Determinants of Choice of Surgery in Asian Patients with Early Breast Cancer in A Middle Income Country

Abstract

Background: Breast-conserving surgery (BCS) plus radiotherapy is equivalent to modified radical mastectomy (MRM) in terms of outcome. However there is wide variation in mastectomy rates dependent both on tumour and patient characteristics. Objective: This study aimed to assess the determinants of surgery choice in Asian patients with early breast cancer in a middle-income country. Materials and Methods: 184 patients with early breast cancer treated between Jan 2008 and Dec 2010 were recruited to complete a questionnaire. Chi-square test was used to analyze the association between surgery choice and demographic and tumour factors, surgeon recommendation, family member and partner opinions, fear of recurrence, avoidance of second surgery, fear of disfigurement, interference with sex life, fear of radiation and loss of femininity. Results: 85 (46%) had BCS while 99 (54%) had mastectomy. Age >60, Chinese ethnicity, lower education level, and larger tumour size were significantly associated with mastectomy. Surgeon recommendation was important in surgery choice. Although both groups did not place much importance on interference with sex life, 14.1% of the BCS group felt it was very important compared to 5.1% in the mastectomy group and this was statistically significant. There was no statistical difference between the two groups in terms of the other factors. When analyzed by ethnicity, significantly more Malay and Indian women considered partner and family member opinions very important and were more concerned about loss of femininity compared to Chinese women. There were no statistical differences between the three ethnic groups in terms of the other factors. Conclusions: When counseling on surgical options, the surgeon has to take into account the ethnicity, social background and education level, age and reliance on partner and family members. Decision-making is usually a collective effort rather than just between the patient and surgeon, and involving the whole family into the process early is important.

Factors influencing patient decision-making between simple mastectomy and surgical alternatives

“…This fear of cancer recurrence as a deciding factor for choosing mastectomy is similar to the findings of previous studies from western countries , , as well as in Hong Kong. Interestingly, a study performed in Malaysia found no significant difference in terms of fear of cancer recurrence between women who chose mastectomy and those who chose BCT.…”

“…The respondents in this study were largely aged over 50 years, of Chinese ethnicity, and of secondary school level of education and below. The demographic profile of the recruited patients was similar to that of patients who chose to undergo mastectomy in other studies.…”

“…Re‐excision rates for positive margins after BCT range from 17 to 68 per cent. Previous studies have had differing results regarding the importance of this factor to patients, with Lam and colleagues showing that ‘avoiding having further surgery in the future’ was a key consideration in women who choose simple mastectomy over BCT, whereas Teh and co‐workers reported otherwise. In the present study, this factor was shown to play a prominent role.…”

“…The second part of the questionnaire examined reasons for choosing mastectomy over BCT. The reasons included in the survey were based on similar studies done in other countries, such as patient's age, family history of breast cancer, existing co‐morbidities, fear of cancer recurrence, concerns about radiotherapy, avoiding risk of second surgery for margins, cost, sexuality, the perception that health is more important than retaining a breast, and length of time away from work. In the third part, patients' reasons for not undergoing breast reconstruction after mastectomy were explored.…”

Understanding Women’s Choice of Mastectomy Versus Breast Conserving Therapy in Early-Stage Breast Cancer

“…7–9 Common demographic factors examined in such studies include age, education, and ethnicity. Age has shown many discrepant results, with the most consistent finding being an increased likelihood of undergoing mastectomy in younger age groups under 40 or 50.…”