More Women Choosing Mastectomy For Early Breast Cancer Management

MedicalResearch.com Interview with:
Dr. Kristy Lynn Kummerow MD

Division of Surgical Oncology and Endocrine Surgery
Vanderbilt University Medical Center
Tennessee Valley Healthcare System, Veterans Affairs Medical Center
Geriatric Research, Education, and Clinical Center
Nashville, Tenn

Medical Research: What is the background for this study? What are the main findings?

Dr. Kummerow: This study looked at how we are currently treating early stage breast cancer in the US – early stage breast cancer includes small cancers with limited or no lymph node involvement and no spread to other body site – it was prompted by something we observed an our own cancer center, which is that more and more women seem to be undergoing more extensive operations than are necessary to treat their cancer.  It is helpful to understand the historical context of how we treat early breast cancer.  Prior to the 1980s, the standard of care for any breast cancer was a very extensive procedure, which involved removal of the entire breast, as well as underlying and overlying tissues and multiple levels of lymph nodes drained by that area.  Informative clinical trials were completed in the 1980s demonstrated that these extensive procedures were unnecessary, and that equivalent survival could be achieved with a much more minimal operation, by removing only the tumor, with a margin of normal breast tissue around it, and performing radiation therapy to the area; this technique is now known as breast conservation surgery, also known as lumpectomy with radiation.  In the 1990s, breast conservation was established by the national institutes of health and was embraced as a standard of care for early stage breast cancer; performance of breast conservation surgery also became a quality metric – accredited breast centers in the US are expected to perform breast conservation surgery in the majority of women who they treat for breast cancer.  However, what our research team observed at our institution didn’t fit – over time it appears more aggressive surgical approaches are being used for more women.  This has been found in other institutions as well, and is supported by smaller national studies.  We wanted to understand how surgical management of early breast cancer is changing over time at a national level using the largest data set of cancer patients in the United States.


Medical Research: What should clinicians and patients take away from your report?

Dr. Kummerow: The study findings have implications for clinical care and measurement of quality of care.  We hope our data will increase awareness of current trends and prompt efforts to better understand what is driving decisions for mastectomy in early breast cancer.  At the end of the day, the operation that a women undergoes for early breast cancer should be determined by that individual woman and her provider; that said, the onus is on us as healthcare providers to take the time to make sure patients are truly informed of the risks and benefits of available treatment options and able to make decisions that incorporate good information with an understanding of outcomes that matter most to them.

Implications for quality measurement are also important.  Considering the variation in standards internationally, as well as the upward trend in our country, we can anticipate this issue is not going away.  The fact that trends in mastectomy for early breast cancer are steepest in women with pre-cancerous lesions compared to true invasive cancers suggests an increasing influence of factors unrelated to disease burden in performance of mastectomy, particularly in younger women.  Moving forward, it is essential that our quality metrics are aligned with appropriate indications for mastectomy and bilateral mastectomy for early, one-sided tumors so that we send the right message to patients and so that providers are incentivized to provide appropriate care.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Kummerow: More research is needed to understand factors that influence patients and providers with respect to surgical treatment of early breast cancer.  We need to better understand the drivers of these decisions in order to develop tools for high quality decision making.

Citation:

Kummerow KL, Du L, Penson DF, Shyr Y, Hooks MA. Nationwide Trends in Mastectomy for Early-Stage Breast Cancer. JAMA Surg. Published online November 19, 2014. doi:10.1001/jamasurg.2014.2895.