Mastectomy rate has officials asking why options not used

By Jeff Raymond

Published: September 23, 2007

Oklahoma ranks fifth nationally in the rate at which women have breasts removed because of cancer.

Data from the Centers for Medicare and Medicaid Services from 2003, the most recent year available on the Dartmouth Atlas of Health Care Web site, show Oklahoma has a high prevalence of mastectomies to treat breast cancer among Medicare enrollees. Researchers often use Medicare patients for health care measurements because data are collected nationally and available for comparisons, and the elderly make up a large percentage of hospital visitors.

In 2003 in Oklahoma, 1.6 out of every 1,000 Medicare enrollees had mastectomies. The national rate was 1.2 per 1,000. The state had 398,604 Medicare recipients that year, so the difference between the two rates means approximately 150 additional mastectomies.

That year, Oklahoma women had 2,400 new breast cancer diagnoses, according to the American Cancer Society. The mastectomy rate varies from year to year and dropped in at least one subsequent year, but to focus on the up and down is to miss the larger picture — why do women have breasts removed when it may not be medically necessary?

The breast removal rate poses questions of whether the high-tech expertise and treatment available in Oklahoma City and Tulsa lead to earlier discovery of tumors and thus to pre-emptive mastectomies, and whether Oklahomans who live outside the metropolitan areas are getting the same advanced breast cancer care.

Oklahoma City is equipped with several breast MRIs and hospitals with women's health centers and specialists in breast cancer.

Further complicating matters is research that shows women who have radiation treatment and lump removal have the same survival rate as those who have mastectomies, doctors say.

Some observers believe it's more psychological than medical. Others question whether the mastectomy rate is a reliable indicator of treatment quality.

"That's the million-dollar question that no one in the nation has really been able to answer conclusively,” OU Physicians Surgeon Dr. Ronald Squires said of why so many women choose mastectomies and why regional differences persist.

Dr. Alan Hollingsworthfocuses his practice on women's breast health. In an e-mail, he called the breast-removal rate a "controversial parameter.”

"It has been theorized that in those areas with very high lumpectomy rates, women are being pushed this direction when they, perhaps, are more comfortable undergoing mastectomy,” he explained, noting that about 80 percent of women are lumpectomy candidates.

"Studies have shown that when women are allowed to contribute more and play a vital role in the decision process, the mastectomy rate goes up, not down. These findings have prompted all sorts of psychological studies trying to figure out why women choose mastectomy when their doctors offer lumpectomy,” he said.

In rural areas, he said, women sometimes don't hear of lumpectomies as a viable option or choose mastectomies because they don't have access to the necessary daily radiation therapy.

Although he was unfamiliar with Oklahoma's numbers, Hollingsworth had ready access to numbers from Mercy Health Center, where he works, having recently written a paper on the subject. At Mercy, and nationally, 60 percent of women have lumpectomies, he said. As for whether high-tech tools lead to more mastectomies, he said they may, but that's not necessarily a bad thing because they catch tumors early or reveal them to be larger than expected.

Mercy's lumpectomy rate has grown since it began using a breast MRI.

"It's a very complex issue — an interplay of physician preferences (and biases), patient preferences (and biases), and now, with MRI technology,” he concluded.

Tonya Hughes, a registered nurse with OU Physicians, knows the complex calculus that goes through a woman's head when she is told she has breast cancer.

Hughes was diagnosed at 33. After mulling her options, she had both breasts removed even though one had not shown signs of having cancer. She is now 35 and completed her breast reconstruction in February. She said the peace of mind from knowing her breasts would not likely become cancerous again was reason enough to have them removed.

Other women, she acknowledged, see things differently. Hughes would know: She now helps women navigate the confusion of breast cancer treatment and life afterward as a "patient advocate” for the physicians group.

Each woman's circumstances are different and individual, she explained.

In her case, doctors couldn't remove a safe "margin” around her tumor to be satisfied. She decided to have her breast removed because she didn't feel good about radiation treatment and was following her gut reaction. She then decided to have the cancer-free breast removed also.

For women who choose mastectomies, Hughes stressed that their reconstructed breasts will not look the same or better than before — breast augmentation, it's not.

Breast cancer is not a death sentence, she said, but women need to be aware of their options.

"We're not going to offer you inferior cancer treatment,” said Squires, whose practice includes many breast cancer patients.

He said surgeons should be able to present information in such a way that it overcomes their bias toward or against certain procedures.

Physician bias can be measured, he noted, but the effect of a woman's socioeconomic status on surgery selection is harder to coax out.

The impediment of daily external beam radiation treatment likely plays a role, he said, especially when patients live some distance from a radiation center.

And fear of chemotherapy, even though it isn't tied to which surgery is chosen, is common.

"It's no small investment of a patient's time,” he said of radiation.

Accelerated partial breast irradiation, which involves implanting a radiation source in the breast, is still in the evaluation stage and isn't widely available.

The effectiveness of radiation, he said, is greatest seven years after the lumpectomy is performed. Radiation is needed because sometimes rogue cells have migrated into ducts to other places in the breast, which the lumpectomy doesn't catch.

In young women, however, exposure to radiation may put them at greater risk for future recurrence.

"All of the studies have shown equal disease-free survival and overall survival,” he said.

When Squires sits down with a newly diagnosed woman, he makes sure to spend as much time as necessary to fully explain treatment options.

"The only advantage of lumpectomy is cosmetic,” he said, but added that he wasn't downplaying the importance of appearance to his patients. Some listen to his impartial explanation of the pros and cons of each procedure while others cut him off. They often ask him what he would suggest to his wife or mother. His response is to think things over.

Of which choice a woman will make, he said: "I can't predict.”

"I think a lot of it depends on how much time you spend with the woman,” he said.

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