Double mastectomy rates are up, but survival is not improved

Among women in California with early stage breast cancer, the percentage of those who underwent a double mastectomy increased substantially between 1998 and 2011 even though the procedure was not associated with a lower risk of death than breast-conserving surgery plus radiation, according to a new study. The authors did find that surgery for the removal of one breast was associated with a higher risk of death than the other options examined in the study.

Randomized trials have demonstrated similar survival for patients with early stage breast cancer treated with breast-conserving surgery and radiation or with mastectomy. However, previous data show increasing use of mastectomy, and particularly bilateral mastectomy among US patients with breast cancer. Evidence for a survival benefit with this procedure appears limited to rare patient subgroups.

"Because bilateral mastectomy is an elective procedure for unilateral breast cancer [in one breast] and may have detrimental effects in terms of complications and associated costs as well as body image and sexual function, a better understanding of its use and outcomes is crucial to improving cancer care," according to background information in the article. The article was published in JAMA (2014; doi:10.1001/jama.2014.10707).

Allison W. Kurian, MD, MSc, of the Stanford University School of Medicine, Stanford, California, and colleagues used data from the California Cancer Registry from 1998 through 2011 to compare the use of and rate of death after bilateral mastectomy, breast-conserving therapy with radiation, and unilateral mastectomy.

The analyses included 189,734 patients. The researchers found that the rate of bilateral mastectomy increased from 2.0% in 1998 to 12.3% in 2011, an annual increase of 14.3%. The increase in bilateral mastectomy rate was greatest among women younger than 40 years: the rate increased from 3.6% in 1998 to 33.0% in 2011, increasing by 17.6% annually. Use of unilateral mastectomy declined in all age groups.

Bilateral mastectomy was more often used by non-Hispanic white women, those with private insurance, and those who received care at a National Cancer Institute-designated cancer center; in contrast, unilateral mastectomy was more often used by racial/ethnic minorities and those with public/Medicaid insurance.

Compared with breast-conserving surgery with radiation, bilateral mastectomy was not associated with a mortality difference, whereas unilateral mastectomy was associated with higher mortality.

"In a time of increasing concern about overtreatment, the risk-benefit ratio of bilateral mastectomy warrants careful consideration and raises the larger question of how physicians and society should respond to a patient's preference for a morbid, costly intervention of dubious effectiveness," the authors wrote.

"We can now say that the average breast cancer patient who has bilateral mastectomy will have no better survival than the average patient who has lumpectomy plus radiation," said Allison Kurian, MD, an assistant professor of medicine and of health research and policy at Stanford University School of Medicine in California. "Furthermore, a mastectomy is a major procedure that can require significant recovery time and may entail breast reconstruction, whereas a lumpectomy is much less invasive with a shorter recovery period."

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