franc Buck Breast Cancer Center at the University of California at San Francisco, addressed the importance of patient knowledge and respecting choices made by patients.

“Some people will choose one path, others a different one. We need to accept that women will have different values and want different choices,” they wrote. “Our job should be to make sure patients have the choices, the information, the time and environment in which to make an informed, value-driven decision.”

J Clin Oncol. 2008;doi:10.1200/JCO.2008.16.6215.
J Clin Oncol. 2008;doi:10.1200/JCO.2008.19.5057.