February 04, 2020
5 min read
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Many US women eligible for breast-conserving therapy still opt for mastectomy

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Mehra Golshan, MD, MBA
Mehra Golshan

Breast-conserving therapy, also known as lumpectomy, followed by radiation has been shown to be as effective as mastectomy for most women with breast cancer, conferring the same survival rates.

The less surgically extensive option may be considered preferable to mastectomy due to its shorter recovery time and favorable cosmetic outcomes.

For some women with large, operable breast cancer that normally would require mastectomy, neoadjuvant systemic therapy can shrink tumors and enable some women to instead undergo breast-conserving therapy (BCT).

Yet, results of a study published in JAMA Surgery showed that only 55% of women in the United States who became eligible for BCT after neoadjuvant systemic therapy chose the procedure over mastectomy, compared with 80% of women in Europe and Asia.

“We had studied this before in the United States, but this was the first time we compared with the rest of the world, and there was a significant difference,” Mehra Golshan, MD, MBA, the Dr. Abdul Mohsen and Sultana Al-Tuwaijri distinguished chair in surgical oncology at Brigham and Women’s Hospital and director of the breast surgical oncology fellowship at Dana-Farber/Brigham and Women’s Cancer Center, said in an interview with Healio. “Potentially, this could be due to associated costs, but it could also be societal factors. Did the cancer or inherited predisposition to cancer treatments of American celebrities such as Angelina Jolie and Christina Applegate resonate differently in the U.S. population than in the rest of the world? Or does the way the surgeon gives the information influence patient decision-making?”

Variations by region

Golshan and colleagues analyzed surgical decisions as part of their prespecified secondary analysis of the randomized, phase 3 BrighTNess trial, which included 634 women (median age, 51 years; range, 22-78) with operable, clinical stage II and stage III triple-negative breast cancer treated at 145 centers in 15 countries. All women underwent genetic testing for germline BRCA mutations and were randomly assigned to one of three 12-week chemotherapy regimens prior to surgery.

Researchers obtained data from surgical evaluations of BCT candidacy for 599 women.

Before neoadjuvant systemic therapy, 458 women (76%) had been deemed eligible for BCT and 141 women (24%) had been categorized as ineligible. After therapy, 75 (53.2%) of those previously ineligible become candidates for BCT.

Most women (68.1%) eligible for BCT underwent the procedure, including 42 (56%) of those who became eligible after neoadjuvant systemic therapy. However, researchers observed substantial variations in BCT rates based on location of treatment.

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An adjusted analysis controlling for baseline factors such as age, BRCA status, tumor size and smoking history showed women treated in Europe and Asia had a greater likelihood of undergoing BCT (OR = 2.66; 95% CI, 1.84-3.84) than those treated in North America.

Further, among those who tested negative for germline BRCA mutations and underwent mastectomy, North American women appeared far more likely to receive contralateral prophylactic mastectomy than women treated in Europe and Asia (70.4% vs. 20%; P < .001).

Anees Chagpar, MD, MBA, MPH, FACS, FRCS
Anees Chagpar

Anees Chagpar, MD, MBA, MPH, FACS, FRCS, full professor in the department of surgery at Yale School of Medicine, said several factors could influence a woman’s decision to choose one surgical intervention over another.

“Fear of recurrence, desire to avoid radiation, trepidation at having further imaging on an ongoing basis, and the availability of cosmetically acceptable immediate breast reconstruction are just a few reasons why women may opt for mastectomy over breast-conserving surgery,” Chagpar, who was not involved with the study by Golshan and colleagues, told Healio. “On the other hand, some women may wish to keep their breasts, as this is an important part of their femininity, sexuality and body image. The earlier return to work and quicker recovery may be factors they consider, as well.”

Financial factors

Cost may be a major factor that could explain some of the differences in surgery preference between women in the U.S. and those in other countries, according to researchers.

Women in Europe and Asia have higher out-of-pocket expenses for mastectomy than women in the U.S. Unlike in the United States, removal of the contralateral, unaffected breast and subsequent reconstruction are usually not covered by insurance in Europe and Asia, barring a genetic mutation that puts the patient at risk for contralateral involvement.

“If a patient is in Berlin or Seoul, for example, she would have to pay out-of-pocket, costs that could reach a hundred thousand dollars or more,” Golshan told Healio. “If her genetic test is negative for germline BRCA, or sometimes even if it’s positive, insurance may not cover the removal of the opposite breast.”

Chagpar said she and her colleague Julian Huang, MD, conducted a study in 2018 evaluating the impact of anticipated cost and financial burden on women’s decision to undergo contralateral prophylactic mastectomy in the U.S.

“We found that 16% of patients stated that their decision was at least in part influenced by anticipated cost,” she told Healio.

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The issue of cost is complex, and it is therefore difficult to draw overall conclusions about how it factors into a woman’s decision-making process, Chagpar added.

“Certainly, there are added costs of radiation and continued imaging for surveillance in patients who opt for breast conservation, but there are also costs of reconstruction for patients who opt for mastectomy with immediate reconstruction,” she told Healio. “Although many of these services are covered by insurance in the U.S., there are still copays and deductibles that patients consider, not to mention time off work and other ancillary costs that may not be readily calculable.”

Chagpar added that even within a country, the various types of insurance coverage available may influence the surgical decisions.

“It is difficult to make a blanket statement regarding how cost and insurance may affect this decision in other countries,” she said. “The nuances of health insurance coverage are unique to each country.”

Societal differences

According to Chagpar, variations in the demographics of women in other countries make it difficult to draw definitive conclusions about surgery preference among these women.

“Although this study found that women with triple-negative breast cancer in the U.S. were more likely to undergo mastectomy after neoadjuvant therapy than those in Europe and Asia, it is important to keep in mind the cohort of patients who were involved in this study,” she said. “Many women in low- to middle-income countries in Asia and Africa with triple-negative breast cancer, who were not included in this study, are even more likely to undergo mastectomy than women in the United States for a number of reasons: they often have a later stage at presentation, limited access to quality neoadjuvant chemotherapy or postoperative radiation therapy and, for many, even where breast-conserving surgery is feasible and radiation is available, the costs of such treatment is more prohibitive than mastectomy alone.”

Golshan added that BCT is as effective as mastectomy, with no difference in survival between the two procedures and a slightly higher risk for local recurrence with BCT compared with mastectomy.

“The clinician can give the patient the assurance that they’re going to be watching them much more carefully than they were in the past, that they will be looking for imaging changes, and that they will have a follow-up with the surgeon and the oncologist,” he said. “That, to me, is a very safe option to consider.”

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Chagpar agreed that, ultimately, the decision on which surgery to pursue is as distinct as the woman making it.

“Each patient should make this decision with their surgeon, taking into account all of the factors that are unique to them,” she said. “This is not a one-size-fits all, black-and-white decision that can, or should, be uniform for all patients.” – by Jennifer Byrne

References:

Golshan M, et al. JAMA. 2020;doi:10.1001/jamasurg.2019.5410.

Huang J and Chagpar A. Surgery. 2018;doi:10.1016/j.surg.2018.05.038.

For more information:

Anees Chagpar, MD, MBA, MPH, FACS, FRCS, can be reached at 310 Cedar St., Lauder Hall 118, New Haven, CT 06510; email: anees.chagpar@yale.edu.

Mehra Golshan, MD, MBA, can be reached at 75 Francis St., Boston, MA 02115; email: mgolshan@bwh.harvard.edu.

Disclosures: Chagpar and Golshan report no relevant financial disclosures.