Factors that influence surgical choices in women with breast carcinoma
Article first published online: 5 SEP 2002
Copyright © 2002 American Cancer Society
Volume 95, Issue 6, pages 1185–1190, 15 September 2002
How to Cite
Staradub, V. L., Hsieh, Y.-C., Clauson, J., Langerman, A., Rademaker, A. W. and Morrow, M. (2002), Factors that influence surgical choices in women with breast carcinoma. Cancer, 95: 1185–1190. doi: 10.1002/cncr.10824
- Issue published online: 5 SEP 2002
- Article first published online: 5 SEP 2002
- Manuscript Accepted: 11 APR 2002
- Manuscript Revised: 8 APR 2002
- Manuscript Received: 18 JAN 2002
- Specialized Program of Research Excellence in Breast Cancer. Grant Number: P50CA89018
- Avon Products Foundation
- Lynn Sage Breast Cancer Research Foundation
- breast carcinoma;
- breast-conserving therapy;
- surgical choices;
- patient decision-making
In the absence of medical contraindications, survival after undergoing breast-conserving therapy (BCT), mastectomy (M), and mastectomy with immediate reconstruction (MIR) is equal. The authors studied demographic factors to identify the variables that differed significantly among women making different surgical choices.
Women with ductal carcinoma in situ or clinical Stage I or II breast carcinoma with no contraindications for BCT or MIR who were treated between 1995 and 1998 were identified from a prospectively collected data base. Demographic and tumor factors were compared using the Fisher exact test.
There were 578 women with 586 tumors who did not have contraindications for BCT or MIR. Among this group, 85.2% of women chose BCT, 9.2% of women chose M, and 5.6% of women chose MIR. Women undergoing M alone were older and were more likely to have Stage II carcinoma compared with women undergoing BCT. Patients undergoing M or MIR were more likely to have had a prior breast biopsy compared with patients who chose BCT. Marital status and employment approached significance (P = 0.06); however, a family history of breast carcinoma was not a predictor of treatment choice.
The current findings suggest a need for patient education strategies that emphasize the lack of influence of age and prior breast biopsy on the use of BCT. Differences in demographic variables may reflect true variations in patient preference among groups, emphasizing the need to address the spectrum of treatment options with patients. Cancer 2002;95:1185–90. © 2002 American Cancer Society.
Options for the surgical management of patients with early-stage breast carcinoma include mastectomy (M), mastectomy with immediate reconstruction (MIR), or breast-conserving therapy (BCT). Most of the time, any one of these surgical strategies is medically appropriate. Absolute contraindications to BCT are well defined and include tumor in more than one quadrant of the breast, diffuse suspicious or indeterminate calcifications on mammogram, the inability to achieve histologically negative margins, and contraindications to radiation therapy, such as pregnancy or a history of prior radiation therapy to the breast field.1 Relative contraindications include a large tumor-to-breast ratio, precluding acceptable cosmesis, and collagen vascular disease, such as scleroderma, because radiation may carry a significant risk of soft tissue complications for patients in this group. The incidence of these contraindications varies with tumor stage. In our experience, approximately 10% of women with Stage I breast carcinoma and 28% of women with Stage II breast carcinoma had at least one contraindication to BCT.2 In women with contraindications to BCT, M is medically necessary. Although MIR does not alter the risk of local recurrence, the time to recurrence, or the likelihood of detection of recurrence,3, 4 fewer than 10% of women who undergo M also undergo breast reconstruction within 3 months of the initial procedure.5 The main contraindication to immediate reconstruction is the presence of significant comorbid medical conditions.4 Despite the widespread availability of BCT and immediate reconstruction for the past decade, modified radical mastectomy remains the most common surgical therapy for patients with Stage I and II breast carcinoma in the United States.6–8 The objective of this study was to identify differences in demographic factors among women choosing BCT, M, and MIR who were offered a choice between the three procedures.
