U.S. Women More Likely to Have Mastectomy
Doctors May Be Biased Despite Equal Lumpectomy Effectiveness
Dec. 13, 2002 (San Antonio, Texas) -- American women with breast cancer may want to seek a second opinion before having a mastectomy, suggests a new study. Researchers found that all other things being equal, U.S. doctors are much more likely to perform a mastectomy than British physicians.
The findings come at a time when lumpectomy, in which the tumor itself and surrounding breast tissue is removed, has clearly been shown to be as effective at saving lives as the more disfiguring mastectomy (complete breast removal).
"When a doctor recommends mastectomy, you have to ask, 'Why?'" says study researcher Gershon Locker, MD, professor of medicine at Northwestern University. "Lumpectomy is a very reasonable alternative for many women."
There are some women for whom mastectomy is a better choice, such as if her breast tumor is very large, he says. "But the patient should participate in the decision-making process."
Locker reported the study at the 25th Annual San Antonio Breast Cancer Symposium.
He looked back at more than 9,000 women enrolled in a large international study. All the women had undergone either a mastectomy or lumpectomy. Both groups of women were deemed to be equal as far as breast-cancer stage.
In the U.S., 51% of women had a mastectomy; in the U.K., 42% had this same surgery. "This means American doctors are [statistically] 21% more likely to perform a mastectomy than British doctors," Locker says.
To find out why, Locker performed a sophisticated statistical analysis that took into account factors such as large tumor size that might make mastectomy a better choice than breast conserving surgery.
Ironically, when these factors were taken into account, American women were even more likely -- 43% more likely -- to have a mastectomy than their British counterparts, Locker says.
"For whatever reason, there is either a bias on the part of the doctor or on the part of the patient to do more mastectomies in the U.S.," he says.
Physician bias is "the factor we really have to be concerned about," says Larry Norton, MD, head of the Division of Solid Tumor Oncology at Memorial Sloan-Kettering Cancer Center in New York.
Impressed with the thorough analysis, Norton asks, "Are doctors doing a good enough job of explaining that for the ideal candidate, lumpectomy has equal survival rates to mastectomy? The data suggest that maybe not."
Norton says he sits down with each woman and talks about the pluses and minuses of each procedure. In some cases, mastectomy plus breast reconstruction by a skilled plastic surgeon can actually be less disfiguring than lumpectomy, he says. But there's a trade-off: After mastectomy, sensation is lost.
"You don't want to be glib about this," he says. "One of things my patients miss most after mastectomy is cuddling -- with their baby, their husband, their partner."
There are some signs the tide may be changing in the U.S., Norton and Locker agree.
The American Society of Clinical Oncology has an active education campaign to get the word out about the benefits of breast-conserving surgery, Norton says. And the National Cancer Institute database that tracks national cancer statistics shows that lumpectomy rates are creeping up in the U.S., Locker notes.
Nevertheless, he adds, the argument can be made that we should be [switching to breast-conserving surgery] faster."