Increasing Mastectomy Rates Among all Age Groups for Early Stage Breast Cancer: A 10-Year Study of Surgical Choice

Abstract

First-line surgical options for early stage breast cancer and ductal carcinoma in situ include breast conserving surgery or mastectomy. We analyzed factors that influence the receipt of mastectomy and resultant trends over time. Registry analysis was carried out for 21,869 women who underwent up-front surgical treatment for stage 0, I or II breast cancer between 1998 and 2007 using data from the Kentucky Cancer Registry. We examined the trend of treatment over time and assessed the probability of receiving mastectomy using multivariate logistic regression. Overall, 54.5% of women received breast conservation and 45.5% received mastectomy over a 10-year period (annual BCS rate range: 46.9-61.2%). The overall mastectomy rate substantially decreased from 53.1% in 1998 to 38.8% in 2005 (p < 0.0001), but then increased to 45% in 2007 (p < 0.001). Between 2005 and 2007, the increase in mastectomies in the age groups of <50 years, 50-69 years, and ≥ 70 years was 7.5% (p = 0.0351), 4.9% (p = 0.0132) and, 8.0% (p = 0.0283), respectively. On multivariate analysis, the rate of receiving mastectomy was drastically higher for women with stage I or II (versus in situ) disease and moderate or poorly differentiated (versus well differentiated) histology. The rate was modestly higher for uninsured and government-insured (versus privately insured) patients, patients older than 70 years (versus younger), rural (versus urban) location, receptor negative (versus receptor positive) disease, and unusual histologies (versus ductal and lobular histology). There was no statistically significant difference in surgical choice with regard to race. Determinants of mastectomy for in situ and early stage breast cancer include stage, histology, age, insurance status, county of residence, receptor status. The rate of mastectomy declined until 2005 and is now increasing across all age groups, especially for women < 50 years and ≥ 70 years.

Factors Predictive of Treatment by Australian Breast Surgeons of Invasive Female Breast Cancer by Mastectomy rather than Breast Conserving Surgery

“…Statement and reviews of evidence from randomized trials (Abrams et al, 1995;Fisher et al, 1995), mastectomy rates declined markedly in the U.S. (Lazovich et al, 1991;Lazovich et al, 1997;Habermann et al, 2010), Canada, (Gaudette et al, 2004) European countries, (Zorzi et al, 2006), although with a more recent upturn suggested in some North American localities (Tuttle et al, 2007;Katipamula et al, 2009;Dragun et al, 2012a;2012b). Australian data also showed a trend away from mastectomy towards breast conserving surgery both nationally and in a number of jurisdictions (Hill et al, 1990;1994;Byrne et al, 1993;South Australian Cancer Registry, 2000;Cuncins-Hearn et al, 2006;Kricker, 2011).…”

“…Mastectomy rates for early invasive disease vary widely within and between countries (Hill et al, 1990;1994;Lazovich et al, 1991;Byrne et al, 1993;Taylor et al, 1999;South Australian Cancer Registry, 2000;Federation European Cancer Societies, 2004;Anderson et al, 2008;Dixon and Mak, 2008;Kricker, 2011;Dragun et al, 2012a), with higher rates reported for…”

“…Studies in Australia and North America have reported higher rates in residents of more remote rural settings than city locations, in women treated by surgeons with low case loads, and for larger and more advanced breast cancers (Lazovich et al, 1991;Taylor et al, 1999;Dragun et al, 2012a;2012b). In North America, private health insurance has been linked to greater use of breast conserving surgery (Lazovich et al, 1991;Dragun et al, 2012a;2012b).…”

“…Studies in Australia and North America have reported higher rates in residents of more remote rural settings than city locations, in women treated by surgeons with low case loads, and for larger and more advanced breast cancers (Lazovich et al, 1991;Taylor et al, 1999;Dragun et al, 2012a;2012b). In North America, private health insurance has been linked to greater use of breast conserving surgery (Lazovich et al, 1991;Dragun et al, 2012a;2012b). In general, breast cancers detected through mammography screening in Australia have had lower mastectomy rates (Samnakay et al, 2005;Cancer Australia, 2012;Roder et al, 2012) with rates of around 28% applying in 1996-2005 and with lower rates applying to cancers detected at subsequent than initial screening rounds (Cancer Australia, 2012;Roder et al, 2012).…”

“…In particular, associations of mastectomy rates with surgeon case load and remoteness of residence are investigated following international and regional evidence from Australia indicating the importance of these features as determinants of mastectomy (Lazovich et al, 1991;Taylor, et al, 1999;Cancer Australia, 2012;Dragun et al, 2012a). Implications of results for health-system improvement are considered.…”