Diana Zuckerman, PhD, Cancer Prevention and Treatment Fund
Approximately 230,000 women in the U.S. will be diagnosed with breast cancer this year. For many years, experts have agreed that for most early-stage breast cancer (stage 0, 1, 2, or 3a), lumpectomy is just as safe as mastectomy, if the lumpectomy is followed by radiation treatment.[1,2,3]. By 2013, a study indicated that lumpectomy patients live longer than mastectomy patients and in 2021, an enormous study that followed almost 49,000 breast cancer patients for a median of 6 years confirmed that women undergoing lumpectomy with radiation were less likely to die of breast cancer or any other cause than women undergoing mastectomy, whether or not they underwent radiation. The benefit of lumpectomy was maintained regardless of tumor characteristics, treatment, demographics, other health issues, and socioeconomic background.
Half of the U.S. women that are eligible for lumpectomy, however, will undergo mastectomy instead. Why remove the entire breast in a mastectomy if it is just as effective to just remove the cancer and a “margin” of tissue around it? Why are so many women undergoing medically unnecessary mastectomies? At a 1990 Conference sponsored by the National Institutes of Health, experts agreed that since survival rates were the same, lumpectomy followed by radiation is the preferable treatment for most women with early-stage breast cancer. But even today, almost 4 decades later, with evidence favoring lumpectomy for almost a decade, many women eligible for breast-conserving surgery are getting mastectomies. Studies have found that some women do not understand that lumpectomies are an equally safe (or even safer) option.
More Mastectomies Related to Poverty, Doctors’ Preferences, Women’s Fear
One reason is economic — surprisingly, it is less expensive to perform a mastectomy than a lumpectomy. In addition to a more time-consuming surgery, radiation adds to the cost of lumpectomy but is rarely required for mastectomy. Moreover, some insurance plans do not cover all the expenses of the lumpectomy or the radiation therapy, because they are usually outpatient procedures. According to a study of one large urban hospital in Texas serving mostly indigent women, 84% of the women with early-stage breast cancer had mastectomies and only 16% had lumpectomies. Similarly, a study of 20,000 breast cancer patients in North Carolina reported lower lumpectomy rates among patients who did not have private insurance. In some hospitals, all breast cancer patients have mastectomies, regardless of their diagnosis.
Older doctors are more likely to recommend mastectomies. For decades, mastectomy was the standard treatment for breast cancer at any stage. Research showing the safety of lumpectomy, dates from the mid 1980’s. A study of 157 hospitals in North Carolina found that patients were more likely to undergo breast-conserving surgery if their surgeons were trained after 1981. One logical explanation is that doctors trained after 1981 were trained to do lumpectomies and are more knowledgeable about the research showing the safety of lumpectomy.
Researchers believe that physician knowledge and attitudes are a likely explanation for the dramatic regional differences they have documented in breast-conserving surgery. In 1986, breast-conserving surgery was more than twice as common in the Middle Atlantic states and New England than in the South Central states. More recent studies show similar regional differences. Unfortunately, the reasons for these disparities have not been adequately studied.
One factor is fear. Some women are very afraid of recurrence and choose mastectomy because the chances of recurrence in the same breast are reduced when the breast is removed. Some women are afraid of radiation therapy. Radiation therapy does cause side effects, but they are usually relatively mild, such as fatigue or skin irritation. Only very infrequently does radiation therapy cause long-lasting problems. However, there is the issue of access to radiation. In rural areas, patients sometimes must travel hundreds of miles five days each week for 5-8 weeks to get radiation treatment after lumpectomy.
Breast cancer is still relatively rare among women in their 20’s and 30’s, but there is some evidence that women diagnosed with breast cancer at an early age tend to have more aggressive cancers. Survival rates are lower.[11,12,13] This does not mean, however, that young women always need mastectomies, and each patient should receive the medical treatment that is best for her, based on her own diagnosis and preferences.
Are New Requirements the Answer?
Several states have tried to ensure that each breast cancer patient knows what surgical options are available and have passed laws requiring that designated written information is provided to every patient. Research has shown the benefits and limitations of these efforts: after passage of the state laws, breast-conserving surgery rates increased by 9% in Michigan and 13% in Hawaii. The increases were not maintained over time, however, perhaps because requiring physicians to provide objective information does not necessarily change their recommendations. Instead, providing objective information directly to the general public might help dispel the fears and myths that contribute to the disparities in treatment across the U.S. In addition, insurance policies that improve patient access to lumpectomy and radiation as an affordable option for treatment would also help ensure that women can make treatment choices instead of having the decisions made for them.
