National trends in mastectomy for early stage breast cancer examined

Higher proportions of women eligible for breast conservation surgery (BCS) are undergoing mastectomy, breast reconstruction, and bilateral mastectomy. The steepest increases are seen in women with lymph node-negative and in situ disease.

BCS has been a standard of excellence in breast cancer care and its use for management of early stage breast cancer had increased steadily since the 1990s. However, evidence shows this trend may be reversing.

Kristy L. Kummerow, MD, of Vanderbilt University Medical Center, in Nashville, Tennessee, and her co-authors examined trends nationwide in mastectomy patients eligible for BCS. The authors used the National Cancer Data Base (NCDB) to study more than 1.2 million women treated at centers accredited by the American Cancer Society and the American College of Surgeons Commission on Cancer from January 1998 through December 2011.

The study showed that 35.5% of the study group underwent mastectomy. The proportion of BCS-eligible women with early stage breast cancer who underwent mastectomy increased from 34.3% in 1998 to 37.8% in 2011.

Younger women were more likely to undergo mastectomy regardless of tumor size, whereas mastectomy in older women was associated with having a tumor greater than 2 cm. In women undergoing mastectomy, rates of breast reconstruction increased from 11.6% in 1998 to 36.4% in 2011. Rates of bilateral mastectomy for disease in only one breast increased from 1.9% in 1998 to 11.2% in 2011.

The authors noted that the observed increase in mastectomy rates was largely due to a rise in bilateral mastectomy for unilateral, early stage disease from 5.4% of mastectomies in 1998 to 29.7% in 2011, with an increase at the same time in reconstructive procedures in this group from 36.9% to 57.2%.

"Our finding of still-increasing rates of mastectomy, breast reconstruction, and bilateral mastectomy in women with early stage breast cancer using 14 years of data from the NCDB has implications for physician and patient decision making as well as quality measurement. Further research is needed to understand patient, provider, policy, and social factors associated with these trends," the authors concluded.

This report was published in JAMA Surgery (2014; doi:10.1001/jamasurg.2014.2895).

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