By: Dr. Geoffrey Modest<\/b><\/p>\n
There was an important\u00a0note of caution in an\u00a0article\u00a0in JAMA,\u00a0finding\u00a0that more women are getting bilateral mastectomies to treat unilateral cancer, with data suggesting this might be harmful (see\u00a0doi:10.1001\/jama.2014.10707<\/strong>). This was observational cohort study in the population-based California Cancer Registry from 1998-2011, with median follow-up of 89.1 months. Findings:<\/span><\/p>\n –189,734 patients with unilateral early-stage breast cancer were\u00a0followed. Excluded those with tumor >5cm\/paget’s\/mammographic diagnosis only.<\/p>\n –Rate of bilat mastectomies\u00a0was 2.0% in 1998, increasing to 12.3%!!! in 2011. unilateral decreased from 46.3 to 33.4% and breast-conserving surgery\u00a0with radiation was pretty stable at 51.7 to 54.2%.<\/p>\n –More specifically, re:\u00a0bilateral mastectomies:<\/p>\n –In those <40yo, the rate increased from 3.6% to 33%<\/span><\/p>\n –Was\u00a0more in those receiving care in National Cancer Institute-designated cancer center: 8.6% vs 6.0%<\/span><\/p>\n \u200b–Was\u00a0most common in non-Hispanic whites at 6.9%, others in the 3-5% range;\u00a0unilateral mastectomy more common in\u00a0racial\/ethnic minorities — Filipina 52.8%, Hispanic 45.6%, vs non-Hispanic whites 35.2%<\/span><\/p>\n \u200b–Tracked with neighborhood socioeconomic status quintile\u200b (highest rate in highest SES communities). also with private insurance (7.7%) vs public\/medicaid (3.3%).\u00a0unilateral mastectomy also more with public\/Medicaid insurance 48.4% than with\u00a0private insurance (36.6%).<\/span><\/p>\n –10-year mortality, compared with breast-conserving surgery with radiation (16.8%): unilateral mastectomy 20.1%. Bilateral mastectomy 18.8% (nonsignif difference for bilat)<\/span><\/p>\n So, large increase in bilateral mastectomy in certain populations (esp privately-insured non-Hispanic whites who went to NCI-designated cancer centers), with no evident benefit after 10 years (of note, their Figure 2 shows data up to 15 years post-surgery, with leveling off of curves from 12-15\u00a0years). Those with unilateral mastectomy did worse\u00a0in this and other observational studies. what are the factors explaining these changes? Those with unilateral mastectomy may have\u00a0had tumors with worse prognosis (eg lymphovascular invasion or extranodal extension —\u00a0items not recorded in this registry). And the above data suggests a shift from unilateral to bilateral mastectomies. Perhaps part of the issue is the role of breast MRI, which finds all kinds of difficult-to-interpret abnormalities, perhaps leading to more aggressive\/bilateral surgery (ie, too much information….). Role of\u00a0genetic testing (though there are pretty good short-term outcome data that bilat mastectomy is associated with improved prognosis in those with\u00a0BRCA 1\/2, though that is a small % of breast cancers). \u00a0But,\u00a0not surprisingly, bilateral mastectomy is associated with more adverse effects (including both those directly related to the surgery, such as flap failure, necrosis, infection, as well as some studies reporting bad effects on body image, sexual function and quality of life). Bottom line: we will probably never get a clear RCT with definitive answers, so we do need to look at these observational studies. Lots of data are collected in the cancer registries, but we can never be sure that there wasn’t a significant bias in who got more extensive surgery. But women should understand that for\u00a0other than those\u00a0positive for\u00a0BRCA 1\/2,\u00a0the current observational data do not support a clinical benefit from more aggressive surgery and that there are real potential\u00a0hazards. By the way, there is a really great book “The Emperor of All\u00a0Maladies” by Siddhartha Mukherjee, which tracks the history of cancer and how its conception and approach to therapy\u00a0over time\u00a0reflects the overall\u00a0dominant social ideology of the period; the book\u00a0has\u00a0a\u00a0special focus on breast cancer.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":" Double mastectomy not improve survival […]<\/p>\n