Reasons for Mastectomy in Early Stage Breast Cancer: An Institutional Review

1. Reasons for Mastectomy in Early Stage Breast Cancer: An Institutional Review Rosebella Agola, MD, MPH Greg Bearden MD, FACS Baptist Health System General Surgery Residency Program

2. Introduction • Early stage breast cancer: cancer that has not spread beyond the breast or axillary lymph nodes • Stage 0, I and II based on American Joint Commission on Cancer (AJCC) classification • Surgical options for treating early stage breast cancer include • Mastectomy: removing entire breast • Breast conserving surgery (BCS): removing part of the breast or lumpectomy, followed by radiation therapy. • Using breast conserving surgery (BCS) to treat patients with early stage breast cancer is a nationally accepted standard of care. • A 50% breast conservation rate is considered the minimum standard in order to meet National Accreditation Program for Breast Centers (NAPBC) compliance • Compliance is evaluated annually. • Published data shows that most centers exceed the 50% BCS rate. • At Princeton Hospital the overall rate of BCS over two years (2010 to 2011) was 54%.

3. Princeton Hospital BCS RatesComparing 2010 and 2011 BCS rate fell from 61% to 50%

4. Objective To find out reasons why patients with stage 0-II breast cancer were treated with mastectomy over breast conserving surgery.

5. Materials and Methods • A retrospective review of data from Princeton Hospital’s Breast Cancer registry was conducted to identify patients with Stage 0, I and II breast cancer who were treated with either mastectomy or BCS between 2010 and 2011 • Exclusion criteria included surgery done at an outside facility or incomplete data in the medical chart. • Reasons for mastectomy were identified as: • Patient choice • Surgeon choice • Failed BCS (inability to obtain negative margins after lumpectomy) • Bilateral breast cancer • Previous breast cancer • Multicentricity

6. Material and Methods • The medical chart of each patient in the mastectomy group was reviewed to identify reasons for mastectomy. • The following data were also reviewed regarding patient and tumor characteristics in each group • Race • Age • Histology • Tumor stage • Tumor Size • Node status • Patient and tumor characteristics were then independently compared between the BCS group and the mastectomy group. • Odds ratios (ORs) were analyzed to determine association with mastectomy. • This was done using MS Excel XLSTAT software.

7. Results • Between January 2010 and December 2011, 218 patients had surgery for early stage breast cancer. • 28 patients were excluded based on our exclusion criteria. • A total of 190 patients were identified as either having had a mastectomy or BCS at Princeton Hospital • 89 patients in the mastectomy group • 101 patients in the BCS group. • Patient and tumor characteristics were reviewed and compared according to surgery type.

9. Results • Results of medical chart review of mastectomy group • 79% (70 out of 89) of patients in the mastectomy group had identifiable reasons for mastectomy. • Patient choice (31% ) • Surgeon choice( 3% ) • Failed BCS(28%) • Previous breast cancer (15%) • Bilateral breast cancer (9%) • Multicentricity (8%)

10. Mastectomy Group

11. Results • 21% (19 out of 89) patients in the mastectomy group had unknown reasons for mastectomy. • Characteristics of this group • Mean age of 63. • All had invasive cancer. • 63% (12 out of 19) had tumor stage II. • 68% (13 out of 19) had tumor size < 3cm. • 68% (13 out of 19) had negative node status.

12. Results • Patient and tumor characteristics were analyzed to determine if they were positively associated with mastectomy. • Neither race nor age showed a statistically significant association with increased likelihood of mastectomy (P>0.05, respectively). • Invasive cancer (OR 3.4), positive node status (OR 2.5) tumor stage II (2.23) and tumor size >3cm (OR 3.17) were all independently associated with an increased likelihood of mastectomy over BCS (p<0.05, respectively).

13. Conclusion • Patient choice was the most common reason for mastectomy . • These patients were candidates for BCS on initial evaluation • Patients likely opted out based on personal perceptions of increased risk, family history or for “peace of mind.” • Published studies have also shown patient choice to be a significant determinant of mastectomy rates. • Patients with bilateral breast cancer, history of previous breast cancer, and multicentricity contributed to the overall mastectomy rate but were not candidates for BCS on initial evaluation. • Failed BCS included patients who initially opted for BCS • Surgeon choice/influence has been reported as a significant predictor of BCS versus mastectomy rates in other studies

14. Conclusion • Shortcomings of study based on chart documentation • Unless explicitly stated in the chart it was difficult to determine precise reasons for opting for mastectomy. • We suggest a prospective analysis where specific reasons for choosing mastectomy versus BCS are documented in the breast cancer registry. • Can be used to accurately track and analyze specific determinants of breast conservation versus mastectomy rates. • This information can also be used to improve compliance with NAPBC standards. • Future directions • Further analysis of patient and tumor characteristics to determine true predictors of BCS versus mastectomy • Analysis of surgeon characteristics and association with BCT versus mastectomy

15. Acknowledgements • Dr Greg Bearden, MD, FACS • Judy Lang, Cancer/Trauma Registry Coordinator, Princeton Baptist Medical Center

16. References • Lee MC, Rogers K, Griffith K, et al “ Determinants of Breast Conservation Rates: Reasons for Mastectomy at a Comprehensive Cancer Center.” Breast J. 2009. Jan-Feb: 15(1):31-40. • Hiotis, K., Ye W., Sposto R, and Sinner, KA” Predictors of breast conservation therapy. “Cancer. 2005, 103: 892-899. • Kandace PM, Alredo AS, et al “ Are Mastectomies on the rise? A 13-Year Trend Analysis of the Selection of Mastectomy Versus Breast Conservation Therapy “ Ann SurgOncol (2009) 16: 2682-2690. • National Accreditation Program for Breast Centers , “ Breast conservation” NAPBC Standards Manual .2012:32. • Morrow, M., White, J., et al” Factors Predicting the use of Breast Conserving Therapy in Stage I and II Breast Carcinoma” Am Soc ClinOncol, 2001, 19: 2254-2260 • Reitsamer R., et al “Predictors of Mastectomy in a Certified Breast Center”. Breast J.2008 Jul-Aug: 14 (4):2314-9. • Adkisson CD., et al “Which eligible breast conservation patients choose mastectomy in the setting of newly diagnosed breast cancer” Ann SurgOncol. 2012 Apr; 19(4):1129-36.