MATERIALS AND METHODS
The breast cancer data base of the Lynn Sage Comprehensive Breast Program is maintained in a prospective fashion. Data are entered as women present to the Breast Center and are updated as their course evolves. Therefore, the data used in this study were collected prospectively and analyzed retrospectively. From January, 1995 to December, 1998, 828 newly diagnosed women were seen in our Breast Center. Among this group, 578 consecutive women who presented with 586 cases of DCIS or clinical Stage I or II invasive breast tumors were eligible to choose between BCT, M, and MIR. The patients viewed a commercially available informational video program, which was created by the Foundation for Informed Medical Decision-Making, based on patient experiences of various local therapy options for breast carcinoma prior to their appointment in the Breast Center. The video was designed to give an unbiased comparison between the local therapy options using patient vignettes and medical information. Local therapy options were reviewed again during an in-depth surgical consultation with one of eight surgeons in the Lynn Sage Breast Center. During the consultations, patients were told specifically that BCT, M, and MIR had equivalent rates of survival. Differences in local control rates between M/MIR and BCT also were addressed. Patients were encouraged to ask questions of their surgeon, and additional questions were answered by a breast nurse clinician. Patients were offered the option of consulting with a radiation oncologist or a reconstructive surgeon prior to making a treatment choice. Statistical comparisons between groups were carried out using the Fisher exact test for all categoric variables. Comparisons between surgeons were done using the chi-square test.
Of the 586 tumors in 578 women in this study, 108 tumors (18%) were DCIS, and 478 tumors (82%) were clinical Stage I or II invasive breast carcinoma. After a discussion of treatment options, 500 patients underwent BCT, 54 patients underwent mastectomy alone (M), and 33 patients underwent MIR (Fig. 1). The factors that influenced treatment choices are summarized in Tables 1 and 2.
|Variable||BCT (n = 500 patients)||M (n = 54 patients)||MIR (n = 33 patients)||P value (pairwise)|
|Age (yrs)||54||58||48||< 0.001 (BCT vs. M, BCT vs. MIR, and MIR vs. M)|
|Stage (%)||< 0.001 (BCT vs. M)|
|Insurance (%)||0.02 (MIR vs. M)|
|Prior breast biopsy (%)||0.02 (BCT vs. M and BCT vs. MIR)|
|Marital status (%)||0.66|
|Family history of breast carcinoma (%)||0.10|
|Level of education (%)||n = 178||n = 12||n = 16||0.13|
|≤ High school||28||25||6||—|
|Level of income (%)||n = 120||n = 8||n = 13||0.75|
The mean age of patients who underwent BCT was 54 years, compared with a mean age of 59 years among patients who underwent M alone and a mean age of 48 years among patients who underwent MIR. Patients who chose BCT were significantly younger compared with patients who opted for M alone (P < 0.001), and patients who elected to undergo MIR were significantly younger compared with patients who underwent either BCT or M alone (P < 0.001).
Disease stage at initial presentation also was a significant predictor of treatment choice (Fig. 2). At final pathology, there were 108 (18%) cases of DCIS (Stage 0), 271 (46%) Stage I carcinomas, and 195 (33%) Stage II carcinomas. Twelve patients (2%) with clinical Stage II disease were upstaged to Stage III or IV disease when complete pathology was available. The stage distribution of patients who underwent BCT differed significantly compared with the stage distribution of patients who underwent M alone (P < 0.001). Patients who underwent M alone were more likely to have a clinical Stage II breast carcinoma compared with patients who underwent BCT (48% vs. 31%, respectively; P < 0.001). Patients who underwent MIR showed a stage distribution that was similar statistically to the stage distribution among patients who underwent BCT.
A history of breast biopsy prior to the time of diagnosis with breast carcinoma also affected the patient's choice of surgical procedure. Women who underwent M alone or MIR were more likely than women who underwent BCT to have had a breast biopsy in the past for benign disease (33% and 34% for M and MIR vs. 20% for BCT; P = 0.02).
The insurance status of patients who underwent MIR differed significantly compared with patients who underwent BCT or M alone. There were no significant differences in insurance status between the group who chose BCT and the group who chose M alone. However, the group that underwent MIR was significantly more likely to have private or preferred provider organization insurance compared with the group that underwent M alone (88% vs. 60%, respectively; P = 0.02). The percentage of patients who were covered by Health Maintenance Organizations was similar among the three groups.
Other factors that approached, but did not reach, statistical significance included marital status and employment. There was a trend toward a greater proportion of single women in the BCT group compared with either the M alone group or the MIR group (P = 0.06). Similarly, there was a trend toward a greater proportion of employed women in the BCT and MIR groups compared with the M alone group (P = 0.06).
