The number of women in the US undergoing breast-conserving therapy following a diagnosis of early-stage breast cancer has risen during the past 2 decades, according to a new study published in JAMA Surgery, though the authors reveal there are still barriers preventing women from receiving the treatment.
After skin cancer, breast cancer is the most common cancer among American women, estimated to affect around 1 in 8 at some point in their lives. The majority of women diagnosed with breast cancer undergo some form of surgery, particularly if the cancer is diagnosed in the early stages. The surgical options available include mastectomy and breast-conserving therapy (BCT), or lumpectomy.
While mastectomy involves full or partial removal of the breast tissue, BCT involves only the removal of the part of the breast containing the cancer. There are pros and cons with each procedure. With a mastectomy, a woman may lose an entire breast, while women who undergo BCT may be able to retain the majority of their breast tissue – making it a preferable option for many. However, women who have BCT often need to undergo radiation therapy for around 5-6 weeks following the surgery to ensure any remaining cancer cells are destroyed.
In 1990, the National Institutes of Health (NIH) issued a consensus statement in support of BCT as a treatment option for early-stage breast cancers, after a number of clinical trials demonstrated the efficacy of the procedure. As a result, rates of mastectomy reduced, while more women diagnosed with early-stage breast cancer opted for BCT.
However, the study authors – including Dr. Isabelle Bedrosian, of the University of Texas MD Anderson Cancer Center in Houston – note that there have been many technical advances in the past 10 years that have led to more women with early-stage breast cancer opting for mastectomy over BCT, despite being eligible for the latter procedure.
“These incentives include genetic testing for BRCA1 and BRCA2 mutation, advances in reconstruction techniques, breast magnetic resonance imaging (MRI) and increased patient interest in contralateral prophylactic mastectomy,” the authors note.
For their study, Dr. Bedrosian and colleagues set out to identify the rates of BCT among women in the US diagnosed with early-stage breast cancer, as well as to determine what influences women’s surgical decisions following a breast cancer diagnosis.
More than 60% of women opting for BCT, but treatment barriers remain
The team used the National Cancer Data Base to identify 727,927 women who had been diagnosed with early-stage breast cancer and had undergone surgery for the cancer between 1998 and 2011.
The researchers found that the percentage of women who opted for BCT increased from 54.3% in 1998 to 60.1% in 2011. An increase in BCT use was identified across all age groups.
Women aged 52-61 were more likely to undergo BCT, the team found, as were women with higher levels of education. BCT rates were also found to be greater among women who engaged in academic cancer programs, those who lived in the Northeast of the US, and those who lived less than 17 miles from a cancer treatment facility.
Rates of BCT among women without health insurance were found to be lower compared with women who had private health insurance, at 49.3% versus 62.3%. Women with the lowest average income were also less likely to undergo BCT.
While the study demonstrates that BCT usage increased during the 14-year period, the authors note that their findings reveal a number of factors that continue to restrict further use of the procedure:
“Disparities in the use of BCT based on age, geographic location and type of cancer program have improved since 1998. However, insurance, income and travel distance to treatment facilities persist as key barriers to BCT use. These socioeconomic barriers are unlikely to be erased without health policy changes.”
In an editorial linked to the study, Dr. Lisa A. Newman, of the University of Michigan in Ann Arbor, says the findings from Dr. Bedrosian and colleagues demonstrate an “unfortunate reality” that unequal access to care still influences patient health outcomes.
“Optimal breast-conserving surgery for most lumpectomy-eligible patients requires a commitment to a whole-breast radiation, delivered in daily fractions during a 6-week period,” she notes. “However, this strategy requires access to a radiation oncologist and specialized treatment facility.”
“Patients who lack daily transportation access, patients who cannot coordinate radiation treatments with job and/or child care responsibilities, and patients who live remote from a radiation facility face often insurmountable barriers to pursuing breast-conserving surgery, even if they have a disease pattern that is ideally suited for this treatment,” she continues.
Dr. Newman points to 2010 and 2011 studies from the American College of Surgeons Oncology Group, which demonstrated some long-term benefits of BCT, such as low recurrence rates. However, she notes that because of the barriers identified in this latest study, many patients will be unable to benefit from BCT.
“Tragically, disadvantage will continue to breed more disadvantage,” she concludes. Earlier this month, Medical News Today reported on a study revealing many breast cancer patients could be at half the risk of undergoing a second surgical procedure for the disease if the surgeon removes more tissue during a partial mastectomy.
Published: 18 June 2015. By Honor Whiteman
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