Increasing percentages of patients undergoing breast-conserving therapy

The percentage of patients with early stage breast cancer undergoing breast-conserving therapy (BCT) increased from 54.3% in 1998 to 60.1% in 2011, according to a report published online by JAMA Surgery (2015; doi:10.1001/jamasurg.2015). Notably, nonclinical factors including socioeconomic demographics, insurance, and the distance patients must travel to treatment facilities persist as key barriers to the treatment.

The National Institutes of Health (NIH) issued a consensus statement in 1990 in support of this treatment method. That led to a substantial decline in rates of mastectomy and widespread acceptance of BCT as an appropriate treatment for early stage breast cancer.

However, during the past decade, technical advances and other developments may have created new incentives other than BCT among patients who are good candidates, including genetic testing, advances in reconstruction techniques, and increased patient interest in contralateral prophylactic mastectomy.

Isabelle Bedrosian, MD, of the University of Texas MD Anderson Cancer Center, in Houston, and coauthors used the National Cancer Data Base to examine factors that influenced the surgical choices of women with early stage breast cancer treated between 1998 and 2011. The authors looked at data for a group of 727,927 women.

The percentage of women with early stage breast cancer undergoing BCT increased from 54.3% in 1998 to 59.7% in 2006 and then remained steady, ending at 60.1% in 2011. The use of BCT was greater in patients ages 52 to 61 years (62.8%) compared with younger patients (57.8%) and in those women with more education (61.7%).

Rates of BCT were lower in patients without insurance (49.3%) compared to those women with private insurance (62.3%) and among those women with the lowest median income (51.1%), according to the results.

Academic cancer programs (59.8%), the Northeast (64.5%), and living less than approximately 17 miles (59% to 60.1%) from a treatment facility were factors associated with greater BCT rates compared with community cancer programs (55.4%), the South (52%), and living farther away from a treatment facility (54%).

Researchers report increases in BCT use were seen from 1998 to 2011 across all age groups (from 48.2% to 59.7%), in community cancer programs (48.4% in 1998 vs. 58.8% in 2011), and at facilities located in the South (45.1% in 1998 vs. 55.3% in 2011).

“This comprehensive national review demonstrates that BCT rates have increased during the past two decades. Disparities in the use of BCT based on age, geographic location and type of cancer program have improved since 1998. However, insurance, income, and travel distance to treatment facilities persist as key barriers to BCT use. These socioeconomic barriers are unlikely to be erased without health policy changes,” the study concluded.

In a related commentary (doi:10.1001/jamasurg.2015.1114), Lisa A. Newman, MD, MPH, of the University of Michigan, Ann Arbor, wrote: “It is an unfortunate reality that unequal access to care persists as a significant cause of health outcome disparities.… Optimal breast-conserving surgery for most lumpectomy-eligible patients requires a commitment to a whole-breast radiation, delivered in daily fractions during a 6-week period. However, this strategy requires access to a radiation oncologist and specialized treatment facility. Patients who lack daily transportation access, patients who cannot coordinate radiation treatments with job and/or child care responsibilities, and patients who live remote from a radiation facility face often insurmountable barriers to pursuing breast-conserving surgery, even if they have a disease pattern that is ideally suited for this treatment.”

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