http://my.webmd.com/content/article/110/109618.htm
Breast Cancer: Women Often Reject Lumpectomy

Many Opt for Mastectomy When Offered the Choice

By Salynn Boyles
WebMD Medical News  Reviewed By Brunilda  Nazario, MD
on Thursday, August 18, 2005  

Aug. 18, 2005 -- Women with breast cancer often opt for mastectomy
instead of lumpectomy when offered a choice between the two
treatments, an eye-opening new study shows.

The research could explain why so many women with early-stage breast
cancer still end up having their breasts removed despite no
differences in survival rate compared with women who undergo
lumpectomy plus radiation.

The prevailing wisdom has been that physicians tend to steer patients
toward more aggressive surgical treatment of breast cancer despite
medical recommendations favoring breast-conserving lumpectomy. But the
newly published study suggests the opposite is true.

"We found that surgeons were mainly recommending the less invasive
treatment and that patients tended to have a good deal of involvement
in the decision process," researcher Steven J. Katz, MD, MPH, of the
University of Michigan tells WebMD.

"We also found that greater patient involvement was associated with
greater use of mastectomy."

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1 in 3 Women Get Mastectomy

Roughly a third of women facing breast cancer surgery have their
entire breast removed (mastectomy) instead of breast-sparing
lumpectomy plus radiation.

In an effort to find out why, Katz and colleagues surveyed 1,844 women
in Los Angeles and Detroit with a recent breast cancer diagnosis. The
findings are reported in the Aug. 20 issue of the Journal of Clinical
Oncology.

Overall, about 30% of the women had mastectomy as initial treatment. A
total of 41% reported that they made the surgical decision, and 37%
said they made it with their surgeon. Only one out of five reported
that their surgeon made the treatment decision, with or without their
input.

Among white women, 27% of those who made their own decision about
surgery ended up having a mastectomy, compared to just 5% of women who
said their surgeon made the decision, and 17% of women who said the
decision was a shared one.

African-American women were more likely to receive a mastectomy than
patients of other ethnic groups when the decision was perceived to
have been made by the surgeon

Cancer Fears May Drive Decision

Women who chose mastectomy were more likely to be worried about cancer
recurrence and they expressed more fears and concerns about radiation
treatment, which is done after a lumpectomy.

During a mastectomy the entire breast is removed. In breast-conserving
lumpectomy surgery only the tumor and some surrounding tissue are
removed; this is followed by radiation therapy.

There is a higher risk of breast cancer recurrence among women who opt
for breast-sparing surgery. But these recurrences are usually caught
early, and the overall survival rate with lumpectomy plus radiation is
comparable to mastectomy.

Katz says about 10% to 15% of breast cancer patients are not good
candidates for breast-sparing surgery because their cancer is diffused
throughout the breast or for some other reason.

He adds that other patients who could choose lumpectomy but opt for
mastectomy instead should not be made to feel that the decision is
wrong.

"These are the women who are saying they want a mastectomy because it
will allow them to leave their disease behind quicker," he says. "The
message to doctors, surgeons, and policy makers is that this is a
reasonable choice."

Take Your Time

In an editorial published with the study, Medical College of Wisconsin
professor of medicine Ann Nattinger, MD, MPH, noted that many women
may not buy the notion that lumpectomy plus radiation is as effective
as mastectomy.

"Some patients may have difficulty with the somewhat abstract notion
that an irradiated cancer is just as 'gone' as a cancer that has been
surgically removed," she wrote.

She tells WebMD that women may also have a hard time believing that a
bigger risk of cancer recurrence doesn't translate into poorer
survival.

Both Katz and Nattinger stressed the importance of taking time to
assess medical options when making decisions about breast cancer
treatment. Surgery is often performed as soon as possible after
diagnosis, but this is not usually medically necessary, Katz says.

"Biologically, breast cancer treatment is not a medical emergency," he
says. "Treatment should be initiated promptly, but weeks don't usually
matter. What does matter is getting to the most experienced surgeon
and getting the best information you can. This isn't always possible
if you are rushed into treatment."

Nattinger agrees but says patients aren't often given this message.

"Women need to know that they usually have the luxury of taking a few
weeks or even a month to carefully access their options," she says.
"They should feel free to get a second opinion and spend some time
making this decision."

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SOURCES: Katz, S. Journal of Clinical Oncology, Aug. 20, 2005; vol 23:
online edition. Steven J. Katz, MD, MPH, associate professor of
general medicine, University of Michigan Medical School; professor of
health management, University of Michigan School of Public Health. Ann
Nattinger, MD, MPH, professor of medicine; and chief, general internal
medicine, Medical College of Wisconsin. The Susan G. Komen Breast
Cancer Foundation.