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CLINICIAN'S CORNER
Surgeon Recommendations and Receipt of Mastectomy for Treatment of Breast Cancer
Monica Morrow, MD;
Reshma Jagsi, MD, DPhil;
Amy K. Alderman, MD;
Jennifer J. Griggs, MD, MPH;
Sarah T. Hawley, PhD;
Ann S. Hamilton, PhD;
John J. Graff, PhD;
Steven J. Katz, MD, MPH
JAMA. 2009;302(14):1551-1556.
Context There is concern that mastectomy is overused in the United States.
Objectives 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).
Design, Setting, and Patients 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).
Main Outcome Measures 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.
Results 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).
Conclusion 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.
Author Affiliations: Breast Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Morrow); University of Michigan Health System, Ann Arbor (Drs Jagsi, Alderman, Griggs, Hawley, and Katz); Keck School of Medicine, University of Southern California, Los Angeles (Dr Hamilton); and Karmanos Cancer Institute, School of Medicine, Wayne State University, Detroit, Michigan (Dr Graff).
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