Surgeon recommendations and receipt of mastectomy for treatment of breast cancer

Breast Surgery Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 10/2009; 302(14):1551-6. DOI: 10.1001/jama.2009.1450
Source: PubMed


There is concern that mastectomy is overused in the United States.
To evaluate the association of patient-reported initial recommendations by surgeons and those given when a second opinion was sought with receipt of initial mastectomy; and to assess the use of mastectomy after attempted breast-conserving surgery (BCS).
A survey of women aged 20 to 79 years with intraductal or stage I and II breast cancer diagnosed between June 2005 and February 2007 and reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results registries for the metropolitan areas of Los Angeles, California, and Detroit, Michigan. Patients were identified using rapid case ascertainment, and Latinas and blacks were oversampled. Of 3133 patients sent surveys, 2290 responded (73.1%). A mailed survey was completed by 96.5% of respondents and 3.5% completed a telephone survey. The final sample included 1984 female patients (502 Latinas, 529 blacks, and 953 non-Hispanic white or other).
The rate of initial mastectomy and the perceived reason for its use (surgeon recommendation, patient driven, medical contraindication) and the rate of mastectomy after attempted BCS.
Of the 1984 patients, 1468 had BCS as an initial surgical therapy (75.4%) and 460 had initial mastectomy, including 13.4% following surgeon recommendation and 8.8% based on patient preference. Approximately 20% of patients (n = 378) sought a second opinion; this was more common for those patients advised by their initial surgeon to undergo mastectomy (33.4%) than for those advised to have BCS (15.6%) or for those not receiving a recommendation for one procedure over another (21.2%) (P < .001). Discordance in treatment recommendations between surgeons occurred in 12.1% (n = 43) of second opinions and did not differ on the basis of patient race/ethnicity, education, or geographic site. Among the 1459 women for whom BCS was attempted, additional surgery was required in 37.9% of patients, including 358 with reexcision (26.0%) and 167 with mastectomy (11.9%). Mastectomy was most common in patients with stage II cancer (P < .001).
Breast-conserving surgery was recommended by surgeons and attempted in the majority of patients evaluated, with surgeon recommendation, patient decision, and failure of BCS all contributing to the mastectomy rate.

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Available from: Ann S Hamilton, Oct 06, 2015
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    • "The re-operation rate that we recorded (10.3%) compares favorably, for instance, with the 60.5% reported by Rudloff in their observational study of 304 women with DCIS treated with breast-conserving therapy (Rudloff et al. 2010). In another population-based study (Morrow et al. 2009), a 42.7% rate of additional surgery is reported, "
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    ABSTRACT: What constitutes an adequate surgical margin in partial mastectomy is still controversial: intra-operative specimen radiogram is commonly used during partial mastectomy for nonpalpable lesions in order verify the adequacy of the resection but what margin is to be considered “adequate” is still debatable. An intraoperative specimen mammogram was performed during all consecutive conservative resections for nonpalpable DCIS and a 15-mm radiological margin was considered “adequate”. Margins were pathologically assessed and classified as “negative”, “close” or “positive” and the rate of margin involvement constitued the main outcome of the study. Among 272 conservative interventions, 80.51% had negative margins at final pathology, 3.31% had close margins and 16.18% had positive margins. An intraoperative “adequate” margin of 15 mm as defined on intraoperative specimen mammogram granted a high rate of histologically negative margin at primary surgery; this finding was paralleled by confirmation of the treatment as conservative in 95% of cases.
    SpringerPlus 12/2013; 2(1):243. DOI:10.1186/2193-1801-2-243
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    • "Surgeons have other reasons to be concerned with factors that affect patients' intentions to adhere, especially if they are associated with patients' satisfaction. A majority (81%) of patients diagnosed with stages 0–2 breast cancer do not seek a second surgical opinion, and of those that do, only 12% receive a discordant treatment recommendation from the second surgeon (Morrow et al., 2009); Of these patients that seek a second opinion, a majority (56%) return to their original surgeon, such that more than 90% of all breast cancer patients receive surgery from the first surgeon consulted (Morrow et al., 2009). As acknowledged by the Institute of Medicine (1999), one fundamental component of quality medical care is patient-centered communication (Bensing, 2000), the value of which is pronounced during cancer care (Hayes, 1978). "
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    ABSTRACT: Research has found a negative association between patient question asking and aspects of their satisfaction. In the context of surgical oncology, the aim of this exploratory study was to test the association between patient question asking and 3 indices of their satisfaction. Participants included 51 women who were newly diagnosed with breast cancer engaged in presurgical consultations with a surgical oncologist from a National Cancer Institute-designated cancer center in the Northeastern United States. Outcomes were patients' postconsultation reports of their satisfaction with the treatment plan, intentions to adhere to the treatment plan, and satisfaction with the surgeon. The main predictor was the frequency of patients' self-initiated questions coded from videotapes of consultations. The frequency of patients' self-initiated questions was negatively associated with their satisfaction with the treatment plan (p = .02), intentions to adhere to the treatment plan (p = .02), and satisfaction with the surgeon (p = .07). Results can be explained in terms of patients' perceptions that the surgeon's information was insufficient or inadequate. Future research needs to identify the specific content of patients' questions and how such content might be associated with satisfaction.
    Journal of Health Communication 04/2013; 18(8). DOI:10.1080/10810730.2012.757391 · 1.61 Impact Factor
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    • "Many patients are likely to seek a second opinion for serious diagnoses or complicated procedures [8]. Previous surveys estimated that 16–42% of patients seek second opinions [7,9-11]. The second opinion also became an integral part of many health care systems, featuring a competitive marketing benefit for attracting patients to particular insurance packages. "
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    ABSTRACT: Second opinion is a treatment ratification tool that may critically influence diagnosis, treatment, and prognosis. Second opinions constitute one of the largest expenditures of the supplementary health insurance programs provided by the Israeli health funds. The scarcity of data on physicians' attitudes toward second opinion motivated this study to explore those attitudes within the Israeli healthcare system. We interviewed 35 orthopedic surgeons and neurologists in Israel and qualitatively analyzed the data using the Grounded Theory approach. As a common tool, second opinion reflects the broader context of the Israeli healthcare system, specifically tensions associated with health inequalities. We identified four issues: (1) inequalities between central and peripheral regions of Israel; (2) inequalities between private and public settings; (3) implementation gap between the right to a second opinion and whether it is covered by the National Health Insurance Law; and (4) tension between the authorities of physicians and religious leaders. The physicians mentioned that better mechanisms should be implemented for guiding patients to an appropriate consultant for a second opinion and for making an informed choice between the two opinions. While all the physicians agreed on the importance of the second opinion as a tool, they raised concerns about the way it is provided and utilized. To be optimally implemented, second opinion should be institutionalized and regulated. The National Health Insurance Law should strive to provide the mechanisms to access second opinion as stipulated in the Patient's Rights Law. Further studies are needed to assess the patients' perspectives.
    Israel Journal of Health Policy Research 07/2012; 1(1):30. DOI:10.1186/2045-4015-1-30
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