Choosing mastectomy over lumpectomy: Factors associated with surgical decisions in young women with breast cancer

Reporter: Jacob Shabason, MD
The Abramson Cancer Center of the University of Pennsylvania
Ultima Vez Modificado: 6 de junio del 2013

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Presenter: Shoshana M. Rosenberg, MD
Presenter's Affiliation: Harvard School of Public Health, Boston, MA

Background

  • Many women with early stage breast cancer have the choice of undergoing a mastectomy or breast conserving surgery (BCS), consisting of lumpectomy and radiation.
  • Young women with breast cancer (<40years of age) are more likely to undergo mastectomy than BCS and this trend appears to be rising.
  • Young women have unique medical and psychosocial concerns and little is known about the potential reasons for this medical decision making trend.
  • Identifying factors associated with surgical decisions in the this young population can help inform their decision-making process and allow physicians to better guide the conversation of treatment options.
  • As such, the authors performed a prospective multi-center cohort study of young women with stage I-III breast cancer to better elucidate the key factors that influence patient decision making in this disease.

Materials and Methods

  • This is a prospective multi-center cohort study of women with breast cancer age 40 years or younger.
  • Nine academic and community sites in Eastern Massachusetts and Denver Colorado were included in the study.
  • The study ultimately evaluated 277 women with stage I-III breast cancer who reported having a choice between mastectomy and BCS
  • Logistic regression analysis was used to identify predictors of choosing mastectomy vs. BCS.
  • Independent variables with a p-value ? 0.15 in bivariate analysis were included in the final multivariable model.

Results

  • Median age at diagnosis was 37 years (range: 17-40).
  • The majority of women were married (75%), had stage I or II disease (90%), and estrogen receptor (ER) positive tumors (65%).
  • 14% of the patients were carriers of either a BRCA 1 or 2 mutation.
  • 28% of women screened positive for anxiety and 7% screened positive for depression.
  • 172/277 women (62%) had either a single or bilateral mastectomy as their definitive surgery treatment.
  • 46% of patients reported that they were the ones making the treatment decision, 45% reported that it was a joint decision between the physician and patient, and 9% reported that the decision was mainly made by the physician.
  • Only 3% of patients desired more of a role in the decision making process and 1% desired less involvement.
  • In the multivariable analysis, having a BRCA 1/2 mutation, nodal involvement, HER2-positivity, tumor grade, lower BMI, having 2 or more children, anxiety, and decisional involvement by the patient were all associated with mastectomy (see table below).
  • Age, race, marital status, tumor size, having a first degree relative with breast or ovarian cancer, ER status, fear of recurrence, and depression were not significantly associated with having a mastectomy.

Significant predictors of mastectomy versus BCS.

 

OR (95% Cl)

Mutation positive

10.17 (3.25-31.79)

Any nodal involvement

1.88 (1.01-3.52)

HER2 positive

2.41 (1.20-4.82)

Grade (ref=1)

 

2

3.02 (1.03-8.89)

3

1.78 (0.62-5.08)

Number of children (ref=0)

 

1

1.44 (0.62-3.34)

?2

2.20 (1.06-4.54)

BMI

0.92 (0.88-0.97)

Anxiety

2.19 (1.12-4.29)

Decisional involvement (ref=shared)

 

Mainly patient’s decision

2.07 (1.14-3.76)

Mainly doctor’s decision

0.86 (0.31-2.38)

Author's Conclusions

  • Despite being candidates for BCS, many young women choose to have a mastectomy as the treatment of their breast cancer.
  • Mutation status and high-risk features of distant disease (such as nodal involvement or HER-2 status) are associated with higher incidence of mastectomy.
  • Modifiable factors associated with mastectomy include patient driven decision-making and patient anxiety.
  • Better supportive care and management of anxiety surrounding the diagnosis of breast cancer and more effective communication about treatment options can help address these modifiable factors.
  • Limitations of this study include:
    • Potential MRI studies that may confound the decision process.
    • The study mainly consisted of a homogeneous population of primarily white patients with a relatively high socioeconomic status and therefore may not be applicable to a more diverse population.

Clinical Implications

  • It is important to understand the increasing trend of younger women choosing mastectomy over BCS for the treatment of breast cancer.
  • Although patients may choose mastectomy because it seems safer or more definitive than BCS, they should be fully informed about risks associate with mastectomy, a major surgery compared to lumpectomy.
  • Certain modifiable factors appear to exist, including patient driven decision-making and patient anxiety.
  • Addressing these factors with targeted measures to reduce patient anxiety and with targeted decision aids could help patients make more informed decisions about their treatment.
  • Further important areas of research would be to understand the increasing trend for bilateral mastectomy in young patients and again attempt to identify modifiable factors associated with this decision.
  • The ultimate goal of this research is to ensure that patients are making informed and educated decisions about treatment options that are consistent with their values and goals.

Patient Summary: What Does This Mean For Me?

Many women with early stage breast cancer have the choice of undergoing a mastectomy or breast conserving surgery (BCS), consisting of lumpectomy and radiation. Women under 40 are more likely to choose mastectomy, despite many studies showing equivalent outcomes between the 2 procedures. This study evaluated a group of 277 women under 40 who had the choice of lumpectomy with radiation or mastectomy. Sixty two percent chose mastectomy. While you might assume that factors such as tumor size, having a family history or fear of recurrence would drive this decision, these factors were not found to influence the decision. Factors that were found to influence decision include: BRCA1/2 mutation, HER2 positive, lymph node involvement and anxiety, among others. This study will assist physicians in better counseling women to make educated treatment decisions.

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