Are too many mastectomies being done in the U.S.? Patrick Ivan Borgen, MD Surgeon-in-Chief Maimonides Medical Center Brooklyn, New York

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1 Are too many mastectomies being done in the U.S.? Patrick Ivan Borgen, MD Surgeon-in-Chief Maimonides Medical Center Brooklyn, New York

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3 Of course too many mastectomies are being done. There is too much breast cancer.

4 Too Many Mastectomies Argument is that the ratio of mastectomy to breast conservation in patients with cancer (when everything else is equal) is too high. Debated topic suggests that the choice is the surgeon s choice rather than the patient s choice. Assumes: The surgeon is directing the patient towards mastectomy. The surgeon has placed a value on the breast. The surgeon s valuation of the breast is more important than the patient s valuation. Who has the autonomy to make this decision surgeon or patient?

5 Too Many Mastectomies Ratio of mastectomy to breast conservation in patients with cancer (when everything else is equal) is too high. Debated topic suggests that the choice is the surgeon s choice rather than the patient s choice. Assumes: THAT THE PATIENT IS ILL-EQUIPPED TO MAKE THE DECISION HERSELF. Patients who choose mastectomy regret the decision.

6 Assumptions in Favor of BCT: Advantages to BCT Survival advantage Better local regional control (lower local regional recurrence rate) ALL PATIENTS are willing to receive radiation therapy in exchange for preserving the breast ALL PATIENTS are willing to undergo a lifetime of vigilance Disadvantages to Mastectomy Irrevocable change in body image Psychologically traumatic Painful Total skin sparing with excellent reconstruction does not soften the blow Women define their self image at least partially by their breasts.

7 National Prophylactic Mastectomy Registry women identified from US lay media All had one or both breasts removed prophylactically All followed yearly Extensively questioned DO YOU REGRET YOUR DECISION? 4% SAID YES.WOULD NOT DO IT AGAIN. COMMON DENOMINATOR WAS PHYSICIAN TALKING PATIENT INTO PROCEDURE. Borgen, Tran, Montgomery et al. Cancer 23:

8 Survival Implications Associated with Variation in Mastectomy Rates for Early-Staged Breast Cancer John M. Brooks, 1 Elizabeth A. Chrischilles, 2 Mary Beth Landrum, 3 Kara B. Wright, 2 Gang Fang, 4 Eric P. Winer, 5 and Nancy L. Keating 3, SEER-Medicare databases, 69,140 patients with stage I or II breast cancer that were enrolled in Medicare 1 percentage point increase in the mastectomy rate would reduce the 7-year survival rate by.1 percentage points. International Journal of Surgical OncologyVolume 2012 (2012), Article ID , 9 pages

9 Conclusion These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage. Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients.

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13 Impact of four quarter amputations on the hearing acuity of the frog

14 Background of Authors College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA 2 College of Public Health, University of Iowa, Iowa City, IA 52242, USA 3\ Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA 4 Eshelman School of Pharmacy, University of North Carolina, Chapell Hill, NC 27599, USA 5 Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA 02115, USA 6 Division of General Internal Medicine, Harvard Medical School, Brigham and Women s Hospital, Boston, MA 02120, USA

15 Patients are Educated

16 Patients are educated Website hits by patients on breast cancer; repeat hits Lifelong learning; relatives with cancer Media crunch super high exposure 1 degree of separation with women and breast cancer Many have considered her options before getting the disease

17 Patients are often REALLY educated Patient who knew Bernie Fisher s brother was named Ed. Patient wanted the details on the calibration schedule for our gamma probe for her sentinel node. Patient asked whether the Myriad Genetics technology looking for BRCA gene mutations would reveal gene silencing through promoter methylation?

