Framing the Mastectomy Debate-The Trends

Following publication in 1990 of the National Institutes of Health (NIH) consensus statement recommending breast-conservation surgery as the preferred surgical treatment for the majority of women with stage I and stage II breast cancer,¹ several studies have confirmed similar long-term survival rates of breast-conservation therapy compared with mastectomy 18 to 20 years postoperatively, although these studies present conflicting results as to whether breast-conservation therapy is associated with increased local relapse rates.^2-4

The results of this collective research and the NIH Consensus Statement led to a steady decline in mastectomy rates in the United States for women with stage I or stage II disease receiving surgery^5,6—from a 1988 pre-consensus statement rate of 77%, to a rate of 38% in 2004.⁶ National databases, such as Surveillance, Epidemiology, and End Results (SEER), can provide an overall picture of mastectomy procedures performed in the United States. The most recent publication of mastectomy rates from the SEER database presents data through 2008 for women with T1-2 N0-3 M0 tumors who had surgery (either breast-conservation surgery or mastectomy).⁷ Mastectomy rates steadily decreased from 2001 to 2005, from a high of 40.2% to a nadir of 35.6%. Following this, mastectomy rates began to rise from 2005 through 2008, back up to 38.4%, the highest rate since 2002.

A publication of mastectomy rates from the European Society of Breast Cancer Specialists suggests that this trend observed here is distinct from trends in mastectomy rates in Europe.⁸ In this study, mastectomy rates were analyzed from 2003 to 2010 from >15,000 women throughout Italy, Belgium, Germany, and Switzerland who underwent surgery for early-stage disease. Investigators reported that rates steadily declined from a high of 29.9% in 2005 to only 18.6% in 2010.

Is the Mastectomy Rate Among US Women Too High?

The 30th Annual Miami Breast Cancer Conference ® (MBCC) featured clinical perspectives on this question from Patrick I. Borgen, MD, chair, Department of Surgery, and director, Maimonides Breast Cancer Center, at the Maimondes Medical Center, Brooklyn, New York, and J. Michael Dixon, MD, professor of Breast Surgery at the University of Edinburgh, Scotland, and consultant breast surgeon at Western General Hospital. Below are excerpts from their presentations and from video interviews with OncLive editors conducted at MBCC.

There are both desirable and undesirable explanations for an increasing mastectomy rate. Examples of positive reasons include improvements in the radiographic identification of occult lesions and an increase in the identification of genetic risk factors for aggressive disease (eg, BRCA mutations). Undesirable reasons for increasing mastectomy rates include an unsubstantiated worry about recurrence, an overestimation of the survival benefit of mastectomy, and a general lack of knowledge about the available surgical choices. Additional reasons include improved postmastectomy reconstructive outcomes and a desire to avoid the side effects of adjuvant radiation therapy.

Another crucial factor in judging the significance of an increasing mastectomy rate is the distinction between mastectomy performed therapeutically on the primary tumor and that performed on the contralateral breast as a prophylactic measure. An analysis of records from >150,000 women with stage I-III disease from the SEER database demonstrated that contralateral prophylactic mastectomy rates have increased from 4.2% in 1998 among women already receiving therapeutic mastectomy to 11.0% in 2003.⁹

Most recently, a large, population-based study of women with early-stage breast cancer treated with lumpectomy and radiation found that women who chose the breast-conserving option had both better disease-specific and overall survival compared with their mastectomy counterparts.¹⁰

Follow the Debate On

No: Patrick I. Borgen, MD

Our goal should not be to raise the thermometer up to the highest possible level of breast conservation. The patients I see are highly educated, and we should work with our patients to make sure that with all of the data and the storm of facts that swirl around them in their lives, we wind up in a place where they are happy with their decision. I’ve heard some surgeons say that we shouldn’t mention mastectomy for their stage I breast cancer patients. I don’t really understand that. If 62% of surgeons treating breast cancer patients in an American College of Surgeons survey say, “I would choose mastectomy,” how do we not mention that to our patients? Our goal should be to match patient concerns, values, and priorities with their treatment choice. The best we can hope for is to establish a good enough relationship with our patients that we wind up getting it right as often as possible.

Yes: J. Michael Dixon, MD

Mastectomy in the right patient is the right operation. The problem is, there is huge variation within and between countries in the number of women treated by mastectomy, and there are also huge variations in the mastectomy rate even in the same unit, depending on the surgeon you see. This has to be wrong. Recently published research has shown that survival may be better with breast-conserving surgery and radiation than with mastectomy alone.10 We also have a big problem with breast screening—we’re overdiagnosing cancer that previously wouldn’t even have appeared in a woman’s life, and therefore we have to be careful that we don’t overtreat. The primary reason for patients choosing mastectomy is fear of recurrence, but recurrence rates are falling, and the majority of patients may not be well enough informed to make an evidence-based choice. The outcomes from mastectomy and breast reconstruction are not as good as we think or as good as we tell our patients.

References

1. Treatment of Early-Stage Breast Cancer. NIH Consens Statement Online 1990 Jun 18-21;8(6):1-19.
2. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347(16):1233-1241.
3. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347(16):1227-1232.
4. Poggi MM, Danforth DN, Sciuto LC, et al. Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer Institute Randomized Trial. Cancer. 2003;98(4):697-702.
5. Lazovich D, Solomon CC, Thomas DB, et al. Breast conservation therapy in the United States following the 1990 National Institutes of Health Consensus Development Conference on the treatment of patients with early stage invasive breast carcinoma. Cancer. 1999;86(4):628-637.
6. Freedman RA, He Y, Winer EP, et al. Trends in racial and age disparities in definitive local therapy of early-stage breast cancer. J Clin Oncol. 2009;27(5):713-719.
7. Mahmood U, Hanlon AL, Koshy M, et al. Increasing national mastectomy rates for the treatment of early stage breast cancer [published online ahead of print November 2012]. Ann Surg Oncol. doi:10.1245/s10434-012-2732-5.
8. Garcia-Etienne CA, Tomatis M, Heil J, et al. Mastectomy trends for early-stage breast cancer: a report from the EUSOMA multi-institutional European database. Eur J Cancer. 2012;48(13):1947-1956.
9. Tuttle TM, Habermann EB, Grund EH, et al. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol. 2007;25(33):5203-5209.
10. Hwang ES, Lichtenstein DY, Gomez, Fowble B, Clarke CA. Survival after lumpectomy and mastectomy for early stage invasive breast cancer: the effect of age and hormone receptor status. Cancer. 2013;119(7):1402-1411.