Use of and Mortality After Bilateral Mastectomy Compared With Other Surgical Treatments for Breast Cancer in California, 1998-2011

Abstract

IMPORTANCE Bilateral mastectomy is increasingly used to treat unilateral breast cancer. Because it may have medical and psychosocial complications, a better understanding of its use and outcomes is essential to optimizing cancer care. OBJECTIVE To compare use of and mortality after bilateral mastectomy, breast-conserving therapy with radiation, and unilateral mastectomy. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study within the population-based California Cancer Registry; participants were women diagnosed with stages 0–III unilateral breast cancer in California from 1998 through 2011, with median follow-up of 89.1 months. MAIN OUTCOMES AND MEASURES Factors associated with surgery use (from polytomous logistic regression); overall and breast cancer–specific mortality (from propensity score weighting and Cox proportional hazards analysis). RESULTS Among 189 734 patients, the rate of bilateral mastectomy increased from 2.0% (95% CI, 1.7%–2.2%) in 1998 to 12.3% (95% CI, 11.8%–12.9%) in 2011, an annual increase of 14.3% (95% CI, 13.1%–15.5%); among women younger than 40 years, the rate increased from 3.6% (95% CI, 2.3%–5.0%) in 1998 to 33% (95% CI, 29.8%–36.5%) in 2011. Bilateral mastectomy was more often used by non-Hispanic white women, those with private insurance, and those who received care at a National Cancer Institute (NCI)–designated cancer center (8.6% [95% CI, 8.1%–9.2%] among NCI cancer center patients vs 6.0% [95% CI, 5.9%–6.1%] among non-NCI cancer center patients; odds ratio [OR], 1.13 [95% CI, 1.04–1.22]); in contrast, unilateral mastectomy was more often used by racial/ethnic minorities (Filipina, 52.8% [95% CI, 51.6%–54.0%]; OR, 2.00 [95% CI, 1.90–2.11] and Hispanic, 45.6% [95% CI, 45.0%–46.2%]; OR, 1.16 [95% CI, 1.13–1.20] vs non-Hispanic white, 35.2% [95% CI, 34.9%–35.5%]) and those with public/Medicaid insurance (48.4% [95% CI, 47.8%–48.9%]; OR, 1.08 [95% CI, 1.05–1.11] vs private insurance, 36.6% [95% CI, 36.3%–36.8%]). Compared with breast-conserving surgery with radiation (10-year mortality, 16.8% [95% CI, 16.6%–17.1%]), unilateral mastectomy was associated with higher all-cause mortality (hazard ratio [HR], 1.35 [95% CI, 1.32–1.39]; 10-year mortality, 20.1% [95% CI, 19.9%–20.4%]). There was no significant mortality difference compared with bilateral mastectomy (HR, 1.02 [95% CI, 0.94–1.11]; 10-year mortality, 18.8% [95% CI, 18.6%–19.0%]). Propensity analysis showed similar results. CONCLUSIONS AND RELEVANCE Use of bilateral mastectomy increased significantly throughout California from 1998 through 2011 and was not associated with lower mortality than that achieved with breast-conserving surgery plus radiation. Unilateral mastectomy was associated with higher mortality than were the other 2 surgical options.

Bilateral Mastectomy for Unilateral Breast Cancer: a Perplexing Trend

“…Analysis of data from the California Tumor Registry shed additional light on this issue [6]. These data suggested that trends in the utilization of CPM are closely linked to age at…”

“…Yet, the overall rate of mastectomy in the United States decreased from 40.8 % in 2000 to 37 % in 2006 (when mastectomy rates for invasive breast cancers and DCIS were considered together), indicating that lumpectomy was still the preferred option [4]. Taken together, these results indicate that more women were choosing lumpectomy in the United States, but among those who chose mastectomy, CPM was increasingly becoming the preferred option.Analysis of data from the California Tumor Registry shed additional light on this issue [6]. These data suggested that trends in the utilization of CPM are closely linked to age at…”

“…During the last 15 years, several observation studies have shown improved survival rates among women who undergo CPM versus unilateral mastectomy [6,[13][14][15][16][17][18][19]. These reports have likely influenced surgical decision-making, and may also partly account for the rapid increase in utilization of CPM.…”

General St. Gallen-2015 guidelines for the treatment of early breast cancer (adapted by the experts of the Russian Society of Breast Oncologists)

“…Хотя наблюдалось небольшое преимущество в показателе выживаемости [33], не была доступна информация о статусе BRCA, который, как известно, является показанием к профилактической мастэктомии и маркером получения пользы от такой операции [34]. За последние 2 десятилетия в США отмечается увеличение частоты выполнения контралатеральных профилактических мастэктомий, в частности у женщин моложе 40 лет [35]. В Европе такая тенденция менее выражена [36,37].…”

Enhancing breast projection in autologous reconstruction using the St Andrew’s coning technique and 3D volumetric analysis

“…The number of patients undergoing both prophylactic and therapeutic mastectomy has grown exponentially in the last decade due to the increased availability of genetic testing and breast cancer surveillance (1)(2)(3)(4). For post-mastectomy patients, autologous breast reconstruction has shown to significantly improve their psychosexual well-being and has subsequently become an integral part of the breast cancer treatment (5)(6)(7).…”