The Breast Cancer Patient Protection Act (S 910 and HR 1849) was introduced in the U.S. Congress and would require health insurers that reimburse mastectomies to also reimburse lumpectomies and radiation treatment. This would help make lumpectomy a more affordable choice to more women.
Surgical Treatment Disparities for Early-Stage Breast Cancer
These are a few examples of the studies of thousands of patients, published in major medical journals, which indicate that:
- Between 75 and 80 percent of women newly diagnosed with breast cancer have early-stage breast cancer. The vast majority of these women are eligible for breast-conserving surgery, but at many medical centers, most women undergo mastectomies instead.
- Women are more likely to undergo breast-conserving surgery if their physicians graduated from medical school after 1981, according to a study in North Carolina, compared to physicians who graduated before 1961.
- Surgeons have a greater propensity towards performing breast-conserving surgery if they practice in an area with higher Medicare fees for breast-conserving surgery, believe in patient participation in treatment decisions, and are female. Among women with early-stage breast cancer, mastectomies are much more likely in some states, such as Minnesota, than other states, such as Massachusetts. Mastectomies are especially common in the Midwest and South.[19,20]
- Breast-conserving surgery is much more likely to be performed on younger women, and becomes increasingly unlikely as a woman ages. The exception is women 80 years of age or older, among whom the frequency of breast-conserving surgery is highest.
- Women who are treated in university-based hospitals are more likely to have breast-conserving surgery, and patients in community hospitals are less likely.
- Women who are treated in hospitals that have radiation facilities are more likely to have breast-conserving surgery than women treated in hospitals that do not have such facilities. This is not only because of the availability of radiation treatment; breast-conserving surgery is less likely to be performed even if radiation facilities are conveniently located nearby.
- Mastectomies are especially likely to be unnecessary for most non-invasive breast cancers, such as ductal carcinoma in situ, yet many women with those cancers undergo mastectomies.[23,24,25]
- Breast-conserving surgery with radiation is somewhat more expensive than mastectomy in the short run, but breast-conserving therapy is less expensive than mastectomy after 5 years. Breast-conserving therapy is much less expensive than mastectomy with reconstruction.
- Low-income women and those who are less educated are less likely to have breast-conserving surgery. Patients without private insurance are also less likely to have breast-conserving surgery.
- Patients who undergo breast-conserving surgery are more likely to have sought a second opinion and more frequently report having made the decision themselves, whereas mastectomy patients are more likely to have relied on the advice of their physicians.
- Fisher B, Anderson S, Redmond CK, Wolmark N, Wickerham DL, Cronin WM. Reanalysis and Results After 12 Years of Follow-up in a Randomized Clinical Trial Composing Total Mastectomy With Lumpectomy With or Without Irradiation in the Treatment of Breast Cancer. N Engl J Med 1995 Nov 30;333(22):1456-61.
- Gangi, A et al.Breast-Conserving Therapy for Triple-Negative Breast Cancer. JAMA Surg. 2014;149(3):252-258.
- Agarwal, S et al. Effect of Breast Conservation Therapy vs Mastectomy on Disease-Specific Survival for Early-Stage Breast Cancer. JAMA Surg. 2014;149(3):267-274.
- Hwang ES, et al “Survival after lumpectomy and mastectomy for early stage invasive breast cancer: The effect of age and hormone receptor status” Cancer 2013 April 1; 119(7); DOI: 10.1002/cncr.27795.
- de Boniface J, Szulkin R, Johansson ALV. Survival After Breast Conservation vs Mastectomy Adjusted for Comorbidity and Socioeconomic Status: A Swedish National 6-Year Follow-up of 48 986 Women. JAMA Surg. Published online May 05, 2021. doi:10.1001/jamasurg.2021.1438.
- Abrams JS, Phillips PH, Friedman MA. Commentary: Meeting Highlights: a Reappraisal of Research Results for the Local Treatment of Early Stage Breast Cancer. J Nat’l Cancer Institute, 1995 Vol. 87. No. 24, Dec 20.
- Dolan JT, Granchi TS. Low Rate of Breast Conservation Surgery in Large Urban Hospital Serving the Medically Indigent. Am J Surgery 1998 Dec;176(6):520-4.
- Kotwall CA, Covington DI, Rutledge R, Churchill MP, Meyer AA. Patient, Hospital, and Surgeon Factors Associated with Breast Conservation Surgery. A Statewide Analysis in North Carolina. Ann Surg 1996 Oct;224(4):419-26.
- Kotwall, CA, Covington D, Churchill P, Brinker C, Weintritt D, Maxwell JG. Breast Conservation Surgery for Breast Cancer at a Regional Medical Center. Am J Surg 1998 Dec;176(6):510-4.
