CHICAGO -- September 2, 2014 -- Among women diagnosed with early-stage breast cancer in California, the percentage undergoing a double mastectomy increased substantially between 1998 and 2011, although this procedure was not associated with a lower risk of death than breast-conserving surgery plus radiation, according to a study in the September 3 issue of JAMA.
The authors did find that surgery for the removal of one breast was associated with a higher risk of death than the other options examined in the study.
Randomised trials have demonstrated similar survival for patients with early-stage breast cancer treated with breast-conserving surgery and radiation or with mastectomy. However, previous data showed increasing use of mastectomy, and particularly bilateral mastectomy among US patients with breast cancer. Evidence for a survival benefit with this procedure appears limited to rare patient subgroups.
“Because bilateral mastectomy is an elective procedure for unilateral breast cancer and may have detrimental effects in terms of complications and associated costs as well as body image and sexual function, a better understanding of its use and outcomes is crucial to improving cancer care,” wrote Allison W. Kurian, MD, Stanford University School of Medicine, Stanford, California, and colleagues.
For the current study, researchers used data from the California Cancer Registry from 1998 through 2011 to compare the use of and rate of death after bilateral mastectomy, breast-conserving therapy with radiation, and unilateral mastectomy. The analyses included 189,734 patients.
The researchers found that the rate of bilateral mastectomy increased from 2.0% in 1998 to 12.3% in 2011, an annual increase of 14.3%. The increase in bilateral mastectomy rate was greatest among women aged younger than 40 years -- the rate increased from 3.6% in 1998 to 33.0% in 2011, increasing by 17.6% annually. Use of unilateral mastectomy declined in all age groups.
Bilateral mastectomy was more often used by non-Hispanic white women, those with private insurance, and those who received care at a National Cancer Institute-designated cancer centre. In contrast, unilateral mastectomy was more often used by racial/ethnic minorities and those with public/Medicaid insurance.
Compared with breast-conserving surgery with radiation, bilateral mastectomy was not associated with a mortality difference, whereas unilateral mastectomy was associated with higher mortality.
“In a time of increasing concern about overtreatment, the risk-benefit ratio of bilateral mastectomy warrants careful consideration and raises the larger question of how physicians and society should respond to a patient’s preference for a morbid, costly intervention of dubious effectiveness,” the authors concluded. “These results may inform decision-making about the surgical treatment of breast cancer.”
In an accompanying editorial, Lisa A. Newman, MD, University of Michigan, Ann Arbor, Michigan, wrote: “The need for patients to be accurately informed regarding safe and oncologically acceptable treatment options is indisputable. The dense fog of complex emotions that accompanies a new cancer diagnosis can impair the ability to process this information. Patients should be encouraged to allow the intensity of these immediate reactions to subside before committing to mastectomy prematurely. Physicians should not permit excessive treatment delays to compromise outcomes, but the initial few weeks surrounding the diagnosis are more effectively utilised by time invested in patient education and procedures that contribute to comprehensive treatment planning as opposed to hastily coordinating impulsive, irreversible surgical plans.”