Factors that did not differ among the treatment groups included the presence of a family history of breast carcinoma, income, and education. However, the percentage of respondents to questions about income and education was only 24% and 35%, respectively (Table 2). Only 21 patients in the non-BCT groups provided data regarding economic status; thus, no meaningful conclusions could be reached. In addition, because 90% of the patients in this study were Caucasian, we were unable to assess the influence of ethnicity or culture on patient decision-making.
The impact of the treating surgeon on patient choice also was examined. Of eight surgeons in the group, three surgeons were female, and the remaining five surgeons were male. The number of patients who were treated by each surgeon ranged from 1 patient to 347 patients. Despite these differences, no correlation between the choice of surgical procedure and the consulting surgeon was noted.
In this study, 85% of patients who were offered a choice between BCT, M, and MIR elected to undergo BCT. This rate of BCT is substantially higher compared with what has been reported in national or even regional studies.7–10 Several studies have delineated the factors that influence the type of surgery women with early-stage breast carcinoma will receive. In a study by Lazovich et al. that examined women of all ages with Stage I or II breast carcinoma who were identified from the Seattle-Puget Sound Cancer Registry, the presence of a radiation therapy facility in the county of residence was an important factor in the rate of BCT.11 Data from the SEER Program suggests that having a cancer care center in the county also was important, although the definition of a cancer care center was not specified.10 Other variables that reportedly have a significant impact on the use of BCT include patient age at diagnosis, physician density in the region, and level of education in the county.10 In a study by Kotwall and coauthors, patient age > 70 years, lack of private insurance, and treatment at small hospitals by older surgeons were indicators of a decreased likelihood of receiving BCT in North Carolina.12
Patient age at the time of diagnosis frequently is reported as a significant variable in studies of BCT rates, with older women less likely to undergo BCT compared with their younger counterparts.6–8, 10, 12 Immediate reconstruction also is chosen significantly less often in older women. This is true despite the failure to document an increase in radiation-associated complications in older women,13 despite the suggestion that local failure rates after BCT are lower in older age groups,14 and despite the demonstration that expander reconstructions are tolerated well in older women.15 Our study suggests that patient preference may account in part for the lower rates of BCT and MIR observed in older populations. Handel and colleagues surveyed 158 women: 71 women who underwent BCT and 87 women who did not. Of the women in that survey who did not undergo reconstruction, 40% reported that their age was a deciding factor.16 Age-related differences in the use of reconstruction may reflect the reluctance of older women to undergo the additional office visits and surgical procedures necessary to complete reconstruction. Differences in the use of BCT are explained less easily, because BCT clearly is a smaller operative procedure compared with M. Difficulty with transportation to the radiation facility may be a problem in the older age group. It is important to note that, although patients who underwent M alone were significantly older compared with patients who underwent BCT or MIR, 84% of patients age ≥ 70 years in our study chose to undergo BCT.
The advice or bias of the surgeon also has been reported as a major factor in the decision-making process.9, 17, 18 In a study of patient perceptions associated with breast surgery, Kotwall et al. reviewed 174 patients who were deemed eligible for BCT over a 2-year period.9 Only 18% of those patients actually received BCT, and, of 143 patients who underwent mastectomy, only 28 had an immediate reconstruction. Sixty-nine percent of those patients reported that their surgeon had recommended a particular therapy, and, in 89%, the recommendation was that they should undergo mastectomy. Ninety-three percent of the women whose surgeons recommended mastectomy, in fact, did undergo the procedure. Sixty-percent of the patients who underwent BCT in the study by Kotwall et al. reported making their own surgical decision, compared with only 37% of the patients who underwent mastectomy. Cyran et al. reported that, in addition to patient age and education, physician gender was a significant variable in the type of operation performed.18 In their study of 176 women with no known contraindication to BCT, women who underwent a lumpectomy were more likely to have had a female physician. We did not confirm this observation in our study. The rate of BCT did not differ among the three female surgeons and five male surgeons whose patients were included in this report, nor did it differ based on the volume of patients with breast carcinoma who were treated. This lack of variation among surgeons may be because all of these physicians had sufficient interest in breast disease to practice in a dedicated breast center. Multidisciplinary case review occurs weekly, and surgeons are provided with stage-specific information on their use of BCT compared with the aggregate of surgeons practicing in the breast center.
