Too Many Mastectomies? Maybe Not

Oct. 13, 2009 -- Are surgeons too quick to perform mastectomy instead of breast-conserving surgery? No, a new study suggests.

When it's medically appropriate, breast-conserving surgery ( lumpectomy) cures as many cancers as removal of the entire breast (mastectomy). Yet there's a sense that surgeons are too quick to perform mastectomies.

Indeed, some cancer centers point to their low mastectomy rates as a measure of quality care. And women with breast cancer have been urged to get a second opinion if their first surgeon recommends mastectomy over lumpectomy.

What's going on with these doctors? To find out, Monica Morrow, MD, of Memorial Sloan-Kettering Cancer Center, and colleagues asked nearly 2,000 breast cancer survivors about their experience.

The findings are something of a surprise. For women with early (intraductal, stage I and stage II) breast cancer:

• Doctors recommended lumpectomy more than 75% of the time.
• 8.8% of women who underwent mastectomy did so based on their own preference.
• Second opinions reversed initial recommendations only 12% of the time, even though 33% of women advised to get mastectomies sought a second opinion.
• When a first opinion advised mastectomy and a second opinion advised lumpectomy, only half of women followed the second doctor's advice.
• 38% of women who underwent lumpectomy needed further surgery. Twelve percent of women who underwent lumpectomy had to have a mastectomy.

"We concluded that most surgeons appropriately recommended options for breast cancer treatment, with no differences in terms of patient race or ethnicity," Morrow said at a news conference. "Patients themselves account for a large proportion of initial mastectomies."

So are there too many mastectomies? If there are, Morrow said, it's because of two factors.

The first is that when a patient has a tumor too large for lumpectomy, fewer than half of doctors consider trying to shrink the tumor with chemotherapy before surgery.

The second reason is that surgeons have never agreed on exactly how much of the breast tissue surrounding a cancer -- the tumor "margin" -- must be removed. The lack of such a standard contributes to uneven mastectomy rates.

Morrow and colleagues report their findings in the Oct. 14 issue of the Journal of the American Medical Association.