Many choose more aggressive breast cancer surgery despite breast-sparing option

U-M-led study finds fear of recurrence and radiation treatment drives women – not their surgeons – to opt for mastectomy

When a woman is diagnosed with breast cancer, her top priority is to get the cancer out and reduce the odds that it will ever return. But for some women just getting the cancer out doesn’t feel like enough.

According to a new study led by researchers at the University of Michigan Comprehensive Cancer Center, when women, not their surgeons, have control over the type of surgery they receive, they are more likely to choose a more aggressive surgery that removes the entire breast, even though survival rates are the same for surgery that removes only the tumor.

With breast-conserving surgery, or lumpectomy, followed by radiation therapy, there’s a higher risk of the cancer coming back than with mastectomy, surgery that removes the whole breast. But many of these recurrences are caught early and treated effectively, so overall survival rates are the same for either type of surgery. The study authors suggest that’s a detail the average person does not understand or care about when faced with a cancer diagnosis.

Study results appear in the August 20 issues of the Journal of Clinical Oncology.

Medical practice guidelines encourage surgeons to promote whenever possible breast-conserving surgery, in which only the tumor and a small amount of normal tissue around it are removed. But more than one-third of women are still receiving mastectomy.

“The current policy assumes that the high rate of mastectomy, the more invasive treatment, is a result of two things: providers not following guidelines that favor breast-conserving therapy and patients not being involved in the treatment decision. What we find is the opposite: Surgeons are strongly promoting lumpectomy, and most women say they were involved in the decision,” says lead study author Steven Katz, M.D., M.P.H., associate professor of general medicine at the U-M Medical School and of health management and policy at the U-M School of Public Health.

Katz and his team surveyed 1,844 women in the Los Angeles and Detroit metropolitan areas who had been recently diagnosed with breast cancer. The women were asked whether they made the surgical treatment decision, their doctor made the decision or they decided together. Patients were also asked whether their doctor had discussed mastectomy, breast-conserving therapy or both.

Additional questions were aimed at how much control the patient wanted to have over the decision process and whether she had any regret about her choice.

The researchers found that 27 percent of women who said they made the surgical decision received a mastectomy, compared to only 5.3 percent of women who said their surgeon made the decision, and 16.8 percent of women who said it was a shared decision.

Women who chose mastectomy were more likely to cite a fear of recurrence or fears about radiation treatment, which is necessary after lumpectomy.

In a paper published in June in Health Services Research, the researchers report that women who said they were involved in the surgical decision-making process were less likely to have low satisfaction with their surgery or regret their decision, suggesting that how women make their surgery decision is more important than what decision they make.

Overall, the researchers found, women were satisfied with their choice, with only 11.7 percent of all women reporting low satisfaction with the type of surgery they received and 11.4 percent expressing regret over their decision.

“There are a lot of people who think that mastectomy is overtreatment and that rates are too high. However, our study results suggest that women are thinking very rationally about breast cancer surgery from their own perspectives, weighing a lot of different factors. When women are diagnosed with breast cancer, they are looking for as complete a solution as possible so they can continue on with their lives. As long as women are not pressured to have one type of surgery over the other, either choice is a viable option,” says study co-author Paula Lantz, Ph.D., associate professor of health management and policy at the U-M School of Public Health and a member of the U-M Comprehensive Cancer Center.

In an editorial accompanying the Journal of Clinical Oncology paper, Ann Nattinger, M.D., M.P.H., a professor at the Medical College of Wisconsin, writes, “Even if standardized information could be provided to patients, it seems likely that their interpretation and synthesis of this information would vary with their social context, leading to variability in the surgical choice. It also requires a high level of faith in medical science and clinical trial results to accept the idea that the possibility of local recurrence or new cancers in a conserved breast does not translate into any survival decrement.”

In addition to Katz and Lantz, study authors for both papers were Nancy Janz, Ph.D., U-M School of Public Health; Angela Fagerlin, Ph.D., U-M Medical School; Kendra Schwartz, M.D., M.S.P.H., Karmanos Cancer Institute; Lihua Liu, Ph.D., University of Southern California; and Barbara Salem, M.S.W., and Indu Lakhani, both from the U-M Medical School. Additional authors on the Journal of Clinical Oncology paper were Dennis Deapen, Dr.P.H., University of Southern California; and Monica Morrow, M.D., Fox Chase Cancer Center.