JAMA: Higher proportions of women eligible for breast conservation surgery
(BCS) are undergoing mastectomy, breast reconstruction and bilateral
mastectomy (surgical removal of both breasts), with the steepest
increases seen in women with lymph node-negative and in situ (contained)
disease, according to a report published online by JAMA Surgery.
BCS has been a standard of excellence in breast cancer care and its
use for management of early-stage breast cancer had increased steadily
since the 1990s. However there is evidence that that trend may be
reversing.
Kristy L. Kummerow, M.D., of Vanderbilt University Medical Center,
Nashville, Tenn., and her co-authors examined trends nationwide in
mastectomy patients eligible for BCS. The authors used the National
Cancer Data Base to study more than 1.2 million women treated at centers
accredited by the American Cancer Society and the American College of
Surgeons Commission on Cancer from January 1998 through December 2011.
The study showed that 35.5 percent of the study group underwent
mastectomy. The proportion of BCS-eligible women with early-stage breast
cancer who underwent mastectomy increased from 34.3 percent in 1998 to
37.8 percent in 2011. Younger women were more likely to undergo
mastectomy regardless of tumor size, while in older women mastectomy was
associated with having a tumor greater than 2 centimeters. In women
undergoing mastectomy, rates of breast reconstruction increased from
11.6 percent in 1998 to 36.4 percent in 2011. Rates of bilateral
mastectomy for unilateral (in one breast) disease increased from 1.9
percent in 1998 to 11.2 percent in 2011.
The authors note that the observed increase in mastectomy rates was
largely due to a rise in bilateral mastectomy for unilateral,
early-stage disease from 5.4 percent of mastectomies in 1998 to
29.7percent in 2011, with an increase at the same time in reconstructive
procedures in this group from 36.9 percent to 57.2 percent.
“Our finding of still-increasing rates of mastectomy, breast
reconstruction and bilateral mastectomy in women with early-stage breast
cancer using 14 years of data from the NCDB has implications for
physician and patient decision making as well as quality measurement.
Further research is needed to understand patient, provider, policy and
social factors associated with these trends,” the authors conclude.
(JAMA Surgery. Published online November 19, 2014. doi:10.1001/jamasurg.2014.2895. Available pre-embargo to the media at http://media.jamanetwork.com.)
Editor’s Note: This
material is based on work supported by the Office of Academic
Affiliations, Department of Veterans Affairs, Veterans Affairs National
Quality Scholars Program and with use of facilities at Veterans Affairs
Tennessee Valley Healthcare System, Nashville. Please see the article
for additional information, including other authors, author
contributions and affiliations, financial disclosures, funding and
support, etc.
Commentary: The Swinging Pendulum
In a related
commentary, Bonnie Sun, M.D., and Michael E. Zenilman, M.D., of Johns
Hopkins Medicine, Baltimore, write: “Existing guidelines are in place to
ensure that patients are offered the appropriate options. The article
by Kummerow et al should at least serve as a wake-up call that as we
fulfill that responsibility, and use every modality of care to give
patients the best quality of life and survival advantage, the guidelines
may need to change again.”
(JAMA Surgery. Published online November 19, 2014. doi:10.1001/jamasurg.2014.2902. Available pre-embargo to the media at http://media.jamanetwork.com.)
Editor’s Note: An
author made a conflict of interest disclosure. Please see the article
for additional information, including other authors, author
contributions and affiliations, financial disclosures, funding and
support, etc.