Uneven Access to Breast-Conserving Surgery
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 with radiation and other recommended treatments to prevent recurrence.
A study just released by Solucient Leadership Institute (formerly the HCIA-Sachs Institute) found that breast cancer patients being treated at top medical centers are more likely to undergo breast-conserving surgery such as lumpectomy, compared to similar patients at other hospitals.
The study, entitled "100 Top Hospitals' Clinical Research Program: Management of Breast Cancer," examined how top-performing hospitals compare with other hospitals in three areas: use of breast-conserving surgery; use of radiation therapy following breast-conserving surgery; and the performance of immediate breast reconstruction following mastectomy.
"Overall, the rates we found of breast-conserving surgery are lower than we expected," said the study's research consultant, Kathryn Rexrode, M.D., an associate physician in women's health at Brigham and Women's Hospital, Boston, and an instructor at Harvard Medical School. "The results suggest that we need to be sure women are given treatment choices they can consider in the context of their unique personal and clinical factors."
The study also found that:
"The good news is that top-performing hospitals are clearly leading the industry in providing more progressive initial treatment and follow-up of breast cancer," said Jean Chenoweth, the institute's executive director.
"However, an additional area of concern identified in this study is that women on Medicaid are significantly less likely to have immediate reconstructive surgery than privately insured women," Chenoweth added. "This underscores the fact that women with breast cancer may not be offered the same options, and that some treatment may not reflect best practice and follow-up care."
Similarly, a disturbing report published in 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.
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.)
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.
SOURCES:
"100 Top Hospitals' Clinical Research Program: Management of Breast Cancer," The Solucient Leadership Institute (http://www.TopHospitals.com)
Cancer, December 1, 2000; 89:2202-2213
Annual meeting of the Radiological Society of North America, November 28, 2000, Chicago, IL
The Lancet, September 30, 2000; 1124-1125, 1148-1153
American Journal of Public Health, February 2000; 90:281-284
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