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Mastectomy Instead of BCS: What Is the Role of the Surgeon's Recommendation?

Reasons for mastectomy are related to surgeon's recommendation, patient's preference, and contraindications to breast-conserving surgery.

Although rates of breast-conserving surgery (BCS) have risen substantially during the last 2 decades, many clinicians feel that mastectomy is still performed too often. To assess reasons for mastectomy as initial treatment and rates of mastectomy after attempted BCS, investigators surveyed women with ductal carcinoma in situ or stage I–II breast cancer. Participants were asked which procedure was recommended by their initial surgeons (and why) and, if applicable, by second surgeons.

Of 1984 respondents, 66% indicated that their first surgeons had recommended BCS, 17% reported that mastectomy was initially recommended, and 17% said that neither procedure was recommended over the other. In more than two thirds of women who received initial recommendations for mastectomy, BCS was contraindicated. Among respondents who did not report contraindications to BCS, only 6% received surgical recommendations for mastectomy. Second opinions were sought by 19% of respondents (most often when mastectomy was initially recommended); however, 90% of women were operated on by the first surgeon they consulted. Among women in whom BCS was attempted, no additional surgery was required in 62%, reexcision lumpectomy was performed in 26%, and subsequent mastectomy was performed in 12%.

Comment: These results indicate that surgeons generally are making appropriate treatment recommendations for stage 0–II breast cancer, and that patient preference plays a role in the choice of surgery. Such preferences — which often arise from fears of tumor recurrence and concerns about radiation therapy — might not be based on sound knowledge, underscoring the importance of candid preoperative counseling. The authors did not ascertain the influence of preoperative magnetic resonance imaging on surgical recommendations, although this approach could be partially responsible for recent trends in mastectomy rates (JW Gen Med Oct 1 2009). Notably, increasing numbers of patients are selecting bilateral mastectomy for initial management of breast cancer (Ann Surg Oncol 2009; 16:2697).

— Andrew M. Kaunitz, MD

Published in Journal Watch Women's Health October 22, 2009

Citation(s):

Morrow M et al. Surgeon recommendations and receipt of mastectomy for treatment of breast cancer. JAMA 2009 Oct 14; 302:1551.

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