Higher proportions of women eligible for breast conservation surgery (BCS) are undergoing mastectomy, breast reconstruction and bilateral mastectomy (surgical removal of both breasts), with the steepest increases seen in women with lymph node-negative and in situ (contained) disease, according to a report published online by JAMA Surgery.1
BCS has been a standard of excellence in breast cancer care and its use for management of early-stage breast cancer had increased steadily since the 1990s. However there is evidence that that trend may be reversing.
Kristy L. Kummerow, M.D., of Vanderbilt University Medical Center, Nashville, Tenn., and her co-authors examined trends nationwide in mastectomy patients eligible for BCS. The authors used the National Cancer Data Base to study more than 1.2 million women treated at centers accredited by the American Cancer Society and the American College of Surgeons Commission on Cancer from January 1998 through December 2011.
The study showed that 35.5 percent of the study group underwent mastectomy. The proportion of BCS-eligible women with early-stage breast cancer who underwent mastectomy increased from 34.3 percent in 1998 to 37.8 percent in 2011. Younger women were more likely to undergo mastectomy regardless of tumor size, while in older women mastectomy was associated with having a tumor greater than 2 centimeters. In women undergoing mastectomy, rates of breast reconstruction increased from 11.6 percent in 1998 to 36.4 percent in 2011. Rates of bilateral mastectomy for unilateral (in one breast) disease increased from 1.9 percent in 1998 to 11.2 percent in 2011.
The authors note that the observed increase in mastectomy rates was largely due to a rise in bilateral mastectomy for unilateral, early-stage disease from 5.4 percent of mastectomies in 1998 to 29.7percent in 2011, with an increase at the same time in reconstructive procedures in this group from 36.9 percent to 57.2 percent.
“Our finding of still-increasing rates of mastectomy, breast reconstruction and bilateral mastectomy in women with early-stage breast cancer using 14 years of data from the NCDB has implications for physician and patient decision making as well as quality measurement. Further research is needed to understand patient, provider, policy and social factors associated with these trends,” the authors conclude.
In a related commentary 2, Bonnie Sun, M.D., and Michael E. Zenilman, M.D., of Johns Hopkins Medicine, Baltimore, write: “Existing guidelines are in place to ensure that patients are offered the appropriate options. The article by Kummerow et al should at least serve as a wake-up call that as we fulfill that responsibility, and use every modality of care to give patients the best quality of life and survival advantage, the guidelines may need to change again.
1. JAMA Surgery. Published online November 19, 2014. doi:10.1001/jamasurg.2014.2895.
2. JAMA Surgery. Published online November 19, 2014. doi:10.1001/jamasurg.2014.2902.