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Physician-related factors affect likelihood of breast preservation after second event
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Mastectomy was more frequently used among patients with a second breast event than breast-conserving surgery in areas with high rates of radiotherapy for ductal carcinoma in situ, according to the results of a retrospective population-based analysis.
Because this analysis was restricted to patients eligible for breast conservation, this trend suggests physician-related factors may influence likelihood of breast preservation, according to the researchers.
“Patients and their physicians are often confronted with a decision between more intensive or less intensive treatment for a particular diagnosis,” Rinaa S. Punglia, MD, MPH, associate professor at Harvard Medical School and senior physician at Dana-Farber Cancer Institute, and colleagues wrote. “Whether a woman undergoes a second breast-conserving surgery for a new diagnosis may not only be a function of the stage of diagnosis, but may also be determined by the regional treatment patterns used for the management of ductal carcinoma in situ (DCIS).”
Receipt of radiation after a first breast event can complicate reconstructive options after a second event; however, patients who undergo breast-conserving surgery alone usually are candidates for that procedure again if they experience a second breast cancer in the same breast.
Punglia and colleagues evaluated the relationship between intensity of radiotherapy and the use of mastectomy for a second breast event across geographic regions, focusing on patients eligible for a second breast-conserving surgery.
Researchers used the SEER database to identify 2,697 women (median age, 64 years) from 166 health service areas who were diagnosed with DCIS between 1990 and 2011. Researchers also used the SEER–Medicare database to identify 757 older women (median age, 79 years) from 97 health service areas diagnosed with DCIS from 1991 to 2009. All women had received breast-conserving surgery without radiation as their initial treatment.
The regions included California, Connecticut, Georgia, greater Detroit, Iowa, Kentucky, Louisiana, New Jersey, New Mexico, northwestern Washington state, and Utah. Researchers considered the proportion of all patients who underwent radiotherapy for DCIS within health service areas to determine treatment intensity as low (< 57%), medium (57%-69%) or high (> 69%) within that area.
The primary outcome was the use of mastectomy compared with breast-conserving surgery for the treatment of DCIS recurrence or a new invasive breast cancer.
Among women from the SEER cohort who experienced a subsequent breast event, a greater proportion of those who resided in the highest intensity areas underwent mastectomy than women in the lowest treatment intensity areas (49.6% vs. 40.8%). This corresponded with a 43% increased likelihood of undergoing mastectomy (OR = 1.43; 95% CI, 1.1-1.85).
This likelihood increased to 90% for older women with a second breast event, or from 38.6% to 54.5% (OR = 1.9; 95% CI, 1.27-2.84).
When researchers restricted the analysis to women in the SEER cohort with an ipsilateral second diagnosis, likelihood of mastectomy increased 63% among women in the highest treatment intensity areas (OR = 1.63; 95% CI, 1.17-2.32).
Researchers acknowledged that the lack of sensitivity for capturing radiotherapy use and breast events may have limited findings.
“Physicians in regions of high use of radiotherapy may guide patients with DCIS toward mastectomy because many of these patients are ineligible for breast-conserving surgery at the time of a second breast event — having already received radiotherapy — leading to mastectomy being recommended for patients who did not receive radiotherapy and are eligible for breast-conserving surgery,” the researchers wrote. “Awareness of this effect of practice patterns may be the first step toward its eradication and movement toward more patient-centered care.” – by Nick Andrews
Disclosure: The researchers report no relevant financial disclosures.
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