Although more women with early-stage breast cancer have been opting for breast conserving therapy (BCT) over mastectomy, variations in the use of BCT by sociodemographic factors persist, according to a study from researchers at the Medical College of Wisconsin in Milwaukee ( Medical Care 2002;40(3):1819[Medline]). Age, income, education, and population density continue to influence whether a woman will receive BCT or mastectomy.
The report also pointed out that some sociodemographic factors affect whether a woman will receive a complete BCTsurgical removal of the tumor and surrounding tissue accompanied by axillary node dissection and radiotherapyor only tumor removal.
"These are really two different issues with different implications," commented Ann Nattinger, M.D., coauthor of the study and chief of general internal medicine and professor of medicine at the Medical College of Wisconsin.
An Appropriate Alternative
Randomized clinical trials demonstrated in the 1980s that BCT is an appropriate alternative to mastectomy for the majority of women with early stage breast cancer. The evidence prompted a National Institutes of Health consensus panel to issue recommendations in 1990 stating that BCT is preferable to mastectomy for women with stage I and II breast cancer because it yields the same outcome while preserving the breast.
When BCT was introduced, variations in its use were observed. Younger women and women living in urban areas, for example, were more likely to receive BCT than older women or those living in more rural regions. Eventually these variations were expected to decline as knowledge about the therapy disseminated through the medical community.
But, contrary to these expectations, the differences in BCT use did not shrink during the time period analyzed by the Wisconsin researchers. "We were actually very surprised when we found that the use of BCT was not becoming more consistent over time," said Nattinger.
The researchers examined data from a cohort of 158,496 women aged 30 and older who had been treated for early stage breast cancer between 1983 and 1996. Data were drawn from the Surveillance, Epidemiology, and End Results (SEER) national tumor registries.
The results showed that women age 80 years and older were less likely to undergo complete BCT and more likely to receive incomplete BCT than women in the other age groups. Women living in counties with higher education levels were about 1.5 times more likely to receive complete BCT than women living in the least educated areas.
Those residing in the wealthiest counties were more likely to receive both complete and incomplete BCT than those living in the poorest counties. And women living in urban areas were also more likely to receive complete and incomplete BCT than those living in rural areas. No significant differences based on race were noted.
"The results led us to rethink the presumption that these variations in treatment were largely due to the surgeons knowledge of or comfort with the procedure," said Nattinger. Although many experts assume that variations in the use of BCT are not desirable, she said these findings suggest that it may be that patients who do not undergo BCT are making a choice that reflects their own circumstances. Whether this variation is acceptable depends on whether the differences are motivated by patient preferences or by forces external to the patient, she said.
Quality of Care
The second issuethe greater use of incomplete BCT in certain groups of womenraises concerns about quality of care, said Nattinger. Women who do not undergo the entire therapy BCT may be at greater risk for local disease, she said.
One of the main problems in determining whether women who are age 80 years or older should receive radiation therapy and axillary node dissection in addition to lumpectomy is a lack of relevant clinical trial data, said Rebecca Silliman, M.D., Ph.D., chief of the Geriatrics Section and professor of medicine and public health at Boston University Medical Center.
This is not only because older women are underrepresented in clinical trials, but also because there is concern about generalizing from existing data to this population. "The debate about how to treat older women is not being informed by clinical trials because trials to date have generally not been designed to answer the key relevant efficacy questions," she said.
Commenting on this study and similar reports, Monica Morrow, M.D., director of the Lynn Sage Breast Program at Northwestern University, Chicago, said what are needed now are studies that analyze the factors influencing the variations in breast cancer therapy. "We need good population-based studies on a broad spectrum of patients who have been treated by a variety of surgeons in different practice settings that would let us answer the question more universally."
![]() |
||||
|
Oxford University Press Privacy Policy and Legal Statement |