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Journal of Clinical Oncology, Vol 23, No 24 (August 20), 2005: pp. 5429-5431 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.04.913
Variation in the Choice of Breast-Conserving Surgery or Mastectomy: Patient or Physician Decision Making?Medical College of Wisconsin, Milwaukee, WI In 1985, the 5-year results were published of the first US randomized trial (National Surgical Adjuvant Breast and Bowel Project [NSABP] B-06) demonstrating equal survival for early-stage breast cancer patients whether they underwent mastectomy or breast-conserving surgery (BCS).1 The translation of these trial results into clinical care has been an interesting model for studying the adoption of a new cancer treatment. In 1986, the year after the initial publication of the NSABP B-06 trial, the use of BCS among a population-based cohort of Medicare patients was characterized by marked geographic variation, with greatest use in the Northeastern and West Coast parts of the country and less use in the Central, Southern, and Plains states.2 The use of BCS shortly after the initial publication of the trial was also characterized by variation based on patient age, socioeconomic status, urban versus rural residence, and hospital characteristics.2-4 Briefly summarized, greater use of BCS was found among younger women, women of higher socioeconomic status, women residing in urban areas, and women treated in larger teaching hospitals. Inconsistent variation in use of BCS by race was noted, with some, but not all, studies showing lower use by African Americans, when controlled for geographic factors.4,5 Despite expectations that the use of BCS would climb during the years immediately after the 1985 publication of the 5-year results of the NSABP B-06 trial, the overall use of BCS increased little, if at all, between 1985 and 1990. An increase in use of BCS did occur after the 1990 National Institutes of Health Consensus Development Conference, which determined that BCS was preferable for the majority of women with early-stage breast cancer.6,7 Between 1990 and 1996, the percentage of early-stage breast cancer patients undergoing BCS approximately doubled.7 However, the substantial variation in receipt of BCS by age, geographic region, socioeconomic status, and urban versus rural residence persisted despite the greater use of this treatment in almost all subgroups.7,8 The slow overall adoption of BCS, the variation in use of BCS by nonclinical factors, and the lesser use of BCS by lower income and less well-educated women led to concern that patients might not have an appropriate level of information and decision making with respect to this treatment decision.9 With this context, the study reported by Katz et al10 in this issue provides useful information. The investigators surveyed a population-based sample of women diagnosed in 2002 with early-stage breast cancer from Detroit and Los Angeles, which are two areas that have previously demonstrated differing practice patterns with respect to BCS. Among these women, approximately 70% underwent BCS, and 30% received mastectomy. Thirty-seven percent of the women perceived the surgeon to recommend neither surgical procedure over the other. However, when a specific recommendation was perceived by women, BCS was reported as being recommended by the surgeon more often (49% of women) than mastectomy (15% of women). Almost 80% of the women reported making their own decision or sharing the decision with their surgeon. Greater patient involvement in decision making was associated with greater use of mastectomy rather than greater use of BCS. These findings may be surprising to some because they challenge the implicit assumption in the literature that more widespread adoption of BCS has been held back by surgeons who favor mastectomy. The small percentage of surgeons recommending mastectomy leads one to question whether there has been a dramatic shift in the recommendations of breast cancer surgeons in the last two decades. Although some increased physician comfort with the use of BCS has likely accompanied the publication of later randomized trial results reporting outcomes for up to 20 years,11 evidence to support a recent shift in the thinking of surgeons is lacking. Even in 1987, surveys of US and Canadian physicians found only 20% to 30% of physicians recommending mastectomy for a hypothetical early-stage breast cancer patient,12,13 which is not so different from the 15% of surgeons who were reported to recommend mastectomy in the Katz et al10 study. Furthermore, even in 1987, physicians recommending mastectomy and physicians recommending BCS were found to be "equally involved with and cognizant of the value of clinical trials."12 Another argument against the assumption that surgeons have been responsible for slow adoption of BCS is the finding that only approximately half of breast cancer patients regard their surgeon to have been the most influential individual with respect to their surgical decision; the remaining patients are influenced mostly by nonphysicians.9 Another implicit assumption in the literature that is challenged by the results of the Katz et al10 study is that better informed patients will tend to choose BCS therapy. Indeed, there is other support for the concept that variation in use of BCS is attributable, at least partially, to variation in patient perceptions and values. The persistent variation in use of BCS for so many years itself supports this possibility.7 In addition, state laws mandating surgeon disclosure of surgical treatment options had a limited effect on the adoption of BCS, even in states with substantive penalties for failure to provide full disclosure.14 This finding could be interpreted to suggest that women were already receiving information on their treatment options before the passage of these laws. Furthermore, when the wife of a sitting president chose to undergo a mastectomy in preference to BCS, the use of BCS decreased markedly for 6 months, which is a finding unlikely to be attributable to surgeon behavior.15 In interviews, both patients and surgeons cite a wish to avoid a cancer recurrence, a desire to avoid the need for another operation, and concern about side effects of radiotherapy as reasons why patients may choose mastectomy over BCS.9,16 In the study by Katz et al,10 as in much of the literature on patient decision making, the information provided to patients about their decision was not standardized. This fact raises the question of whether women truly understand the somewhat complex information supporting BCS and mastectomy as treatment options. There is evidence that patients may