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Surgeon preference influences likelihood of mastectomy
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CHICAGO — The likelihood of undergoing mastectomy for localized breast cancer varied widely by individual surgeon, according to study results presented at the ASCO Annual Meeting.
Women with localized breast cancer can be treated with mastectomy or breast-conserving surgery. No recent study has focused on the degree to which the preferences of the individual surgeon influences the decision-making process.
“In an ideal world, women with breast cancer should receive an unbiased presentation of all treatment options, including mastectomy and breast-conserving surgery, with the ultimate decision coming from patient preference,” Isabel Boero, MD, MS, who was a medical student at University of California, San Diego, during the conduct of this study, told HemOnc Today. “However, physician bias or institutional bias can sway a patient’s decision, and can result in greater than expected variability in patterns of care.”
Boero and colleagues identified 44,698 Medicare beneficiaries diagnosed with localized breast cancer between 2000 and 2009, who underwent breast-conserving surgery or mastectomy as definitive treatment.
Researchers used claims data to identify the type of surgery and the individual surgeon. They then used logistic models, which clustered surgeons and geographic regions, to determine the likelihood of mastectomy.
The researchers controlled for the impact of demographic and clinical covariates, and calculated median ORs to describe the relative impact of geographic region and individual surgeon on the likelihood of mastectomy.
Overall, 10,156 women (22.7%) underwent mastectomy. The unadjusted rates ranged from 3.2% in the bottom quintile of surgeons to 47.1% among surgeons in the top quintile.
Surgeons had a greater impact on the likelihood of mastectomy (median OR = 2.14) than geographic location (median OR = 1.56). The influence persisted over all other clinical and demographic values, except tumor size (OR = 3.02) and nodal status (OR = 2.86).
“We expected some variability in mastectomy rates,” Boero said. “After all, certain patients have tumors or anatomy that make them ineligible for breast-conserving surgery, or underlying conditions that make them poor candidates for certain procedures. However, we learned that there is substantial variability, and that surgeons play a large role in driving these variations.”
Male surgeons, less experienced surgeons, and surgeons whose practice saw a lower volume of patients with breast cancer were more likely to favor mastectomy over breast-conserving surgery (P < .05 for all).
“We hope that our study will spur efforts to reduce provider bias, such as the increased use of multidisciplinary clinics, improved patient and physician education, and implementation of shared decision-making tools,” Boero said. “The ultimate goal is to raise physician awareness of their biases to better respect patient autonomy.” – by Cameron Kelsall
Reference:
Boero I, et al. Abstract 1008. Presented at: ASCO Annual Meeting; June 3-7, 2016; Chicago.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Anees Chagpar, MD, MSc, MBA, MPH, FACS, FRCS(C)
It has been well known that mastectomy rates are rising in the United States, but the ideological factors behind the increase remain uncertain. Patients today are better aware of their genetic risks and other factors that increase their risk for recurrence. There also has been an increase in MRI use, and it has been shown that MRI rates and mastectomy rates tend to track very well together. Further, improved techniques in reconstructive surgery have made mastectomy more cosmetically appealing.
The question that has always remained uncertain was whether physician bias promoting mastectomy existed. These data tried to tease that out, and to define whether there were surgeons whose practice matters clearly tended to favor mastectomy over breast-conserving surgery, even though it is well known that both of these practices yield similar survival benefits.
We need to interpret these data with some caution, because even in the setting where we can find that certain surgeons may have a disproportionate number of mastectomies compared with others, one has to wonder whether that was mediated by the surgeons themselves, or whether their patient populations played a strong role in the choice. Some patients may have had higher genetic predispositions that influence the choice. Reconstructive options are not uniform throughout the country, so a patient who is treated in an area with good reconstructive options may make a different choice than one who does not. In a retrospective study like this, it is difficult to parse out the conversations that happened between surgeon and patient in the office leading up to the procedure.
Is there really a bias on the part of a surgeon, or is it simply a matter of chance? That remains to be definitively determined.
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