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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    • "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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    • "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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