Mastectomy
Selected More often than Lumpectomy
Concerned about cancer recurrence, women with breast cancer
often choose a mastectomy over a less-drastic lumpectomy when they have control
over the decision, according to a study reported in the Journal
of Clinical Oncology.
October is national Breast Cancer
Awareness Month.
This, despite the fact that survival odds - though not recurrence
rates - are the same with the two procedures.
In recent years, medical practice guidelines have recommended
that a lumpectomy, in which just part of the breast is removed, should be performed,
if possible, in lieu of a mastectomy - removal of the entire breast.
But there has been concern among health experts that the
mastectomy rate has remained high, says study lead author Dr. Steven Katz,
associate professor of medicine and health management and policy at the University
of Michigan Medical School in Ann Arbor.
"The issue is that surgeons have been blamed for being too
aggressive with recommendations" for mastectomies, he says.
However, Dr. Katz's study suggests that it is often patients,
not their surgeons, who are opting for the mastectomies.
"Some policy-makers have said that women are not adequately
informed [about options for breast-cancer surgery], leading to legislative
efforts in 20 states mandating women be informed of surgical options," he explains.
The study findings, Dr. Katz says, suggest that surgeons
are following policy recommendations and recommending the less-invasive treatment
and that women are informed and usually involved in the decision-making process.
"But the most interesting finding is, the more involvement
[by women] reported, the more likely they receive a mastectomy," he says.
Dr. Katz and his colleagues surveyed 1,844 women in the
Los Angeles and Detroit areas who had recently learned they had breast cancer.
They were asked if they made the decision about surgical treatment, if their
physician did, or if both did and which options were discussed.
They found that among Caucasian women, who made up more
than 70 percent of the sample, 27 percent who said they made the decision chose
a mastectomy. This compared to just 5.3 percent of women who said their surgeon
made the treatment choice, and 16.8 percent who said the decision was shared.
The study also found that African-American women seemed
to have more difficulty reaching a decision - they sought more opinions from
more surgeons and made decisions later.
But because the prognosis is similar for both mastectomy
and lumpectomy, these differences in the decision-making process may not be
significant, the study finds.
Overall, 30.2 percent of the women underwent mastectomy
as their initial treatment. Forty-one percent of those patients said they made
that surgical decision, while 37.1 percent said it was a shared decision and
21.9 percent said the surgeon made the decision - with or without their input.
Those who chose mastectomy were likely to say they did so
due to a fear of cancer recurrence or concerns about radiation treatment, which
follows lumpectomy.
Women who chose mastectomy, Dr. Katz notes, "view the mastectomy
as a more complete treatment and it reduces their concern about the return
of the cancer."
While survival rates between the two options is not different,
the risk of recurrence is substantially higher in lumpectomy patients than
in mastectomy patients.
"For all women with early stage disease - that is noninvasive
and early stage invasive - their risk of recurrence is 15 to 20 percent over
10 years in the local breast, the one with cancer, versus 1 percent in those
with mastectomy," Dr. Katz says.
Dr. Ann Nattinger, chief of the Division of General Internal
Medicine at the Medical College of Wisconsin, wrote an accompanying editorial
in the journal.
In an interview, she says, "Methodologically this is a well-done
study. It's well analyzed." In addition, "it is the first study that has looked
systemically at how the decision was made," she adds.
The message for women, Dr. Nattinger says, is "they should
make sure they are making a decision consistent with their own values."
They should also consider getting several opinions about
treatment from different physicians, she says.
Dr. Katz adds that women should weigh their choices deliberately.
While it is not wise to delay cancer treatments, women with breast cancer often
have more time to make their therapy decisions than they think they do, he
says.
Involve a patient advocate, a family member, or friend to
help sort out the options, Dr. Katz advises.
Always consult your physician for more information.
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