Breast-conserving surgery provides results equivalent to those of traditional modified radical mastectomy in approximately 75 percent of women with early-stage breast cancers. Nevertheless, only about one half of eligible women with in situ or stage I breast cancers and about 30 percent with stage II cancers undergo breast-conserving surgery. The proportion of eligible women undergoing breast-conserving surgery is increasing but varies greatly among regions of the country (e.g., 75 percent in Massachusetts; 48 percent in Minnesota). Use of breast-conserving surgery is linked to size of home community, affiliation of hospital with a medical school and availability of radiation facilities. The advice of the surgeon is highly influential in decisions about the type of surgery. Women are reported to follow surgical advice about 90 percent of the time when choosing between breastconserving surgery and modified radical mastectomy. Nold and colleagues studied factors influencing the choice of surgical strategy by patients with early breast cancer.
More than 130 women who had been treated surgically for breast cancer between 1994 and 1999 by one female and one male surgeon in a midwestern city were surveyed. The surgeons had determined if the patient was a candidate for breast-conserving surgery, and patients had been selected because of suitability for either strategy. The patients were surveyed by mail or by follow-up telephone calls. Attempts were made to contact patients who did not return surveys. Most of the survey questions concerned factors that influenced patients' decisions about choice of surgical strategy. Other data collected included satisfaction with information provided and treatment administered, demographic information and data about factors related to opinions about cancer and its treatment. Patients ranked these items using a one-to-five Likert scale
|Factor||Number of responses||Median (25th, 75th percentiles)*|
|Fear of breast cancer||94||4 (2, 5)|
|Surgeon||95||3 (1, 5)|
|Concern about radiation||95||3 (1, 5)|
|Cosmetic appearance||94||2 (1, 4)|
|Psychologic aspects||93||2 (1, 4)|
|Family||96||2 (1, 4)|
|Family history||96||1 (1, 3.5)|
|Medical oncologist||95||1 (1, 3)|
|Primary care physician||94||1 (1, 2)|
|Time for radiation therapy||95||1 (1, 3)|
|Previous (personal) history||96||1 (1, 1)|
|Travel for radiation||96||1 (1, 1)|
|Insurance||95||1 (1, 1)|
Ninety-six usable surveys (71.6 percent) were returned. The average age of the patients was 62 years (range: 36 to 84), and more than 90 percent were white. Forty-five percent of the respondents had undergone breast-conserving surgery, and patients in this group were significantly younger than patients treated with modified radical mastectomy. More breast-conserving surgeries were performed by the surgeon whose practice was breast-based (50 percent) than by the surgeon whose practice was more varied (28 percent).
The respondents overwhelmingly reported that treatment options had been satisfactorily explained before surgery. The most influential factor in decision making was fear of breast cancer followed by the advice of the surgeon and concern about radiation therapy. The latter two factors were rated equally (see the accompanying table). Concerns about cosmetic appearance, family attitudes and psychologic aspects of treatment were the next most common factors in decision making. Medical insurance and concerns about travel for treatment were not important factors in the patients studied. The advice of the surgeon was particularly significant for women who chose breast-conserving surgery. They were also highly influenced by cosmetic result and psychologic aspects of the disease and its treatment. Women who selected modified radical mastectomy were predominately motivated by fear of cancer.
The authors conclude that the surgeon's input is an important factor for women making decisions about surgical treatment of breast cancer. However, in many women, fear of cancer is the predominant concern and leads to a preference for modified radical mastectomy.