Study Finds Lumpectomy as Effective as Mastectomy : Health: Results support experiment that was clouded by falsified data. Less-invasive surgery is called underused.
In a study that experts hope will provide reassurance to thousands of nervous breast cancer patients, UC Irvine researchers have confirmed that lumpectomy--in which only the cancerous tumor, rather than the entire breast, is removed--is just as safe and effective as mastectomy. But, the research found, many women who are eligible for the procedure do not get it.
The findings come on the heels of a major controversy over falsified data in a massive international breast cancer study that advocated lumpectomy in conjunction with radiation therapy. Experts hope that the new results will comfort lumpectomy patients who are wondering if they made the right choice.
Yet the study of 5,892 Orange County women in 126 Southern California hospitals may be as troubling as it is comforting. The researchers uncovered stark disparities in the way breast cancer patients are treated, and found that whether a patient lived or died after surgery depended in part on the type of hospital in which she received care. Those in large hospitals fared the best.
“This again emphasizes that lumpectomy and radiation is very acceptable therapy,” said Dr. Harmon Eyre, chief medical officer for the American Cancer Society. “But the second message is that you want to have cancer care given in an institution where they pay attention to quality of care, and those are generally the large institutions with the larger number of cases.”
Published in today’s issue of the Journal of the American Medical Assn., the UC Irvine study examined medical records for white women whose breast cancer was diagnosed between 1984 and 1990. It is the first in the nation to compare the treatment and survival of breast cancer patients by hospital type. It found that:
* Women who went to university-affiliated teaching hospitals were far more likely than others to have lumpectomies.
Experts estimate that 70% of all breast cancer patients are eligible for the procedure, also known as breast-conserving surgery, or BCS. Toward the end of the six-year study period, the researchers reported, 70% of patients in teaching hospitals had lumpectomies. In other hospitals, about 25% had lumpectomies; the rest had mastectomies, a far more invasive surgery in which the entire breast is removed.
“There is an urgent need to encourage more frequent use by physicians of recommended BCS plus radiation in qualified women,” the researchers wrote.
* Patients in large hospitals--those with more than 200 beds--fared the best. They were 26% less likely to die in the five years after surgery than those who had lumpectomies or mastectomies in small hospitals.
* Patients in HMO hospitals--both large and small--fared poorly. HMO patients with “localized” breast cancer--meaning the disease had not spread--were almost twice as likely to die during the five-year post-surgery period as those treated in large hospitals, and their chance of dying was 63% greater than women whose operations took place in small hospitals.
However, the researchers found, HMO hospital care was improving toward the end of the study period, and those with “regionalized” cancer, meaning the disease had spread, fared about the same as patients in small hospitals.
* All other factors considered, women who chose lumpectomy with radiation were just as likely to survive as those who had mastectomies. This finding confirms research conducted by the National Surgical Adjuvant Breast and Bowel Project, the large-scale study that has recently come under scrutiny amid disclosures that a Canadian doctor had falsified data.
That study was headed by renowned cancer researcher Dr. Bernard Fisher of the University of Pittsburgh, who was forced to step down after the disclosures. It examined the use of lumpectomy in a controlled clinical trial, with carefully selected patients who met strict criteria, and were then picked at random to undergo either lumpectomy or mastectomy.
In contrast, the Irvine study used medical records to take a snapshot of how breast cancer surgery is practiced in a suburban area, in this case Orange County. Names of patients and hospitals were kept confidential.
“It’s really an illustration of how does (lumpectomy) work out there in the community,” said epidemiologist Anna Lee-Feldstein, the lead author of the study. “This shows that the findings of the Fisher study really are applicable to the community at large.”
Breast cancer is the most common cancer in women. In the United States, experts estimate that 182,000 women will be diagnosed with breast cancer this year, and 46,000 will die of it. (The disease also strikes a small number of men; about 1,000 each year.)
Treatment for breast cancer has changed dramatically in the past two decades. As recently as the 1970s, doctors were performing radical mastectomies, a disfiguring surgery in which the entire breast as well as pectoral muscle were removed. The trend then shifted to “total” mastectomy, in which only the breast and lymph nodes are removed, and later, in the wake of Fisher’s 1985 study, to lumpectomies in combination with radiation treatment.
At least eight other studies have confirmed Fisher’s results, which even with the falsified data are not in dispute. But the Irvine research shows that not all doctors and women have taken heed of his findings.
“A lot of it is physician bias,” said Dr. Susan Love, a nationally regarded breast cancer expert at UCLA. “I saw a patient today and the surgeon said to her: ‘Well, I know they showed that (lumpectomy is just as safe) but I’ve been doing mastectomies for a long time and I don’t care what the studies show.”
Others say patients, particularly older women who grew up with the notion that the entire breast should be cut out at the first sign of cancer, are frightened of lumpectomy.
“Some very intelligent, clear-thinking women do not want to have a lumpectomy and radiation therapy,” said Eyre of the American Cancer Society. “Some women just want to get the diseased organ gone. They feel better when the breast is removed.”
