The increased rate of bilateral mastectomies, as shown in recently released data from the Agency for Healthcare Research and Quality (AHRQ), is “perplexing,” Ismail Jatoi, MD, PhD, told The ASCO Post. “We are seeing more and more women with unilateral breast cancer opt for bilateral mastectomy, when in fact contralateral breast cancer rates are going down because of better treatment. This is very perplexing and something we need to come to grips with. I don’t think it is consistent with the trends that we should really be seeing,” Dr. Jatoi said. He is Professor and Chief of Surgical Oncology and holds the Dale H. Dorn Endowed Chair in Surgery at The University of Texas Health Science Center, San Antonio.
“Overall mastectomy rates are going up. What’s driving it is the bilateral mastectomy rates,” Dr. Jatoi noted. “Unilateral mastectomy rates have been relatively stable, according to the AHRQ report, and there are some centers that report the unilateral mastectomy rate is even perhaps going down a little bit. Lumpectomy rates have been stable or going down.”
Rate More Than Tripled
The AHRQ reported that the rate of mastectomies increased by 36% between 2005 and 2013, with much of that increase “attributed to an increase in bilateral mastectomy involving early-stage cancer.”1 While the overall rate of mastectomy increased from 66 to 90 per 100,000 adult women, the rate of unilateral mastectomies remained relatively stable at around 60 per 100,000 women, but the rate of hospital-based bilateral mastectomies (inpatient and outpatient combined) more than tripled, from 9.1 to 29.7 per 100,000 women.
The new data released by AHRQ is from the Healthcare Cost and Utilization Project Statistical Brief #201. The report noted that the analysis is limited to hospitals in 13 states—representing more than one-fourth of the U.S. population—for which bilateral vs unilateral mastectomies could be identified in both inpatient and ambulatory surgery settings.
“This brief highlights changing patterns of care for breast cancer and the need for further evidence about the effects of choices women are making on their health, well-being, and safety,” AHRQ Director Rick Kronick, PhD, said in an agency press release.2 The data garnered coverage by national major media, including PBS NewsHour, CBS Evening News, and ABC News, as well as health-care media.
Two Separate Issues
Dr. Jatoi pointed out that there are two separate issues involved in bilateral mastectomies. “It is important to understand that we are talking about patients with breast cancer and also patients who are mutation carriers and are getting a bilateral mastectomy as a preventive measure,” he said.
“We are seeing more genetic testing,” he noted. At least some of that testing is a lingering effect of the widely reported decision by Angelina Jolie in 2013 to have a bilateral mastectomy because of family history and a BRCA1 mutation. “Patients often bring up the Angelina Jolie issue, but it is important to understand that she did not have breast cancer—she had a BRCA mutation. For patients who have the mutation and don’t have breast cancer, I would agree that bilateral mastectomy is an important option.” He said he would also “agree that for women who have the BRCA mutation and have unilateral breast cancer, bilateral mastectomy should be considered.”
The majority of patients with unilateral breast cancer, however, do not have BRCA mutations or don’t have any hereditary predisposition for breast cancer, “so for them, the risk of cancer in the opposite breast is very, very, low,” Dr. Jatoi said. “What is alarming is that we are seeing more patients with unilateral breast cancer undergoing bilateral mastectomy, when in fact lumpectomy would be the better option in preserving quality of life. Ultimately, most women would be better served and happier with a lumpectomy—a less disfiguring operation than a bilateral mastectomy.”
Some observational studies have suggested a survival advantage with bilateral mastectomy. Dr. Jatoi contended, however, that these studies “have a strong selection bias. Even when you account for all the potential confounders in the database, there are unmeasured confounders, which can threaten the validity of the studies.” An observational cohort study among close to 190,000 women with stage 0 to III unilateral breast cancer in the California Cancer Registry found that bilateral mastectomy “was not associated with lower mortality than that achieved with breast-conserving surgery plus radiation.”3
More Likely Among Younger Women
“Women who had a bilateral mastectomy in 2013 were about 10 years younger than those who had a unilateral mastectomy”—51 years vs 61 years—according to the AHRQ data.
“I am not surprised by that,” Dr. Jatoi said, “because many of us have seen that trend: Younger women raise the issue of bilateral mastectomy more than do older women. That is consistent with several reports that have been published in the literature throughout the world. That is a trend that we need to address.”
The trend, he said, might be driven by patients’ plans to have breast reconstruction to achieve symmetry. “It may be driven by their concerns about getting cancer of the opposite breast over the long term. Younger women might be more concerned about recurrences,” Dr. Jatoi remarked.
Outpatient Procedures Increasing
The AHRQ report also noted that unilateral and bilateral mastectomies are increasingly performed as outpatient procedures: “From 2005 to 2013, the rate of bilateral outpatient mastectomies increased more than fivefold and the inpatient rate nearly tripled. The rate of unilateral mastectomies nearly doubled in the outpatient setting but decreased 28% in the inpatient setting. By 2013, nearly half of all mastectomies were performed [on an outpatient basis].”
“I usually keep patients overnight after a unilateral mastectomy or a bilateral mastectomy, but it can be done [on an outpatient basis],” Dr. Jatoi said, adding that he was not surprised by the increase in outpatient mastectomies. “Oftentimes in our center, when we do the bilateral mastectomy, for example, for BRCA mutation carriers, it involves reconstruction, and those patients usually stay the night.”
Global Issue
“The trend toward bilateral mastectomies is greater in the United States than other parts of the world, but other countries are reporting increased use of bilateral mastectomy for unilateral breast cancer as well,” Dr. Jatoi noted. “This is going to be an important topic for the next several years and is becoming a global issue in terms of management of unilateral breast cancer.” ■
Disclosure: Dr. Jatoi reported no potential conflicts of interest.
References
1. Steiner CA, Weiss AJ, Barrett ML, et al: Trends in bilateral and unilateral mastectomies in hospital inpatient and ambulatory settings, 2005-2013. Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Statistical Brief #201, February 2016.
2. New data show mastectomies increased 36 percent from 2005 to 2013. Agency for Healthcare Research and Quality press release, February 22, 2016.
3. Kurian AW, Lichtensztajn DY, Keegan TH, et al: Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011. JAMA 312:902-914, 2014.
