More Women Are Choosing Breast-Conserving Surgery, but Disparities Remain

Lisa A Newman, MD, MPH

The number of women deciding to have breast-conserving therapy (BCT) to treat their early-stage breast cancer has been steadily increasing, but these gains are muted for some women due to such factors as insurance status, income, and travel distance to treatment centers, according to findings from the largest study to date examining patterns of BCT uptake over a 20-year period.

These findings, published online in JAMA Surgery, are based on an analysis by researchers at The University of Texas MD Anderson Cancer Center of the surgical choices of nearly 728,000 women with stage I/II breast cancer who were included in the National Cancer Data Base, a national oncology outcomes databank that includes approximately 70% of newly diagnosed cancer cases in the United States.

Overall, the percentage of patients with early-stage breast cancer who had BCT went up from 54.3% in 1998 to 60.1% in 2011, the researchers reported. Use of BCT was greater among women aged 52-61 and among women with higher education levels (62.8% and 61.7%, respectively) compared with younger patients (57.8%).

BCT rates increased more than 10% over the two decades analyzed for women receiving treatment in community cancer programs (48.4% in 1998 to 58.8% in 2011) and those receiving treatment in the South (45.1% and 55.3%, respectively).

Notable differences in BCT uptake were observed among certain patient subgroups, however, especially for those without insurance (49.3%) and among those with the lowest median income (51.1%), compared with patients who had private insurance (62.3%).

“Looking at the big picture, strides have been made to reduce disparities in the use of this very effective treatment for women with early-stage breast cancer,” noted principal investigator Isabelle Bedrosian, MD, FACS, an associate professor in the Department of Surgical Oncology, and medical director of the Nellie B. Connelly Breast Center at MD Anderson, in a statement.

“However, these data also demonstrate the breadth of the socioeconomic factors that need to be considered to adequately address the disparate use of BCT across demographic groups,” she added.

Rates of BCT also were comparatively higher in the Northeast (64.5%) versus 52% in the South, where women often have longer distances to travel to treatment facilities, the researchers suggested. Another factor for low-income women is that it may be harder for them to take the time needed for the 6-week course of radiotherapy usually prescribed with BCT.

“Optimal breast-conserving surgery for most lumpectomy-eligible patients requires a commitment to whole-breast radiation,” explained Lisa A Newman, MD, MPH, a professor of surgery and director of the University of Michigan Breast Care Center, in a related commentary on the study. “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.”

The National Institutes of Health’s 1990 consensus statement supporting BCT for early-stage breast cancer resulted in a substantial reduction in mastectomy rates. During the past decade, however, the researchers noted that other developments (eg, genetic testing for BRCA1/2 mutations, advances in breast reconstruction techniques, and increased interest in contralateral prophylactic mastectomy) have tempered this trend toward increased use of BCT in some women who opt for mastectomy instead.

At the start of the study period in 1998, most BCT was performed at institutions with academic/research programs, but during the ensuing decades, rates of BCT increased significantly at nonacademic programs. Access to a treatment facility with academic/research programs remained associated with greater use of BCT, however, as was living in the Northeast and residing within 17 miles of a treatment facility.

Nevertheless, study authors noted that one of the most encouraging findings of their analysis is, “the considerable improvement of disparities based on facility type and the options afforded to older populations,” although women aged >70 years continue to have mastectomies at higher rates than younger patients.

Lautner M, Lin, H, Shen Y, et al. Disparities in the use of breast-conserving therapy among patients with early-stage breast cancer [published online June 17, 2015]. JAMA Surg.