It is shocking but true: approximately 70 percent of American women who have a breast removed as treatment for cancer do not need such radical surgery. 1 Whether a woman undergoes a mastectomy or a lumpectomy (which removes the cancer but not the breast) depends less on her specific diagnosis than on other factors, such as where she lives, her income and health insurance, where she receives medical care, her age, and when her doctor was trained.
Experts agree that for most early-stage breast cancer (stage 0, 1, 2, or 3a), lumpectomy is just as safe as mastectomy, if the lumpectomy is followed by radiation treatment. 2 3 4 In fact, a 2013 study indicates lumpectomy patients live longer than mastectomy patients. 5 At a 1990 Conference sponsored by the National Institutes of Health, experts agreed that since survival rates were the same, lumpectomy followed by radiation is the preferable treatment for most women with early-stage breast cancer. But even today, almost 4 decades later, many women eligible for breast-conserving surgery are getting mastectomies. Although it’s been known for years that lumpectomy and other breast-saving surgeries are just as effective as mastectomy for patients in the early stages of breast cancer, in many parts of the country most of the women who receive an early-stage diagnosis will undergo the more radical and disfiguring surgery. Limited information and biased recommendations are undermining breast cancer patients’ choices.
Articles published in some of America’s most prestigious journals show that many of the 268,600 women who are newly diagnosed with invasive breast cancer and more than 60,000 women who are diagnosed with ductal carcinoma in situ (DCIS), or early-stage breast cancer, each year do not have access to all the information they need to make the treatment choices that are best for them. 6 7 This raises questions about what doctors know and what they are telling their patients.
In addition, mastectomy is often followed by “reconstructive” breast surgery that involves the use of synthetic breast implants or tissue transfers from other parts of the body. These reconstructive surgeries have risks, but the lack of published epidemiological studies means that many of the women making these decisions have limited information about their safety.
After all the research that has been done on the safety of lumpectomies, why are so many women undergoing mastectomies they don’t need and then having reconstruction that can cause serious problems? One reason is economic — surprisingly, it is less expensive to perform a mastectomy than a lumpectomy. In addition to a more time-consuming surgery, radiation adds to the cost of lumpectomy but is rarely required for mastectomy. Moreover, some insurance plans do not cover all the expenses of the lumpectomy or the radiation therapy, because they are usually outpatient procedures.
Surgical Treatment Disparities:
- In some hospitals, all breast cancer patients had mastectomies, regardless of their diagnosis. In one large urban hospital serving mostly poor women in Texas, 84% of the women with early stage breast cancer had mastectomies and only 16% had lumpectomies. 8
- In a study of 157 hospitals, patients treated by doctors trained before 1981 were less likely to have lumpectomies or other breast-saving surgery than women who had younger doctors. For decades, mastectomy was the standard treatment for breast cancer at any stage. Research showing the safety of lumpectomy dates from the mid 1980’s. 9
- One study indicated that women getting mastectomies were more likely to have followed their doctors’ recommendations, but women getting lumpectomies were more likely to have obtained a second opinion, and felt more actively involved in making the decision. 10
- Surgeons have a greater propensity towards performing breast-conserving surgery if they practice in an area with higher Medicare fees for breast-conserving surgery, believe in patient participation in treatment decisions, and are female. 11
Women deserve better. Breast cancer patients should make the choices that are best for them, wherever they live and no matter how affluent they are. We need to do a better job of making sure that all doctors and their patients have accurate, unbiased information so that women can make those choices, no matter who they are, or who provides their medical care.
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All articles are reviewed and approved by Diana Zuckerman, PhD, and other senior staff.
- Hawley ST, Jagsi R, Morrow M, Janz NK, Hamilton A, Graff JJ, Katz SJ. Social and clinical determinants of contralateral prophylactic mastectomy. JAMA surgery. 2014 Jun 1;149(6):582-9 ▲
- Fisher B, Anderson S, Redmond CK, Wolmark N, Wickerham DL, Cronin WM. Reanalysis and Results After 12 Years of Follow-up in a Randomized Clinical Trial Composing Total Mastectomy With Lumpectomy With or Without Irradiation in the Treatment of Breast Cancer. N Engl J Med 1995 Nov 30;333(22):1456-61. ▲
- Gangi, A et al.Breast-Conserving Therapy for Triple-Negative Breast Cancer. JAMA Surg. 2014;149(3):252-258. ▲
- Agarwal, S et al. Effect of Breast Conservation Therapy vs Mastectomy on Disease-Specific Survival for Early-Stage Breast Cancer. JAMA Surg. 2014;149(3):267-274. ▲
- Hwang ES, et al “Survival after lumpectomy and mastectomy for early stage invasive breast cancer: The effect of age and hormone receptor status” Cancer 2013 April 1; 119(7); DOI: 10.1002/cncr.27795. ▲
- U.S. Breast Cancer Statistics. Breastcancer.org. https://www.breastcancer.org/symptoms/understand_bc/statistics. Updated February 13, 2019. Accessed May 30, 2019. ▲
- Zuckerman DM. The need to improve informed consent for breast cancer patients. Journal of the American Medical Women’s Association (1972). 2000;55(5):285-9. ▲
- Dolan JT, Granchi TS. Low Rate of Breast Conservation Surgery in Large Urban Hospital Serving the Medically Indigent. Am J Surgery 1998 Dec;176(6):520-4. ▲
- Kotwall CA, Covington DL, Rutledge R, Churchill MP, Meyer AA. Patient, hospital, and surgeon factors associated with breast conservation surgery. A statewide analysis in North Carolina. Annals of surgery. 1996 Oct;224(4):419. ▲
- Morrow M, Jagsi R, Alderman AK, Griggs JJ, Hawley ST, Hamilton AS, Graff JJ, Katz SJ. Surgeon recommendations and receipt of mastectomy for treatment of breast cancer. Jama. 2009 Oct 14;302(14):1551-6. ▲
- Mandelblatt JS, Berg CD, Meropol NJ, et al. Measuring and Predicting Surgeons’ Practice Styles for Breast Cancer Treatment in Older Women. Med Care 2001 Mar;39(3):228-42. ▲