Clinicians must educate patients about risks, benefits of surgical treatments for early breast cancer

“Nationwide Trends in Mastectomy for Early-Stage Breast Cancer” — a study published by Kummerow and colleagues in JAMA Surgery in November 2014 — is the most recent addition to the growing literature that demonstrates an increasing use of mastectomy for early-stage breast cancer in the United States.

The authors queried the National Cancer Database (NCDB) — a large cancer registry maintained by the American College of Surgeons that contains data on more than 2.7 million primary breast cancer cases since 1998 — to assess the proportion of patients who were treated with mastectomy for early-stage breast cancer and to determine whether surgical treatment trends have changed during the study period.

The authors found that overall, 35.5% of women with early-stage breast cancer underwent mastectomy. The likelihood of mastectomy increased 34% from 1998 to 2003 compared with 2004 to 2011. Consistent with other studies, the greatest increase was seen in women with small cancers and negative nodes (35% increase from 2003-2011) and those with pre-invasive cancer (105% increase from 2003-2011).

Much of the increased mastectomy rate could be attributed to the risk in bilateral mastectomy over the study period. Almost 30% of women with unilateral breast cancer underwent bilateral mastectomy in 2011, up from 5.4% in 1998.

This is the largest study on this topic to date, and results support those of prior published studies. What none of the studies was able to show, however, is why women are increasingly choosing mastectomy for the earliest, least life-threatening cancers.

There are clearly both short-term and long-term costs to mastectomy. Not only is there a longer recovery time for mastectomy — particularly if reconstruction is also performed — but the physical, psychosocial and overall health consequences of mastectomy can be considerable and lifelong. Also important is the overall burden to the health care system, given that studies definitively show no survival benefit to mastectomy compared with lumpectomy for early-stage breast cancer.

That women have the choice of lumpectomy or mastectomy is largely due to patient advocacy movements in the United States and Europe in the 1970s, which demanded that researchers study lumpectomy as a viable option for women with breast cancer. Thus, women now have surgical options, and they must be strongly encouraged to seek the treatment choice that best aligns with their own individual needs. However, the increase in mastectomy rates despite data that clearly demonstrate no survival advantage to mastectomy is troubling, and raises the question of whether women are being properly counseled about their surgical choices.

The trend for increased mastectomy is clearly multifactorial, but it is imperative that the medical community do its part in continuing to educate patients about the risks and benefits of surgical treatment decisions for early-stage breast cancer. Better health habits, rather than mastectomy, should be promoted as the best way to improve future health.

Reference:

Kummerow KL. JAMA Surg. 2014;doi:10.1001/jamasurg.2014.2895.

For more information:

E. Shelley Hwang, MD, MPH, is professor of surgery in the department of surgery, division of advanced oncologic and gastrointestinal surgery at Duke University School of Medicine. She can be reached at DUMC 3513, Durham, NC 27710.