One major difference between our study and large national studies that have addressed the use of BCT7, 8, 10 is that all of the patients in our study were identified as candidates for BCT as well as MIR, and the patients were educated regarding each of these options. Particular emphasis was placed on the lack of a survival difference between therapies. Many of the patients who present to our tertiary care institution are seeking a second opinion and may be doing so based on their desire to avoid mastectomy. Chang et al., reporting the results of a multidisciplinary second-opinion program, observed that, among 32 women for whom there was a disagreement with the initial therapy opinion, failure to recommend BCT in eligible women occurred in 41%.19 In a report of our experience comparing treatment recommendations from an initial surgical consultation with recommendations from our second-opinion program, we found that only 46% of patients initially were offered all three treatment options.20 In 17% of the women in our series, patients who were candidates for BCT were offered only mastectomy.
This study confirmed the findings of Kotwall et al. that patients who lack private insurance are more likely to be treated by M alone.12 The passage of legislation mandating insurance coverage for immediate reconstruction largely should have eliminated the financial reasons for this difference. It has been suggested that women of lower socioeconomic status may be less likely to be cared for in a hospital with qualified reconstructive surgeons or may have less time to devote to body-image issues.21 Lack of access to a reconstructive surgeon does not explain the difference observed in our study, but we were unable to measure the influence of other factors, such as the cost of travel for more frequent physician visits and the more prolonged recovery period after reconstruction compared with M alone, that may have a significant impact on treatment choice. Similarly, the extra time and travel needed for radiation therapy after patients undergo breast-conserving surgery may influence the treatment choice.
A greater proportion of patients with Stage II disease chose mastectomy alone compared with BCT. The reason for this is unclear. Although more patients with Stage II disease are ineligible for BCT due to a large tumor-to-breast ratio,2 all of the patients in this study were eligible for the procedure. Because many of these women came to our center for a second opinion, it is possible that they were advised to undergo mastectomy elsewhere, consistent with national data on the effect of stage on treatment,8 and this influenced their treatment choice. It is also possible that a desire to avoid the more prolonged treatment time associated with the use of both adjuvant systemic chemotherapy and breast irradiation contributed to this pattern. Finally, patient perception that a bigger operation would be more effective for the treatment of a more “advanced” tumor may have been a factor. Regardless of the explanation, our study suggests that some of the differences in the use of BCT by tumor stage may be patient driven rather than physician driven.
More patients in both mastectomy treatment groups reported a history of prior benign breast biopsy compared with patients in the BCT group. The reason for this is unclear, and we were unable to find other analyses of the impact of prior biopsy on treatment choice. It is possible that these women may have the perception that their remaining breast tissue is prone to disease or that their awareness of the anxiety associated with breast biopsy caused them to choose a mastectomy option.
Marital status, employment history, and family history of breast carcinoma were not significant predictors of treatment choice. Polednak, analyzing 5266 patients with breast carcinoma in the Connecticut Tumor Registry who were diagnosed between 1990 and 1992, also found that marital status was not a significant predictor of the use of BCT.22 Employment status was not assessed in his study, but socioeconomic status on the basis of census tract also was not a predictive factor.
Overall, this study indicates that the majority of women, regardless of age, tumor stage, insurance status, or other demographic factors, will opt for BCT after treatment choices are explained. The less frequent selection of BCT in older women, women with Stage II disease, and women with a history of prior breast biopsy suggests that educational messages to patients should emphasize the lack of importance of these factors in treatment selection. In our study, the individual surgeon did not influence the type of operative procedure performed, despite variations in age, gender, and volume of patients among surgeons. Although it was not the primary purpose of this study, this finding suggests that the use of a multidisciplinary case-review process and data feedback may minimize the impact of individual surgeon attitude on patient treatment choice. Finally, our results confirm that patient preferences for treatment vary, emphasizing the importance of an explanation of all medically appropriate treatment options for each patient.
- 1Standards for diagnosis and management of invasive breast carcinoma. American College of Radiology. American College of Surgeons. College of American Pathologists. Society of Surgical Oncology. CA Cancer J Clin. 1998; 48: 83–107., .