Surgeon's Role in Choice
There has been a great deal written about women's choices when considering whether to proceed with a wide excision/lumpectomy or a mastectomy when diagnosed with early stage breast cancer. As you probably know, in most situations, the health outcome is the same, and the choice is related to personal feelings, instincts, and history. Some women only feel relieved and safe if the whole breast is gone; many others prefer to keep a breast as long as it is as medically wise. And a few women, even if told that it would reduce their recurrence risk to have a mastectomy, insist on preserving their breast.
I was very interested to see this short article about the impact of the surgeon's role in this decision. Of course, we all listen to our surgeon's experience and suggestions and most of us do what is recommended. Thinking about the possibility that a surgeon's words are driven not only by medical knowledge but also by gender, age, and volume of breast surgery is a new twist. I think the bottom line about this is that most surgeons, probably almost all surgeons, make the surgical recommendation based only on their knowledge of what is the safest/best choice for you. If you are feeling at all unsure about this, it's time for a second opinion.
Here is the article: Annals of Surgery:
May 2009 - Volume 249 - Issue 5 - pp 828-833
Surgeon Characteristics and Use of Breast Conservation Surgery in Women With Early Stage Breast Cancer
Hershman, Dawn L. MD, MS; Buono, Donna MS; Jacobson, Judith S. PhD, MBA; McBride, Russell B. MPH; Tsai, Wei Yann PhD; Joseph, Kathie Ann MD, MPH; Neugut, Alfred I. MD, PhD
Background: Most women with localized breast cancer have a choice between mastectomy and breast conserving surgery (BCS). Aside from clinical factors, this decision may be associated with surgeon and patient characteristics. We investigated the effect of surgeon characteristics on the BCS rate.
Methods: We used the Surveillance, Epidemiology, and End Results-Medicare database to identify women >65 years, diagnosed with stages I-II BC, between 1991 and 2002, and used the Physician Unique Identification Number linked to the American Medical Association Masterfile to obtain information on surgeons. We investigated the association of patient demographic, tumor, and surgeon-related factors with receipt of BCS, using Generalized Estimating Equations to control for clustering.
Results: Of 56,768 women with breast cancer, 30,006 (53%) underwent BCS, whereas 26,762 (47%) underwent mastectomy. Between 1991 and 2002, the proportion of patients undergoing BCS increased from 35% to 60%. In a multivariate analysis, patients who received BCS were younger, of higher SES, and had more favorable tumor characteristics. They were also more likely to be black and live in metropolitan areas. Women who underwent BCS were more likely to have surgeons who were female (OR = 1.40; 95% CI: 1.25-1.55), US-trained (OR = 1.12; 95% CI: 1.02-1.22), with a larger patient panel (OR = 1.29; 95% CI: 1.21-1.39), and completed training after 1975 (OR = 1.16; 95% CI: 1.08-1.25), than surgeons of patients who underwent mastectomy.
Conclusions: Surgeon characteristics, such as gender, training, year of graduation, and volume, are small but significant independent predictor of BCS. Efforts to differentiate whether these associations reflect patients' preferences, quality of physician training, surgeon attitudes, physician patient communication, or other effects on decision-making are warranted.