Breast Cancer: Many Opt for Mastectomy

Women with breast cancer often opt for mastectomy instead of lumpectomy when offered a choice between the two treatments, an eye-opening new study shows.

The research could explain why so many women with early-stage breast cancer still end up having their breasts removed despite no differences in survival rate compared with women who undergo lumpectomy plus radiation.

The prevailing wisdom has been that physicians tend to steer patients toward more aggressive surgical treatment of breast cancer despite medical recommendations favoring breast-conserving lumpectomy. But the newly published study suggests the opposite is true.

"We found that surgeons were mainly recommending the less invasive treatment and that patients tended to have a good deal of involvement in the decision process," researcher Steven J. Katz, MD, MPH, of the University of Michigan tells WebMD.

"We also found that greater patient involvement was associated with greater use of mastectomy."

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One in Three Women Get Mastectomy

Roughly a third of women facing breast cancer surgery have their entire breast removed (mastectomy) instead of breast-sparing lumpectomy plus radiation.

In an effort to find out why, Katz and colleagues surveyed 1,844 women in Los Angeles and Detroit with a recent breast cancer diagnosis. The findings are reported in the Aug. 20 issue of the Journal of Clinical Oncology.

Overall, about 30 percent of the women had mastectomy as initial treatment. A total of 41 percent reported that they made the surgical decision, and 37 percent said they made it with their surgeon. Only one out of five reported that their surgeon made the treatment decision, with or without their input.

Among white women, 27 percent of those who made their own decision about surgery ended up having a mastectomy, compared to just 5 percent of women who said their surgeon made the decision, and 17 percent of women who said the decision was a shared one.

African-American women were more likely to receive a mastectomy than patients of other ethnic groups when the decision was perceived to have been made by the surgeon.

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Cancer Fears May Drive Decision

Women who chose mastectomy were more likely to be worried about cancer recurrence and they expressed more fears and concerns about radiation treatment, which is done after a lumpectomy.

During a mastectomy the entire breast is removed. In breast-conserving lumpectomy surgery only the tumor and some surrounding tissue are removed; this is followed by radiation therapy.

There is a higher risk of breast cancer recurrence among women who opt for breast-sparing surgery. But these recurrences are usually caught early, and the overall survival rate with lumpectomy plus radiation is comparable to mastectomy.

Katz says about 10 to 15 percent of breast cancer patients are not good candidates for breast-sparing surgery because their cancer is diffused throughout the breast or for some other reason.

He adds that other patients who could choose lumpectomy but opt for mastectomy instead should not be made to feel that the decision is wrong.

"These are the women who are saying they want a mastectomy because it will allow them to leave their disease behind quicker," he says. "The message to doctors, surgeons, and policy makers is that this is a reasonable choice."

You Survived Breast Cancer: Now What?

Take Your Time

In an editorial published with the study, Medical College of Wisconsin professor of medicine Ann Nattinger, MD, MPH, noted that many women may not buy the notion that lumpectomy plus radiation is as effective as mastectomy.

"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," she wrote.

She tells WebMD that women may also have a hard time believing that a bigger risk of cancer recurrence doesn't translate into poorer survival.

Both Katz and Nattinger stressed the importance of taking time to assess medical options when making decisions about breast cancer treatment. Surgery is often performed as soon as possible after diagnosis, but this is not usually medically necessary, Katz says.

"Biologically, breast cancer treatment is not a medical emergency," he says. "Treatment should be initiated promptly, but weeks don't usually matter. What does matter is getting to the most experienced surgeon and getting the best information you can. This isn't always possible if you are rushed into treatment."

Nattinger agrees but says patients aren't often given this message.

"Women need to know that they usually have the luxury of taking a few weeks or even a month to carefully access their options," she says. "They should feel free to get a second opinion and spend some time making this decision."

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By Salynn Boyles, reviewed by Brunilda Nazario, MD

SOURCES: Katz, S. Journal of Clinical Oncology, Aug. 20, 2005; vol 23: online edition. Steven J. Katz, MD, MPH, associate professor of general medicine, University of Michigan Medical School; professor of health management, University of Michigan School of Public Health. Ann Nattinger, MD, MPH, professor of medicine; and chief, general internal medicine, Medical College of Wisconsin. The Susan G. Komen Breast Cancer Foundation.