Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial.
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OBJECTIVES--To assess outside a clinical trial the psychological outcome of different treatment policies in women with early breast cancer who underwent either mastectomy or breast conservation surgery depending on the surgeon9s opinion or the patient9s choice. To determine whether the extent of psychiatric morbidity reported in women who underwent breast conservation surgery was associated with their participation in a randomised clinical trial. DESIGN--Prospective, multicentre study capitalising on individual and motivational differences among patients and the different management policies among surgeons for treating patients with early breast cancer. SETTING--12 District general hospitals, three London teaching hospitals, and four private hospitals. PATIENTS--269 Women under 75 with a probable diagnosis of stage I or II breast cancer who were referred to 22 different surgeons. INTERVENTIONS--Surgery and radiotherapy or adjuvant chemotherapy, or both, depending on the individual surgeon9s stated preferences for managing early breast cancer. MAIN OUTCOME MEASURES--Anxiety and depression as assessed by standard methods two weeks, three months, and 12 months after surgery. RESULTS--Of the 269 women, 31 were treated by surgeons who favoured mastectomy, 120 by surgeons who favoured breast conservation, and 118 by surgeons who offered a choice of treatment. Sixty two of the women treated by surgeons who offered a choice were eligible to choose their surgery, and 43 of these chose breast conserving surgery. The incidences of anxiety, depression, and sexual dysfunction were high in all treatment groups. There were no significant differences in the incidences of anxiety and depression between women who underwent mastectomy and those who underwent lumpectomy. A significant effect of surgeon type on the incidence of depression was observed, with patients treated by surgeons who offered a choice showing less depression than those treated by other surgeons (p = 0.06). There was no significant difference in psychiatric morbidity between women treated by surgeons who offered a choice who were eligible to choose their treatment and those in the same group who were not able to choose. Most of the women (159/244) gave fear of cancer as their primary fear rather than fear of losing a breast. The overall incidences of psychiatric morbidity in women who underwent mastectomy and those who underwent lumpectomy were similar to those found in the Cancer Research Campaign breast conservation study. At 12 months 28% of women who underwent mastectomy in the present study were anxious compared with 26% in the earlier study, and 27% of women in the present study who underwent lumpectomy were anxious compared with 31% in the earlier study. In both the present and earlier study 21% of women who underwent mastectomy were depressed, and 19% of women who underwent lumpectomy in the present study were depressed compared with 27% in the earlier study.) CONCLUSIONS--There is still no evidence that women with early breast cancer who undergo breast conservation surgery have less psychiatric morbidity after treatment than those who undergo mastectomy. Women who surrender autonomy for decision making by agreeing to participate in randomised clinical trials do not experience any different psychological, sexual, or social problems from those women who are treated for breast cancer outside a clinical trial.Keywords:
Lumpectomy
Depression
Breast-conserving surgery
Background: Lumpectomy and mastectomy remain the main surgical procedure of breast cancer as a part of treatment as well as management. This study was aimed to compare the early post-operative outcomes of lumpectomy (BCS) versus mastectomy (MRM). Methods: It was an observational study conducted at the Department of Surgical Oncology of National Institute of Cancer Research and Hospital (NICRH), Mohakhali, Dhaka, Bangladesh during the period from October 2016 to January 2019. The study sample consisted of 264 cancer patients who admitted in the hospital. The purposive sampling was done following inclusion criteria. Having collection of data, chi-square test was done to see the association of breast cancer among female patients. Results: Out of 264, 200 (75.75%) patients underwent mastectomy (MRM) and remaining percentage of patients underwent lumpectomy. The mean age of the patients was 37.69 (SD±10.31) and 44.82 (SD±7.65) in lumpectomy and mastectomy group respectively. Wound infection was present among 12.5% and 24% lumpectomy and mastectomy patients. Subsequently, seroma was present among 18.75% and 54% patients who underwent lumpectomy (BCS) and mastectomy (MRM) respectively which was statistically significant (P<0.014). Flap necrosis was found only among 16% mastectomy patients (P<0.04). There was significant difference in income and education among lumpectomy and mastectomy patients. However, the mean duration of hospital stay was 6.06±0.85 days and 17.70±4.70 days in lumpectomy (BCS) and mastectomy (MRM) group respectively which was statistically significant (P< 0.05). Conclusion: This study showed that lumpectomy (BCS) had early recovery and better post-operative treatment progress than mastectomy (MRM).
