When Breast-Conserving Surgery Isn't Offered
Incredibly, thousands of women facing breast cancer surgery each year are not offered the option of breast-conserving surgery (lumpectomy) instead of mastectomy-even when both procedures would result in equal treatment outcomes.
And even for those who are given the breast-conserving surgical option, far too often they do not receive adequate follow-up care.
A disturbing report published in the December 1st issue of the journal Cancer found that breast cancer patients who do not have health insurance-or are insured under Medicaid-are less likely to be given the option of breast-conserving surgery instead of just mastectomy. Dr. Richard Roetzheim of the University of South Florida and colleagues evaluated 11,113 records from the Florida state tumor registry in 1994. They found that patients without any health insurance were less likely to receive breast-conserving surgery compared with those who had private insurance.
Among Medicare recipients, the researchers found that those belonging to a health maintenance organization were more likely to receive breast-conserving surgery, but less likely to receive adjuvant radiation therapy after the surgery.
According to a presentation at the recent annual meeting of the Radiological Society of North America, a woman's choice of breast surgeon could be the most important factor in whether a small, early-stage breast cancer tumor is treated by lumpectomy or mastectomy.
Dr. Lillian Rinker of Methodist Healthcare-Central Hospital in Memphis, Tennessee and colleagues evaluated the treatment records for 142 women at her hospital with early-stage breast cancer, all of whom were eligible for lumpectomy with adjuvant (additional) radiation therapy. However, only 47 percent of the women had breast-conserving surgery, while the balance underwent mastectomies.
Surprisingly, the researchers concluded that the discrepancy in treatment was due primarily to the choice of surgeon. For example, one surgeon at the hospital treated 81 percent of his patients with lumpectomy while another treated only 9 percent of his patients with this breast-conserving option. They suggested that doctors often perform procedures that they feel more comfortable with, rather than basing their treatment decisions on the actual medical evidence at hand.
They further pointed out that surgeons who attended regular interdepartmental conferences to discuss patient cases were more likely to perform lumpectomies than surgeons who did not participate in such collaborative discussions. In effect, peer pressure and input from colleagues can play a major behind-the-scenes role in opening up treatment opportunities for patients, they said.
Rinker's team also found major differences in the actual number of breast surgeries undertaken by individual surgeons. While 33 surgeons provided treatment for breast cancer patients at the hospital, just 5 of them performed well over half of the procedures (60 percent).
The lesson: Do you homework before undergoing surgery-or any other treatment-for your breast cancer. Choose a facility in which interdepartmental and collaborative reviews are conducted to discuss patient cases. And select a surgeon who performs a large number of the type of surgery you will require.
Also, if you are only offered a mastectomy, ask why. There may be strong medical reasons for excluding breast-conserving surgery, but it never hurts to ask. And don't hesitate to get a second opinion just to make sure.
Dr. Ann Butler Nattinger of the Medical College of Wisconsin and colleagues, writing in the British medical journal The Lancet, reported that thousands of American women who underwent breast-conserving surgery for early-stage breast cancer did not receive appropriate follow-up care, including axillary node dissection and postoperative radiation therapy.
According to the findings of Nattinger's team, the proportion of women who received these additional recommended procedures dropped from an average of 88 percent during the period 1983-1989 down to 78 percent by the end of 1995. They based their conclusion on an analysis of 144,759 records from the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute.
Thus, even if more women are having lumpectomies, a declining percentage of them are having the "total package" of recommended procedures as specified in National Institutes of Health guidelines. (It should be noted that omitting radiation therapy in carefully designed clinical trials is an appropriate option.)
Another study, by the U.S. Agency for Healthcare Research Quality, highlighted a bias in the range of treatment options offered to older patients. Dr. Jeanne Mandelblatt of the Georgetown University School of Medicine and colleagues studied 718 women aged 67 or older who were being treated for newly diagnosed localized breast cancer. They found that the oldest women, those aged 80 and older, were significantly less likely than women 67 to 79 years old to be referred to a radiation oncologist. They noted that women sent to a radiation oncologist were 20 times more likely to have breast-conservation therapy rather than other treatments.
Of those who did receive breast-conservation therapy, very elderly women were 70 percent less likely to receive chemotherapy than younger patients, and they were 3.4 times less likely to receive radiation therapy. The researchers suggested that part of the reason for this discrepancy in treatment was that "there remains substantial scientific uncertainty as to the most appropriate treatment for older women."
Cancer, December 1, 2000; 89:2202-2213
Annual meeting of the Radiological Society of North America, November 28, 2000, Chicago, IL
128th Annual Meeting of the American Public Health Association, Nov. 15, 2000
Cancer, October 15, 2000; 89:1739-1747
The Lancet, September 30, 2000; 1124-1125, 1148-1153
Cancer, August 1, 2000; 89:561-573
Journal of the National Cancer Institute, April 5, 2000; 92:550-556
"Health, United States: 2000," National Center for Health Statistics, U.S. Centers for Disease Control and Prevention
Cancer, May 1, 2000; 88:2054-2060
Cancer, January 15, 2000; 88:369-374
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