Many speculate that breast cancer patients are treated with mastectomy without the proper indications, contradicting long-standing recommendations for breast-conserving surgery (BCS) as less-invasive initial treatment. Patients choose treatment methods, however, based on a variety of factors, not the least of which is personal preference.
A group of researchers published a study in JAMA in October 2009, surveying 1,984 patients ages 20 to 79 years with stage I, II or III breast cancer, living in Los Angeles and Detroit. They partnered with the states’ cancer registries, funded by the National Cancer Institute, to evaluate treatment patterns and reasons behind these choices.
One of the authors, Steven J. Katz, MD, MPH, director of health services research in the University of Michigan Comprehensive Cancer Center, and professor in the departments of health management and policy in the School of Public Health, and of internal medicine in the division of general medicine, said that he and his colleagues found the concern about overuse of mastectomy has been misplaced.
The main conclusion they drew was that surgeons recommend, and attempt, BCS in a majority of patients. Of the patients included in the study, 75.4% had initial BCS, and 22.2% underwent initial mastectomy. An additional 8.8% received mastectomy following unsuccessful attempts at BCS.
Perhaps the most significant outcome of this research is the finding that, regardless of womens’ decisions, surgeons’ recommendations appear to be appropriate, Katz said.
Some patients indicated personal preference as the reason for the more aggressive approach; when the surgeon did not recommend one procedure over another or recommended BCS, 8.8% still opted for mastectomy.
“We’ve argued [that it is] under reasonable circumstances that they choose mastectomy,” Katz said. “Many women have a sense of putting more closure on the whole process by having the breast removed.”
One-third of women whose surgeons recommended mastectomy had contraindications to BCS, often because the cancer is too diffuse in the breast for complete removal or for proper cosmesis. Of the patients who received BCS as initial treatment, 62.1% of patients required no additional surgery, while those who experienced treatment failure moved on to either re-excision lumpectomy (26%) or mastectomy (11.9%).
Katz told O&P Business News that these findings provide reassurance that surgeons are correct in their treatments.
“I think there’s good news here that we don’t find overly aggressive surgeons and we do find patients reporting that they are adequately involved in decision-making,” he said.
The results also lay the groundwork for improvement in key areas. Researchers have found in previous studies, for example, that 50% of women could not correctly answer whether lumpectomy and radiation versus mastectomy confer the same survival benefit. The answer is that they do. But perhaps just as important as that benefit is the fact that patients recognize the outcomes of the procedures they undergo. — Stephanie Z. Pavlou
Whether initial breast conserving surgery and or initial mastectomy is recommended and chosen during breast cancer treatment is an individual decision based on personal needs, diagnosis and physician recommendations. However, while breast conserving surgery makes every attempt to preserve as much of the healthy breast tissue as possible, it is still an amputation. The procedure removes the diseased portion of the breast. And, in most cases, either type of surgery creates the need for a post mastectomy fitting.
This recent survey is supported by daily observations during fittings. Surgical types within the past decade have changed. And, with the increase of the use of breast conserving surgical techniques, several products have been developed that allow a certified post mastectomy fitter to appropriately replace the amputated breast tissue.
From a certified fitter’s perspective, a breast conserving surgery may still provide unique challenges for even the most experienced fitter. The key to a successful post mastectomy fitting is an understanding and recognition of the various types of surgical procedures and how the available post mastectomy products can best service a woman’s or man’s post surgical needs.
— Rhonda F. Turner, PhD, CFm, BOCPO
President, American Association of Breast Care Professionals
I think the O&P community should realize that the mastectomy industry is changing. As a fitter we are so used to just seeing mastectomy patients, we need to get on board and learn the techniques and have the tools available to fit all of these BCS surgeries. The new protocols are to have more involved patients; this should also transfer into the O&P community. Ask the woman what she is expecting and wants … This research reveals that surgeons are performing more and more BCS, so we should be prepared. The extent of the surgery varies just as every woman’s shape and size varies. With that being said there are a variety of products available to assist these patients in feeling whole again and every fitter should become knowledgeable with these products to offer a well-rounded environment just as the physicians are doing. There is not just one alternative.
— Kimberly A. Hertz, BOC O, CMF, cFOM
practice manager, Hanger Orthotics & Prosthetics
For more information:
- Morrow M, Jagsi R, Alderman AK, et al. Surgeon recommendations and receipt of mastectomy for treatment of breast cancer. JAMA. 2009; 302(14):1551-1556.