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FigureSAN ANTONIO—The cost of undergoing a mastectomy with reconstruction—especially if complications occur—is the most expensive management of breast cancer surgery, researchers reported here at the San Antonio Breast Cancer Symposium (Abstract S3-07). A study of Medicare and other nationwide data sources determined that the average mastectomy plus reconstruction—and the estimated costs of complications—pushed the average cost of a mastectomy and breast reconstruction within two years to $89,140, reported Benjamin Smith, MD, Associate Professor of Radiation Oncology at the University of Texas MD Anderson Cancer Center. That compares with an outlay of $65,719 for a lumpectomy and 15 sessions of whole-body radiation, a standard-of-care treatment. It also includes the cost of related complications of the procedure, he said at a news conference. That translates to a $23,000 difference. The complications surrounding mastectomy and breast reconstruction can cost an average of $10,005, the analysis found. Those complications are most often infections, he noted, adding that lumpectomy with radiation has a complication cost of $1,397—about a $9,000 difference. “There is a twofold increase in complications with mastectomy and reconstruction compared with lumpectomy and whole-body radiation, resulting in excess costs. The complication costs are lowest with mastectomy alone among younger women—an average of $1,914—and for lumpectomy alone for older women—an average of $696. “Infectious complications are the most common we are seeing with mastectomy and reconstruction surgery,” Smith continued. “Many can be treated with just antibiotics, but some infections require procedures. We also see hematomas and seromas. These can all occur after any of these procedures, but are much more common with mastectomy and reconstruction surgery.” Costs for Older Women Much Lower Those figures represent the costs for younger women—i.e., those with a mean age of 53. The figures follow a similar course when looking at women and their choices for breast cancer management who are among the Medicare population—but the costs for the older women are dramatically lower. For example, total costs including complications for mastectomy and reconstruction top out at $36,166, which is about $2,000 more than lumpectomy and whole body radiation and complication costs or $34,097, Smith said. “The difference between mastectomy and reconstruction is not that much more expensive than lumpectomy—if you can avoid complications. Our findings represent what the average patient treated with these treatments can expect in the community setting. I would be the first to acknowledge that the use of claims codes is imperfect and may not capture the severity of the complications.” ‘These Results Make Perfect Sense’ Asked for his perspective for this article, Kevin Hughes, MD, Co-director of the Avon Breast Evaluation Center at Massachusetts General Hospital Cancer Center and Associate Professor of Surgery at Harvard Medical School, said: “Breast reconstruction is a much bigger operation and certainly you are going to have a greater risk of complications. These results make perfect sense. “There are increased costs of doing the operation, and increased costs of complications. The complications from surgery, however, are very rare. If they were common we would not do the procedure. The complication rate may run to 10 to 15 percent, but many of those complications are minimal and are self-limiting.” The cost analyses were developed by analyzing costs involved with 44,344 women from the MarketScan Commercial Claim and Encounters Database for the younger women and 60,867 women over age 65 selected from the SEER-Medicare database. “Women with early-stage breast cancer have several local therapy options. Although there's nuance as far as what treatment is best for which patient, there is a large group of patients for whom most, if not all, of these treatment options are considered guideline-appropriate,” Smith said. Current guideline-concordant local therapy options for women with early-stage breast cancer include lumpectomy plus whole breast irradiation, lumpectomy plus brachytherapy, mastectomy without reconstruction or radiation, mastectomy with reconstruction without radiation, and lumpectomy without radiation. Believed to Be First Such Study “Mastectomy and reconstruction rates have been increasing in the United States in the past decade, and I think ours is the first study to quantify the harm associated with choosing this procedure as opposed to simpler options,” he said. The investigators collected information on women who were diagnosed with early-stage breast cancer in 2000 through 2011 and had complete insurance coverage for a year before and two years after diagnosis. “When oncologists offer all appropriate therapy options to patients, some women may choose to avoid radiation and opt for mastectomy and reconstruction instead. This study is helpful to such patients because it provides them with information regarding the trade-offs involved in this choice,” Smith said. Hughes said that after the rates of mastectomies dropped as women began learning of lumpectomy surgery, the rates of mastectomy in the last decade have begun rising again. “This phenomenon is totally patient-driven. I think it is mostly fear of cancer. Lumpectomy has maybe a five percent chance of recurrence, but some women think that is too high—even though cancer can return after mastectomy as well.” The study was supported by grants from the Department of Health & Human Services, Varian Medical Systems, and the Duncan Family Foundation.
