According to the American Cancer Society, 209,060 Americans were diagnosed with breast cancer in 2010, and 40,230 died from the disease. When patients are diagnosed with breast cancer, they often feel well enough to continue living their life as they were previously. The treatment options for breast cancer, however, have potentially significant effects on quality of life and life expectancy.
Researchers from the Cancer Surveillance and Outcomes Research Team (CanSORT), a multidisciplinary collaboration among five centers across the country, surveyed 1,780 breast cancer patients and their surgeons in the Los Angeles and Detroit metropolitan areas about treatment choices. The focus of this research was to determine if where patients go for care can impact key surgical choices that are related to local therapy, specifically mastectomy (with or without reconstruction) versus lumpectomy. Results of the study were published in the October 2010 issue of Medical Care.
Consistent, Standardized Care
Previous research has shown that surgical treatment of breast cancer depends largely on surgeon recommendations and patient preferences. A major finding in the study published in Medical Care was that the use of mastectomy over breastconserving lumpectomy varied little by surgeon and was based on patients’ clinical picture and characteristics rather than on practice characteristics (Table). “Primarily, women who were not eligible for lumpectomy or who preferred mastectomy received the more aggressive surgery,” says Steven J. Katz, MD, MPH, who was the study’s lead investigator. “This supports previous research by the CanSORT team, showing that surgeons generally are consistent with their approach when discussing treatment options, contraindications, and recommendations.”
Where a woman goes for breast cancer treatment can vary widely, ranging from small private practices to large hospital settings. “The choice on where to receive breast cancer treatment does not seem to influence the surgical treatments women receive,” says Dr. Katz. “It can, however, impact the type of care a woman receives when it comes to breast reconstruction.”
Assessing Breast Reconstruction
Studies have shown that breast reconstruction following mastectomy is underutilized despite proven benefits. “Reconstruction is often left off of the table in the initial discussion regarding treatment of breast cancer,” Dr. Katz says. “When women are considering the palette of treatments, they can become fatigued by the number of options available to them. The reconstruction issue is complicated, both in terms of the options available and the complexity of the surgical procedure.”
In the study by Dr. Katz and colleagues, the research team explored whether patients with similar characteristics have different rates of breast reconstruction, not based on their characteristics but, rather, on the kind of surgeon they go to. About one-third of women who underwent mastectomy later had breast reconstruction. “There are many reasons why a woman might not have reconstruction,” Dr. Katz notes. “Our study found that 31% of the variation could be attributed solely to how often the patient’s surgeon talked to a plastic surgeon prior to initial surgery [Figure]. The more multidisciplinary the practice was–especially with regard to having a plastic surgeon at the decision table—the more likely a woman was to get breast reconstruction.”
Breast reconstruction is a complex treatment issue that requires plenty of discussion, adds Dr. Katz. “Discussions can be quite different from each other depending on where women go to get initial treatment. Patients with similar characteristics or preferences may get a different story from different surgeons. This depends largely on the involvement of a plastic surgeon on the decision team. Plastic surgeons are the ones with the expertise to explain the options and act as advocates in instances where decisions are more challenging.”
Fortunately, more research is continuing to shed light on the relationship between experience and decision making in breast cancer treatment. “Breast cancer may be a special model for success,” says Dr. Katz, “even though we have a long way to go in eliminating ethnic disparities in treatment awareness and receipt. The good news is we’re making progress in determining the underlying causes of such issues in breast cancer care. Women with this disease have many deeply intimate and important decisions to make about their treatment. The key is to make decisions about reconstruction with the right information and in consultation with plastic surgeons at the very beginning in order to appropriately plan treatments to optimize outcomes for patients.”
Katz SJ, Hawley ST, Abrahamse P, et al. Does it matter where you go for breast surgery? Attending surgeon’s influence on variation in receipt of mastectomy for breast cancer Med Care. 2010;48:892-899. Available at: http://journals.lww.com/lww-medicalcare/pages/articleviewer.aspx?year=2010&issue=10000&article=00006&type=abstract
Marín-Gutzke M, Sánchez-Olaso A. Reconstructive surgery in young women with breast cancer.Breast Cancer Res Treat. 2010;123(Supp):67-74.
Christante D, Pommier SJ, Diggs BS, et al. Using complications associated with postmastectomy radiation and immediate breast reconstruction to improve surgical decision making. Arch Surg. 2010;145:873-878.
Katz SJ, Hawley ST, Morrow M, et al. Coordinating cancer care: patient and practice management processes among surgeons who treat breast cancer. Med Care. 2010;48:45-51.