have preconceived misperceptions about the toxicity associated with radiotherapy.9 Whether most patients fully understand the randomized trial results in this area is unknown. Still, even if standardized information could be provided to patients, it seems likely that their interpretation and synthesis of this information would vary with their social context, leading to variability in the surgical choice.9 Some patients may have difficulty with the somewhat abstract notion that an irradiated cancer is just as gone as a cancer that has been surgically removed.7 It also requires a high level of faith in medical science and clinical trial results to accept the idea that the possibility of local recurrence or new cancers in a conserved breast does not translate into any survival decrement.11 A disturbing finding of the Katz et al10 study is the fact that African American women seemed to have more difficulty than white women with making the initial treatment decision.10 African American women sought opinions from more surgeons, had more visits before surgery, made decisions later, and perceived less receipt of information than white women. Although these items individually are not all necessarily undesirable, taken as a group, they would seem to indicate a greater degree of difficulty with the treatment decision and possibly a lower comfort level with the doctor-patient interaction. Because patient outcomes in terms of survival and quality of life are similar with BCS and mastectomy, racial differences in decision making may not be critical with respect to the surgical decision. However, difficulty with decision making could be more problematic if it extends to other aspects of breast cancer treatment. African American women with breast cancer have lower survival rates than white women.17-19 The poorer survival is at least partially attributable to racial differences in treatment and follow-up care.17-21 Further research is needed to determine whether these disparities in outcomes are mediated by poorer quality of the decision-making process or physician-patient interaction. Decision making regarding early-stage breast cancer is complex, and the decision-making process is problematic for many patients, not only minority patients.22 Patients are often overwhelmed with information and may have difficulty eliciting the information most germane to their situation. Innovative research on methods to improve the quality of the decision-making process would be welcome. This research, which should focus on both surgical and adjuvant therapies, would have the potential to decrease disparities in outcome for breast cancer and improve the overall quality of care for this condition. Author's Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. REFERENCES 1. Fisher B, Bauer M, Margolese R, et al: Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 312:665-673, 1985[Abstract] 2. Nattinger AB, Gottlieb MS, Veum J, et al: Geographic variation in the use of breast-conserving treatment for breast cancer. N Engl J Med 326:1102-1107, 1992[Abstract]
3. Ballard-Barbash R, Potosky AL, Harlan LC, et al: Factors associated with surgical and radiation therapy for early stage breast cancer in older women. J Natl Cancer Inst 88:716-726, 1996 4. Ayanian JZ, Guadagnoli E: Variations in breast cancer treatment by patient and provider characteristics. Breast Cancer Res Treat 40:65-74, 1996[CrossRef][Medline] 5. Michalski TA, Nattinger AB: The influence of black race and socioeconomic status on the use of breast-conserving surgery in Medicare beneficiaries. Cancer 79:314-319, 1997[CrossRef][Medline] 6. Lazovich D, Solomon C, Thomas D, et al: Breast conservation therapy in the United States following the 1990 National Institutes of Health Consensus Development Conference on the treatment of patients with early stage invasive breast carcinoma. Cancer 86:628-637, 1999[CrossRef][Medline] 7. Gilligan MA, Kneusel RT, Hoffmann RG, et al: Persistent differences in sociodemographic determinants of breast conserving treatment despite overall increased adoption. Med Care 40:181-189, 2002[CrossRef][Medline]
8. Morrow M, White J, Moughan J, et al: Factors predicting the use of breast-conserving therapy in stage I and II breast carcinoma. J Clin Oncol 19:2254-2262, 2001 9. Greer AL, Goodwin JS, Freeman JL, et al: Bringing the patient back in: Guidelines, practice variations, and the social context of medical practice. Int J Technol Assess Health Care 18:747-761, 2002[CrossRef][Medline]
10. Katz SJ, Lantz PM, Janz NK, et al: Patient involvement in surgery treatment decisions for breast cancer. J Clin Oncol 23:5526-5533, 2005
11. Fisher B, Anderson S, Bryant J, et al: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347:1233-1241, 2002
12. Deber RB, Thompson GG: Who still prefers aggressive surgery for breast cancer? Implications for the clinical applications of clinical trials. Arch Intern Med 147:1543-1547, 1987 13. Liberati A, Patterson W, Biener L, et al: Determinants of physicians' preferences for alternative treatments in women with early breast cancer. Tumori 73:601-609, 1987[Medline]
14. Nattinger AB, Hoffmann RG, Shapiro R, et al: The effect of legislative requirements on the use of breast-conserving surgery. N Engl J Med 335:1035-1040, 1996
15. Nattinger AB, Hoffmann RG, Howell-Pelz A, et al: Effect of Nancy Reagan's mastectomy on choice of surgery for breast cancer by U.S. women. JAMA 279:762-766, 1998 16. Wu ZH, Freeman JL, Greer AL, et al: The influence of patients' concerns on surgeons' recommendations for early breast cancer. Eur J Cancer Care (Engl) 10:100-106, 2001
17. Bradley CJ, Given CW, Roberts C: Race, socioeconomic status, and breast cancer treatment and survival. J Natl Cancer Inst 94:490-496, 2002
18. Bach PB, Schrag D, Brawley OW, et al: Survival of blacks and whites after a cancer diagnosis. JAMA 287:2106-2113, 2002
19. Li CI, Malone KE, Daling JR: Differences in breast cancer stage, treatment, and survival by race and ethnicity. Arch Intern Med 163:49-56, 2003 20. Du X, Freeman J, Goodwin J: The declining use of axillary dissection in patients with early stage breast cancer. Breast Cancer Res Treat 53:137-144, 1999[CrossRef][Medline] 21. Schapira MM, McAuliffe TL, Nattinger AB: Underutilization of mammography in older breast cancer survivors. Med Care 38:281-289, 2000[CrossRef][Medline]
22. Sepucha KR, Belkora JK, Mutchnick S, et al: Consultation planning to help breast cancer patients prepare for medical consultations: Effect on communication and satisfaction for patients and physicians. J Clin Oncol 20:2695-2700, 2002
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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