Journal of Clinical Oncology, Vol 9, 7-16, Copyright © 1991 by American Society of Clinical Oncology
How American oncologists treat breast cancer: an assessment of the influence of clinical trials
D Belanger, M Moore and I Tannock
Department of Medicine, Princess Margaret Hospital, Toronto, Ontario, Canada.
The present study was designed to assess the preferred methods of treatment
of breast cancer by American oncologists, and the impact of clinical trials
on their practice. We mailed 465 questionnaires to surgical, radiation, or
medical oncologists. The questionnaire described five hypothetic patients
with breast cancer, and respondents were asked to select their preferred
treatment for each patient. For primary breast cancer, most physicians
would offer the choice of local excision followed by radiation therapy or
modified radical mastectomy. About 80% of physicians would prescribe
adjuvant chemotherapy for a premenopausal woman with estrogen
receptor-negative, axillary node negative breast cancer, and for a
postmenopausal woman with estrogen receptor-negative, node-positive
disease. This policy was favored by male and female physicians of each
specialty. Almost all respondents would treat a young woman with
inflammatory breast cancer with initial chemotherapy followed by radiation
and/or surgery, and about 60% would recommend chemotherapy to a
postmenopausal patient with estrogen receptor-negative disease and
minimally symptomatic bone metastases. Clinical trials have compared
treatment strategies that could be applied to patients described in our
questionnaire. Preferred treatments for primary breast cancer, and for
inflammatory breast cancer are supported by the results of clinical trials.
Recommendation of adjuvant chemotherapy for node-negative breast cancer is
not based on a consistent demonstration of improvement in survival,
although randomized trials with short follow-up have shown delay to
recurrence. Recommendation of adjuvant chemotherapy for a postmenopausal
woman with node-positive breast cancer is contrary to the results of large
randomized controlled trials (and to a meta-analysis), which have shown
that this policy does not lead to improved survival. Our report suggests
that even large randomized clinical trials may have a minimal impact on
practice if their results run counter to belief in the value of the
treatment.
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