18 Less invasive is NOT always better in the long run Multiple coronary artery stents vs. CABG (advantage CABG) EVARS (elective) of abdominal aortic aneurysm vs. open definitive repair Long term benefits of tissue transfer reconstruction vs. implant reconstruction Transanal vs. Total Mesorectal Excision of rectal cancer

19 Flawed basic premise 1992, NCI published a consensus statement: Breast conservation (tumor removal, axillary dissection and radiation therapy is equivalent to mastectomy but is preferable as it is less disfiguring. Assumption was made that every woman would CHOOSE BCT.

20 Flawed basic premise As we witnessed the explosion of new breast centers and new breast programs in the 1990s and early 2000s centers were actually GRADED on their utilization of BCT. In some cases thresholds were set that centers were expected to reach for percent utilization of BCT. Negative consequences for failing to reach goals.

21 Survey of women surgeons in American College of Surgeons; these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment. More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES.

22 T0isN0M0 Breast Cancer Outcome Metric Mastectomy Breast Conservation Local Recurrence Rate 1% (0.5% invasive) 5% to 20% (3%-10% Invasive) Need for radiation NEVER ALWAYS Need for reconstruction Virtually always RARE Cosmetic Outcome Reasonable facsimile Excellent SURVIVAL EQUAL EQUAL 3 cm of mixed grade DCIS; ER+ Margins >1cm BRCA negative

23 T2N0M0 Breast Cancer Outcome Metric Mastectomy Breast Conservation Local Recurrence Rate 1% to 3% 5% to 12% Need for radiation RARE ALWAYS Need for reconstruction Virtually always RARE Cosmetic Outcome Reasonable facsimile Excellent SURVIVAL EQUAL EQUAL

24 T2N0M0 Breast Cancer Clinical Trajectory: Next 20 years or so Outcome Metric Mastectomy Breast Conservation Clinical Examination Yes Yes Ipsilat Mammogram NO ALWAYS Ipsilat U/S NO Likely Ipsilat MRI NO Possible Future ipsilat BIOPSY 3% 30% 5% - 12% chance of second cancer; Salvage mastectomy; Reconstruction compromised by radiation therapy Second sentinel node biopsy Previous biopsy site may compromise mastectomy incision planning and cosmesis

25 Decision involvement and receipt of mastectomy among racially and ethnically diverse breast cancer patients. Hawley ST, Griggs JJ, Hamilton AS, Graff JJ, Janz NK, Morrow M, Jagsi R, Salem B, Katz SJ patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer. Excluded Stage III or those with contraindications to breast conservation therapy. The dependent variable was receipt of mastectomy initially. The primary independent variables were patient involvement in decision making, race or ethnicity, attitudes about recurrence, the effects of radiation, the impact of surgery on body image, and the role of others in decision making

26 Conclusions Concerns about recurrence or radiation effects were very important in their surgery decision were more likely to receive mastectomy than those less concerned (for recurrence concerns, estimated relative risk [RR] = 1.66, 95% confidence interval [CI] = 1.28 to 2.10;

27 Conclusions There was a relationship between TIME SPENT with the patient and the choice of mastectomy. Greater patient involvement in decision making was associated with receipt of mastectomy for all racial and ethnic groups. Patient attitudes about surgery and the opinions of family and friends contribute to surgical choices made by women with breast cancer.

28 Summary Goal should not be to maximize utilization of BCT. Goal should be to match patient concerns, values, priorities with treatment choice.

29 Summary Maybe patients are different today: Most work Many single moms Highly educated and highly informed Each with her own set of considerations, values, priorities, worries.. Simply not my place to impose my opinions regarding the benefits of sparing her breast.

30 Best we can hope for is to establish a relationship with each patient and provide accurate information to help them arrive at the choice that is best for them. To sound smart always conclude your presentation by quoting HOMER

31 Facts are meaningless. You could use facts to prove anything that was even remotely true. Homer Simpson 2005

32 I have concluded that, of all cancers I deal with, breast cancer is the most difficult. Its diversity of presentations, multiple avenues of metastasis, unpredictable clinical behavior, requirement for significant tissue loss renders it, in most cases, virtually impossible to arrive at a reasonable adjustment for a means to an end. James Ewing MD 1920