Determinants of Breast-Conserving Surgery and Survival

Institution: Public Health Institute
Investigator(s): Cyllene Morris, DVM, MPVM, Ph.D. -
Award Cycle: 1995 (Cycle I) Grant #: 1KB-0175 Award: $65,235
Award Type: New Investigator Awards
Research Priorities
Community Impact of Breast Cancer>Health Policy and Health Services: better serving women's needs



Initial Award Abstract (1995)
Primary therapy for breast cancer in women with localized disease has changed substantially in recent years. Breast-conserving surgery (BCS) with radiation therapy is an equally effective alternative to mastectomy, and was recommended for most women with stage I or II breast cancer by the 1990 National Institutes of Health Consensus Conference. (For this study, stage I or II is defined as localized tumors without lymph node involvement, or tumors up to 5 cm in diameter, with or without extension to axillary lymph node nodes on the same side.) Nevertheless, fewer than 50% of women who are eligible receive BCS in California, even though mastectomies may have profound emotional consequences and do not improve survival rates in women with small tumors. The goal of this study is to determine the reasons for the apparent underutilization of BCS in California. A better understanding of this phenomenon may reduce the human and economic costs of breast cancer. In particular, the physical and psychological impact associated with unnecessary mastectomies represent a human cost that can be minimized by understanding which factors affect the choice of surgical treatment.

The objectives of the project are to: 1) determine statewide and regional trends of BCS utilization and radiation therapy, 2) determine the most significant predictors of choice of surgery for BCS-eligible women, and 3) compare the five-year survival experience of women receiving BCS and BCS-eligible women receiving mastectomies. Data from the California Cancer Registry (CCR), including all reported diagnoses of first primary breast cancer within the state from 1988 to 1995, will be used in the analysis. This study will be the first to address the issue of BCS utilization and survival on a statewide basis. The CCR operates the most complete cancer reporting system in California, and the CCR breast cancer database will be complemented and enhanced through linkages with several additional statewide files. These linkages will enable the analysis of a wide range of factors which may influence the choice of surgical treatment for primary breast cancer, including socioeconomic status, education, insurance coverage, and co-morbidities. These factors have not yet been evaluated together with information on clinical factors, treatment, characteristics of the patient, hospital, and county of residence as predictors of surgery received and subsequent survival. The database generated during this study will contain the most comprehensive population-based information on breast cancer in California. Given the large number of breast cancer cases in the state, the proposed study will have enough power to reach a statistically sound conclusion. In addition, the substantial variation in race/ethnicity in California allows for in-depth analysis of possible differences in patterns of care among minority women.

Understanding why BCS has been underutilized in California is an important step towards ensuring that women with breast cancer have an informed choice and receive optimal treatment.


Final Report (1999)
Breast-conserving surgery (BCS) is an equally effective alternative to mastectomy for most women with stage I or II breast cancer, and is now the recommended alternative for these cases. However, even though BCS utilization has increased in California, 37% of women with small early stage tumors still received a mastectomy in 1996. The physical and psychological impact associated with unnecessary mastectomies represent a human cost that can be minimized by understanding which factors affect the choice of surgical treatment. The purpose of this study was to uncover some of these factors. The specific aims of the project were to: 1) determine statewide trends of BCS utilization; 2) determine the most significant predictors of choice of surgery for BCS-eligible women; and 3) compare the five-year survival experience of women receiving BCS and BCS-eligible women receiving mastectomies.

The study was based ore early-stage breast cancers diagnosed from 1988 through 1996 and reported to the California Cancer Registry (CCR), which is considered to have complete statewide coverage. Our analysis indicate that women of Asian or Hispanic race/ethnicity, 65 years and older, currently married, diagnosed with a centrally located, stage II lobular or comedo carcinoma, residing in less affluent areas, or in a county without a radiation facility were the least likely to receive BCS in California. On the other hand, African American women were more likely to receive BCS than women of any other race/ethnicity. Despite these differences, BCS utilization is increasing steadily in California. The rate of increase in BCS is similar among women of all race/ethnic groups, and is also similar regardless the socioeconomic status in the patient's neighborhood.

The third aim of the project, a comparison of survival for BCS or mastectomy recipients, has been deferred until survival data gathered by the CCR are complete. Understanding patterns of BCS utilization is an important step towards ensuring that California women with breast cancer have an informed choice about their treatment.

Increasing trends in the use of breast-conserving surgery in California
Periodical:American Journal of Public Health
Index Medicus: Am J Public Health
Authors: Morris CR, Cohen R, Schlag R, Wright WE
Yr: 2000 Vol: 90 Nbr: 2 Abs: Pg:281-4