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One hundred women with breast cancer suitable for lumpectomy or Patey mastectomy were studied. These women were seen consecutively and had presented to a consultant surgeon either as NHS or as a private patient. Each patient was offered either lumpectomy or mastectomy and was interviewed 12 months later to ascertain anxiety and depression. 45% of patients requested conservative surgery. 43% of the NHS patients and 67% of private patients favoured lumpectomy. However, age was a more discriminating factor with 88% of those < 55 years choosing lumpectomy but only 22% of those > 55 years of age. The principal reasons for conservative surgery were cosmetic (70%). Mastectomy was chosen by women who wanted ‘to get everything over with’ (80%). When interviewed at 12 months no woman regretted her decision. The psychological disturbance was similar in both lumpectomy and mastectomy patients. However the NHS patients faired better than those treated privately.
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Depression
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Total Mastectomy
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BACKGROUND: Despite equivalent oncologic outcomes and survivorship, U.S. lumpectomy rates previously declined in favor of more aggressive surgical options such as mastectomy, often performed in conjunction with a contralateral prophylactic mastectomy (CPM). Using three national datasets (the National Surgical Quality Improvement Program [NSQIP], Surveillance, Epidemiology, and End Results program [SEER], and the National Cancer Database [NCDB]), this study aims to evaluate longitudinal trends in lumpectomy, mastectomy, and CPM rates and to determine characteristics associated with current surgical practice. METHODS: An examination of the NSQIP, SEER, and NCDB databases was performed to evaluate trends in lumpectomy and mastectomy rates from 2005-2017. Longitudinal trends were analyzed using Cochran-Armitage Trend tests. We further examined mastectomy rates by assessing annual rates of unilateral mastectomy and CPM per 1000 mastectomies using Poisson regression. Upon determining a notable reversal in lumpectomy rates in 2013, we compared NCDB lumpectomy patients before (2011) and after (2017) this change. Multivariable logistic regression models were performed on the NCDB dataset to identify predictors of lumpectomy and contralateral prophylactic mastectomy. RESULTS: We analyzed a study sample of 3,467,152 female surgical breast cancer patients (1,912,771 lumpectomy patients; 1,554,381 mastectomy patients). Surgical trends were found to be similar in all three databases. Lumpectomy rates reached a nadir between 2010-2013, with a significant increase thereafter (all p<0.001). Conversely, mastectomy rates declined significantly beginning in 2013. Unilateral and contralateral prophylactic (bilateral) mastectomy rates increased significantly from 2005-2013 (all p<0.001) and subsequently stabilized after 2013, with unilateral mastectomy rates remaining higher than CPM throughout the entire time period. Age distribution of lumpectomy patients from 2011 to 2017 demonstrated an increase in patients 60-79 years of age (2011: 35.3%, 2017: 55.9%, p < 0.001) with a concurrent increase in the proportion of patients with Medicare (2011: 39.6%, 2017: 44.7%, p < 0.001). On multivariable logistic regression analysis, the strongest predictors of lumpectomy were older age, black race, treatment at a community center, and clinical N0 disease. The strongest predictors of CPM were younger age, white race, treatment at an integrated network cancer program, and residence in a zip code with a higher median income. CONCLUSION: This is the first study to document a reversal of trend in lumpectomy rates since 2013 with an associated decline in mastectomies. The steady increase in rates of CPM from 2005-2013 has since stabilized. While the databases differ in size and population, the trends are consistent among all three databases. The etiology of the recent reversal in trends is likely multifactorial; however, an increase in age of the breast cancer population is likely related to this change in the trends. Further qualitative and quantitative research is required to understand factors driving these recent practice changes and associated impact on patient reported outcomes.
