factors associated with bilateral vs. unilateral mastectomy in a diverse, population-based sample of...
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Factors Associated with Bilateral vs. Unilateral Mastectomy in a Diverse, Population-based Sample of Breast Cancer Patients
Sarah T. Hawley, PhD, MPHUniversity of MichiganAnn Arbor VA Medical Center
AcknowledgementsAmy Alderman, MD
Reshma Jagsi, MD, DPhilJennifer Griggs, MD, MPH
Nancy Janz PhDAnn Hamilton, PhD
John Graff, PhDSteven Katz, MD
University of MichiganAnn Arbor VA Medical Center
Los Angeles and Detroit Metropolitan Area SEER RegistriesUniversity of Southern California and Wayne State University
Funded by the National Cancer Institute (R01 CA088370)
Background
• Rates of bilateral mastectomy among women with cancer in one breast have been increasing over the past decade
• Bilateral mastectomy has been associated with younger age, white race, previous cancer diagnosis, lobular histology (Tuttle 2009, Tuttle 2007)
Gaps in Research
• Few studies have patient report of receipt of bilateral mastectomy
• Lack of good measures of the role of family history or genetic predisposition
• No large studies have included patient attitudes toward surgical treatment decision making
• Decision-making for bilateral vs. unilateral mastectomy or lumpectomy may be different
Research Objectives
• To evaluate rates of bilateral mastectomy in a racially/ethnically diverse, population based sample of recently diagnosed breast cancer patients
• To compare factors associated with receipt of bilateral mastectomy to unilateral mastectomy and lumpectomy
Study Sample
• All women age < 79 with ductal carcinoma in situ (DCIS) and a 20% random sample of those with invasive cancer reported to the Detroit and Los Angeles SEER registries in 2002
• Surveyed a mean of 9 months post-diagnosis
• 2,647 accrued, 2,382 eligible, 1,844 responded (RR=77.4%)
• Survey data merged to SEER data
Measures• Primary outcome: type of surgery
received obtained from patient self-report– Any mastectomy vs. lumpectomy– Bilateral vs. unilateral mastectomy
• Independent variables– Patient demographics (age, race,
education, marital status)– 1st degree family history– Tumor stage
Patient Attitudes Toward Surgery
When decisions were being made about your surgery, how important was it to you that the type of surgery you had:
Recurrence Body Image
Would keep you from worrying about the cancer coming back
Would not make you feel bad about your body
Would allow you to avoid a 2nd surgery
Would not interfere with your sex life
Would reduce the chance of cancer coming back
Would allow you to feel feminine
Analytic Methods
• Descriptive statistics across all variables• Chi-square and t-tests used to examine
differences in surgery received and independent variables
• Two-part logistic regression model:– Any mastectomy vs. lumpectomy– Bilateral vs. unilateral mastectomy
Sample Characteristics (N=1,844)
%, mean
Mean age 60
Married/partnered 58
RaceWhiteAALatina/other
701812
EducationH.S. graduate or lessSome college or more
3664
1st degree family history 9
Stage 0IIIIII
3732229
Patient attitudes toward surgery
0
10
20
30
40
50
60
70
80
90
100
Recurrence Body image
Very important
Somewhat important
Not important
Overall rates of surgery
65
35
0
10
20
30
40
50
60
70
Any mastectomy (N=646) Lumpectomy (N=1198)
Mastectomy-treated patients
87
13
0
10
20
30
40
50
60
70
80
90
100
Bilateral mastectomy (n=84) Unilateral mastectomy (n=562)
Factors Associated with Surgery
0.75 (0.35-1.63)1.000.89 (0.37-2.16)0.41 (0.10-1.62)**
1.30 (0.84-2.01)1.001.87 (1.18-2.95)4.97 (2.51-9.83)*
Stage 0Stage IStage IIStage III
2.76 (1.14-6.68)1.00 (0.50-2.01)
6.77 (4.67-9.82)0.57 (0.38-0.84)
Patient attitudesRecurrence concernsBody image concerns
3.00 (1.36-3.61)1.10 (0.61-1.18)1st degree family history
0.94 (0.92-0.97)1.58 (1.20-1.86)
1.00 (0.99-1.02)1.16 (0.84-1.61)
DemographicsAgeWhite (vs. Non-white)
Bilateral vs. unilateral mastectomy (N=646)
Any mastectomy vs. lumpectomy(N=1,844)
* Wald Chi-square=25.26, p=0.000
** Wald Chi-square=1.83, p=0.607
Limitations
• Cross sectional survey• Small absolute number of bilateral
mastectomy• May not be generalizable outside of
Detroit or Los Angeles• No information regarding patient use of
genetic testing and/or genetic mutations
Summary• Decision making for any mastectomy vs.
lumpectomy is different from that for bilateral vs. unilateral mastectomy– The former is driven largely by stage and
patient attitudes– The latter is associated with high risk for a
new primary (younger age, white race, 1st degree family history)
– Patient concerns about recurrence appear to affect bilateral mastectomy decisions
Implications
• Further work to evaluate how and when women make bilateral mastectomy decisions is needed
• Providers need to be prepared to discuss bilateral mastectomy with patients
• Tools to help women understand the risks and benefits of bilateral mastectomy vs. other surgical options may be useful in decision making– Family history– Risk of recurrence
Thank you
CanSORT www.cansort.org
USCAnn Hamilton
Dennis Deapen
Wayne StateJohn Graff
Kendra Schwartz
U of MPublic Health
Nancy Janz
Medical SchoolSteven Katz
Sarah Hawley Jennifer GriggsAmy AldermanReshma Jagsi
Tim Hofer Chris FrieseArden Morris
Samantha HendrenChris Sonnenday
David Miller
Cancer Center American CollegeOf Surgeons
Connie BuraDavid Winchester
Sloan-KetteringMonica Morrow
UC BerkeleyMahasin Mujahid
RandAndy Dick
Patient report vs. SEER
Patient reportN
SEER codes Bilateral mastectomy
Unilateral mastectomy
Lumpectomy 10 53
Unilateral mastectomy
25 450
Double mastectomy 37 2