When Informed, All Women Do Not Prefer Breast Conservation

The article by Collins et al in this issue of Journal of Clinical Oncology sheds light on the controversy about increased mastectomy rates in the United States and informs the debate as to whether there should be a quality metric for the rates of mastectomy. The authors clearly demonstrate that when breast conservation surgery (BCS) and mastectomy are both options for local treatment, all women do not prefer BCS. Certainly, when there is considerable variation in the rates of mastectomy by race and geographic region, there is cause for concern as to whether patients are being adequately informed about their choices. Morrow et al demonstrated that, in a review of more than 16,000 patients across the country with stage I and II tumors, mastectomy rates ranged from 46% in the Northeast to 68% in the South. Although the study by Collins et al represents a relatively uniform population from the Northeast, we know that all of the women in the study were extremely well informed, as demonstrated by their high scores on the knowledge survey, and understood the choice between, and the impact of, mastectomy and BCS. Even though only half of patients enrolled finished all three questionnaires, the authors state that the responders and nonresponders were not significantly different. Armed with full understanding of their choices, a substantial fraction of women (35%) preferred mastectomy. This report shows that, in this fairly well-educated, predominantly white population, specifically eliciting preferences from women about three issues will help both the patient and the physician to come to a decision about the optimal choice for that patient. For the surgery decision, the questions are how interested are you in preserving your breast; how important is peace of mind; and how important is it for you to avoid radiation? Peace of mind likely reflects the interest on the part of the patient to forget about that breast and to stop worrying that there is a remnant of disease, which can recur. In discussing these issues with patients, it is not uncommon for women at high risk, who have been screened intensively and have had the experience of multiple recalls and biopsies, to choose bilateral mastectomy when diagnosed with breast cancer. For them, the desire to have peace of mind, to avoid the experience of screening, and to eliminate the anxiety associated with a recall for additional imaging and biopsies makes mastectomy seem the obvious choice. Choice also depends on life circumstances. For the young married woman with small children versus a woman who has grown children, or for a single woman versus a woman who has already found her life partner, motivation and priorities may be different, and these will inform decision making and treatment choices. It is interesting that the Dartmouth group showed that younger women and those with higher stage of disease chose mastectomy even when they had the option for BCS. Sometimes women feel less certain that screening will work for them when they have a larger tumor at the time of diagnosis, especially if the cancer was not detected on routine screening. However, some women will have just the opposite reaction and want to do anything they can to preserve the breast. What is important is that there are genuine differences between treatment choices among women with similar presentations. It is because the options are associated with equivalent survival that it is so critical to make sure that women are full participants in the decision-making process. When initially undecided, and given tools and time for decision making, most patients chose BCS. Interestingly, the slightly higher local recurrence rate associated with BCS was not significant in influencing decisions, possibly because the difference is small and other factors are more dominant. Of the 78 patients who were sure about the decision at the beginning of the process, 20% changed their minds— almost all to BCS from mastectomy. Most changed their minds after realizing that BCS truly was an option. This highlights the importance of giving women time to absorb the information and think about their decision. Many women will feel differently a week after their diagnosis. The initial reaction can certainly be to just get rid of the breast. Once the shock of their cancer diagnosis fades and they have time to reflect on the treatment options and their implications, a significant portion of women will change to BCS. The educational process used by the group described by Collins et al built in time for reflection by making sure women watched the shared decision-making video tape and had time to consider their choices before the surgical consultation. This study also clearly shows that the information that is elicited from patients about their values can be presented to the surgeons at the time of consultation; this information seems to increase the efficacy of the consultation. In this study, 43% of women were unsure about their surgical decisions at the beginning of the process. Even after seeing the shared decision-making tool, 33% were unsure. When informed patients met with surgeons aware of patients values and preferences, the uncertainty resolved for almost all patients. This suggests that if we provide women with the salient facts, elicit their preferences, and discuss the options in that context, they come to a consultation better informed and more involved in the process. It also underscores the value of the surgeon’s role in the decision-making JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 27 NUMBER 4 FEBRUARY 1 2009