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The recurrence and five year disease-free survival rates of 86 patients with carcinoma of the breast located in the medial quadrants who had either lumpectomy and radiotherapy or mastectomy were compared. Patients who had lumpectomy and mastectomy were comparable with respect to variables reflecting extent of the disease. One of 54 patients who had lumpectomy had a local recurrence and five had a recurrence regionally or at distant sites. In the group of 32 patients who had a mastectomy, one patient had a local recurrence and an additional four patients had a recurrence at other sites. The five year study disease-free survival rate was 83 per cent for the lumpectomy group and 78 per cent for the mastectomy group. These data suggest that, for medial quadrant lesions, there may be a disease-free survival advantage associated with lumpectomy and radiotherapy over mastectomy. Further study of this treatment modality for this subset of patients seems indicated.
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Quadrant (abdomen)
Breast carcinoma
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Abstract Purpose. To investigate the recurrence pattern and annual recurrence risk after breast-conserving surgery and compare them with those after mastectomy. Methods. This retrospective analysis included 6,135 consecutive unilateral breast cancer patients undergoing surgery in 1998–2008, with 847 lumpectomy patients and 5,288 mastectomy patients. Recurrence patterns were scrutinized and annual recurrence rates were calculated. Furthermore, a literature-based review including seven relevant studies was subsequently performed to confirm our single-institution data-based observations. Results. After lumpectomy, 50.9% of recurrences occurred within 3 years and 30.2% of recurrences were detected at 3–5 years; after mastectomy, 64.9% of recurrences occurred within 3 years and 20.4% occurred at 3–5 years. The major locoregional recurrence pattern after lumpectomy was ipsilateral breast tumor recurrence, which mainly (81.3%) occurred ≤5 years postsurgery but with a low incidence of 37.5% ≤3 years postsurgery. Annual recurrence curves indicated that the relapse peak after mastectomy emerged in the first 2 years; however, recurrence after lumpectomy increased annually with the highest peak near 5 years. By reviewing relevant studies, we confirmed our finding of different annual recurrence patterns for lumpectomy and mastectomy patients. The hazard ratio of dying for those recurring ≤5 years postlumpectomy relative to patients relapsing >5 years postlumpectomy was 4.62 (95% confidence interval, 1.05–20.28; p = .042). Conclusions. Different recurrence patterns between mastectomy and lumpectomy patients imply that scheduling of surveillance visits should be more frequent during the 4–6 years after lumpectomy. Further prospective trials addressing the necessity of frequent and longer surveillance after lumpectomy are warranted.
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Breast-conserving surgery
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The prevalence of breast cancer among women in compare to other types of cancers in all over the world and in Iran is high. Mastectomy surgery is one of the common treatments for these patients. Another method, which is less invasive, is Lumpectomy. This study comprised the satisfaction of patients under two types of surgery; Mastectomy and Lumpectomy.In this cross-sectional study, two types of patients which had either, Mastectomy or Lumpectomy, were studied.From 119 patients which studied here, 80 patients (66.7%) were treated by mastectomy and 39 patients (32.5%) were treated under lumpectomy. Two groups had not significant differences in duration between diagnostic and surgery, the number of lymph nodes involved and the number of lymph nodes removed. Lumpectomy patients had higher pain and numbness in 24 h, 1 week after surgery and at the time of study than the other group. The observed difference was significant (P = 0.043).It is implied in previous studies that patients under lumpectomy had more satisfaction than patients under mastectomy. However, no differences were observed in quality-of-life between the two groups in some other studies. The differences between various studies might be for the sake of cultural variety and time interval between surgery and filling questionnaire.
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Axillary lymph nodes
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