- Nattinger AB, Gottlieb MS, Veum J, Yahnke D, Goodwin JS. Geographic Variation in the Use of Breast-Conserving Treatment for Breast Cancer. N Engl J Med 1992 Apr23;326(17):1102-7
- Xiong Q, Valero V, Kau V, Kau SW, Taylor S, Smith TL, Buzdar AU, Hortobagyi GN, Theriault RL. Female Patients with Breast Carcinoma age 30 Years and Younger Have a Poor Prognosis: the M.D. Anderson Cancer Center Experience. Cancer 2001 Nov 15;92(10):2523-8.
- Carey K. Anders et al., “Breast Carcinomas Arising at a Young Age: Unique Biology or a Surrogate for Aggressive Intrinsic Subtypes?,” Journal of Clinical Oncology 29, no. 1 (2011): e18-e20.
- Carey K. Anders et al., “Young Age at Diagnosis Correlates With Worse Prognosis and Defines a Subset of Breast Cancers With Shared Patterns of Gene Expression,” Journal of Clinical Oncology 26, no. 10 (2008): 3324-3330.
- Nattinger AB, Hoffman RG, Shapiro R, Gottlieb MS, Goodwin JS. The Effect of Legislative Requirements on the Use of Breast-Conserving Surgery. N Engl J Med 1996 Oct3;335(14):1035-40
- Treatment of Early-Stage Breast Cancer. NIH Consensus Statement Online 1990 Jun 18-21;8(6)1-19.
- Dolan JT, Granchi TS. Low Rate of Breast Conservation Surgery in Large Urban Hospital Serving the Medically Indigent. Am J Surg 1998 Dec;176(6):520-4.
- Mandelblatt JS, Berg CD, Meropol NJ, et al. Measuring and Predicting Surgeons’ Practice Styles for Breast Cancer Treatment in Older Women. Med Care 2001 Mar;39(3):228-42.
- Guadagnoli E, Weeks JC, Shapiro CL, et al. Use of Breast-Conserving Surgery for Treatment of Stage I and Stage II Breast Cancer. J Clin Oncol 1998 Jan;16(1):101-6
- Nattinger AB, Gottlieb MS, Veum J, et al. Geographic Variation in the Use of Breast-Conserving Treatment for Breast Cancer. N Engl J Med 1992 Apr 23;326(17):1102-7.
- Albain KS, Green SR, Lichter AS, et al. Influence of Patient Characteristics, Socioeconomic Factors, Geography, and Systemic Risk on the Use of Breast-sparing Treatment in Women Enrolled in Adjuvant Breast Cancer Studies: An Analysis of Two Intergroup Trials. J Clin Oncol 1996 Nov;14(11):3009-17.
- Ballard-Barbash R, Potosky AL, Harlan LC, et al. Factors Associated with Surgical and Radiation Therapy for Early Stage Breast Cancer in Older Women. J Natl Cancer Inst 1996 Jun 5;88(11):716-26.
- Elward KS, Penberthy LT, Bear H, et al. Variation in the Use of Breast-Conserving Therapy for Medicare Beneficiaries in Virginia: Clinical, Geographic, and Hospital Characteristics. Clin Perform Qual Health Care 1998 Apr-Jun;6(2):63-9
- Katz SJ, Lantz PM, Zemencuk JK. Correlates of Surgical Treatment Type for Women with Noninvasive and Invasive Breast Cancer. J Womens Health Gend Based Med 2001 Sep;10(7):659-70.
- Ernster VL, Barclay J, Kerlikowske K, et al. Incidence of and Treatment for Ductal Carcinoma In Situ of the Breast. JAMA 1996 Mar 27;275(12):913-8
- Gomez SL, et al. Increasing mastectomy rates for early-stage breast cancer? Population-based trends from California. J Clin Oncol. 2010 Apr 1;28(10):e155-7.
- Barlow WE, Taplin SH, Yoshida CK, et al. Cost Comparison of Mastectomy versus Breast-conserving Therapy for Early-stage Breast Cancer. J Natl Cancer Inst 2001 Mar 21;93(6):447-55.
- Desch CE, Penberthy LT, Hillner BE, et al. A Sociodemographic and Economic Comparison of Breast Reconstruction, Mastectomy, and Conservative Surgery. Surgery 1999 Apr;125(4):441-7.
- Roetzheim RG, Gonzalez EC, Ferrante JM, et al. Effects of Health Insurance and Race on Breast Carcinoma Treatments and Outcomes. Cancer 2000 Dec 1;89(11):2202-13
- Kotwall CA, Maxwell JG, Covington DL, et al. Clinicopathologic Factors and Patient Perceptions Associated with Surgical Breast-conserving Treatment. Ann Surg Oncol 1996 Mar;3(2):169-75.