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© 2001 American Society for Clinical Oncology
Utilization of Breast-Conserving Surgery in Breast CancerHoag Cancer Center, Newport Beach, CA To the Editor:Morrow et al1 reported data regarding the use of breast-conserving surgery (BCS) for women with stage I and II breast cancer and concluded that BCS is being underutilized. Using tumor registry data for 16,643 patients diagnosed in 1994, they found that only 42.6% had BCS. They noted significant regional differences in the use of BCS, with rates of 54% in the Northeast, 47% in the West, 37% in the Midwest, and 32% in the South. We feel that the recent publication of data from 7 years ago is misleading in terms of the application of BCS in more recent years. In support of this, we submit the following data showing the progressive adoption of BCS in a 417-bed community hospital that has had a comprehensive community cancer center since 1990, with accompanying weekly multidisciplinary tumor boards and weekly educational conferences to foster improved practices (Fig 1). In 1995 a specific breast cancer services program was initiated that included a full-time coordinator. The data shown include all patients with invasive breast cancer who lacked distant metastases at diagnosis and underwent a surgical procedure on the breast. There were 456 such patients in the interval of 1983 through 1986, 585 during 1987 through 1990, 766 during 1991 through 1994, and 965 during 1995 through 1998.
The data clearly show the dramatic shift in the use of BCS that occurred in each successive 4-year time period. It should be noted that during the period 1991 through 1994, only 52% of our patients had BCS, but this dramatically increased during the next 4-year time period. Although the adoption of BCS has occurred more slowly than one might expect, we would suggest that it has been adopted more rapidly in university and large community hospitals that have well-developed cancer centers and that the use of BCS has increased dramatically since 1994. REFERENCES
1.
Morrow M, White J, Moughan J, et al: Factors predicting the use of breast-conserving therapy in stage I and II breast carcinoma. J Clin Oncol 19: 2254-2262, 2001
ResponseNorthwestern University Medical School, Chicago, IL In Reply:We thank Drs Dillman and Finestone and Ms Chico for their letter regarding our article. We would agree that data collected 7 years ago may not accurately reflect the precise incidence of breast-conserving surgery today. Unfortunately, the collection of large national data sets is a time-consuming and cumbersome process. The three national data systems, the Surveillance Epidemiology and End Results Program, the National Cancer Data Base, and the National Program of Cancer Registries, all take a minimum of 2 to 3 years to report cases ascertained in a given year, and detailed analysis such as the one in our report may take considerably longer. The need for more timely national cancer data collection was recognized in the Institute of Medicine report "Enhancing Data Systems to Improve the Quality of Cancer Care,"1 but this is unlikely to happen until computerized medical records and a more efficient system of collection for office-based data are routinely available. Although individual experiences such as the one provided by the authors are useful, there is no guarantee that they reflect national patterns of care. A Surveillance Epidemiology and End Results report examining time trends in the use of breast-conserving surgery between 1983 and 1995 indicates a very slow increase in the use of breast-conserving surgery, consistent with the findings of our study, with no evidence of a change in the slope of this curve during the latter portion of the time interval studied.2 In addition, by focusing solely on the percentages of patients undergoing breast-conserving surgery, Dillman et al miss the major point of our article, which has to do with the factors that are being used to select patients for mastectomy. Although other studies have previously identified patient age, geographic location, and payer status as factors influencing the use of breast conservation,3-5 our study is one of the first to provide detailed information about the impact of clinical stage and histologic features of the tumor on treatment selection in a large patient population. The adoption of breast-conserving therapy has been a slow process, in spite of a large body of scientific data supporting its efficacy. The identification of factors used to inappropriately select patients for mastectomy provides an opportunity for targeted educational messages to patients and physicians. REFERENCES 1. Hewitt M, Simone JV: Enhancing Data Systems To Improve The Quality of Cancer Care. Washington, DC, National Academy Press, 2000, pp 8-122 2. Du X, Freeman DH Jr, Syblik DA: What drove changes in the use of breast conserving surgery since the early 1980’s? The role of clinical trial, celebrity action and an NIH consensus statement. Breast Cancer Res Treat 562: 71-79, 2000 3. Farrow DC, Hunt WC, Samet JW: Geographic variation in the treatment of localized breast cancer. N Engl J Med 36: 1097-1101, 1992
4.
Nattinger AB, Hoffmann RG, Shairo R, et al: The effect of legislative requirements on the use of breast conserving surgery. N Engl J Med 335: 1035-1040, 1996 5. Lazovich D, White E, Thomas DB, et al: Underutilization of breast-conserving surgery and radiation therapy among women with stage I and II breast cancer. JAMA 226: 3422-3438, 1991 This article has been cited by other articles:
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Copyright © 2001 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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–, mastectomy; –
–, breast conservation.
