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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.

Why have procedure?
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.

Doctors unsure
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.

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Myth vs. reality
A number of misconceptions exist regarding breast cancer and its treatment. They include:

Myth: Mastectomy is safer in the long run than lumpectomy.

Reality: Both show similar long-term rates of cancer recurrence

Myth: Only women get breast cancer.

Reality: Men represent about 1 percent of breast cancer cases.

Myth: Whether a women undergoes chemotherapy depends on the surgery she has.

Reality: Chemotherapy depends on a tumor's stage, not its size.

Myth: If your grandmother and/or mother had breast cancer, you will get it.

Reality: Family history is only one risk factor.

Myth: If you are cancer-free after five years, you are cured.

Reality: Although the chances of recurrence are greatest in the first two years after diagnosis, cancer can return at any time.

Myth: Mammograms prevent breast cancer.

Reality: They can only detect cancers, not cure them.

Myth: Antiperspirants cause breast cancer.

Reality: This is just a rumor and is too simplistic to be true.

Myth: A high-fat diet is linked to breast cancer.

Reality: Studies have not shown that a high-fat diet decreases risk.

Myth: One in eight women will develop breast cancer.

Reality: If all women lived to be 85 years old, one in eight would develop breast cancer.

Myth: Breast cancer is a death sentence.

Reality: Although it is the second-leading cause of cancer death in women, the vast majority of women with breast cancer live at least five years.

Source: OU Physicians; Breast Cancer Action

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