Are too many mastectomies being done in the US

Patrick Ivan Borgen MD

Surgeon-in-Chief

Maimonides Medical Center

Brooklyn New York

Of course too many mastectomies are being done There is too much breast cancer

Too Many Mastectomies

Argument is that the

ratio of mastectomy to

breast conservation in

patients with cancer

(when everything else

is equal) is too high

Debated topic

suggests that the

choice is the surgeonrsquos

choice rather than the

patientrsquos choice

Assumes

The surgeon is

directing the patient

towards mastectomy

The surgeon has

placed a value on the

breast

The surgeonrsquos

valuation of the

breast is more

important than the

patientrsquos valuation Who has the autonomy to make this

decision ndash surgeon or patient

Too Many Mastectomies

Ratio of mastectomy to

breast conservation in

patients with cancer

(when everything else

is equal) is too high

Debated topic

suggests that the

choice is the surgeonrsquos

choice rather than the

patientrsquos choice

Assumes

THAT THE PATIENT

IS ILL-EQUIPPED TO

MAKE THE

DECISION HERSELF

Patients who choose

mastectomy regret

the decision

Assumptions in Favor of

BCT Advantages to BCT

Survival advantage

Better local regional

control (lower local

regional recurrence

rate)

ALL PATIENTS are

willing to receive

radiation therapy in

exchange for

preserving the breast

ALL PATIENTS are

willing to undergo a

lifetime of vigilance

Disadvantages to

Mastectomy

Irrevocable change in body

image

Psychologically traumatic

Painful

Total skin sparing with

excellent reconstruction

does not soften the blow

Women define their self

image at least partially by

their breasts

National Prophylactic

Mastectomy Registry 1995-

2005 1240 women identified from US lay media

All had one or both breasts removed

prophylactically

All followed yearly

Extensively questioned

ldquoDO YOU REGRET YOUR DECISIONrsquo

4 SAID YEShellipWOULD NOT DO IT AGAIN

COMMON DENOMINATOR WAS PHYSICIAN

TALKING PATIENT INTO PROCEDURE

Borgen Tran Montgomery et al Cancer 23 220 2005

Survival Implications Associated with

Variation in Mastectomy Rates for

Early-Staged Breast Cancer John M Brooks1 Elizabeth A Chrischilles2 Mary Beth

Landrum3 Kara B Wright2 Gang Fang4 Eric P Winer5 and Nancy L

Keating36

1992ndash2002 SEER-Medicare databases 69140

patients with stage I or II breast cancer that were

enrolled in Medicare

1 percentage point increase in the mastectomy

rate would reduce the 7-year survival rate by 1

percentage points

International Journal of Surgical

OncologyVolume 2012 (2012) Article ID 127854 9

pages

Conclusion

These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage

Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients

Impact of four quarter amputations

on the hearing acuity of the frog

Background of Authors

bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2

bull College of Public Health University of Iowa Iowa City IA 52242 USA3

bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4

bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5

bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6

bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA

Patients are Educated

Patients are educated

Website hits by patients on breast cancer repeat

hits

Lifelong learning relatives with cancer

Media crunch ndash super high exposure

1 degree of separation with women and breast

cancer

Many have considered her options before getting

the disease

Patients are often REALLY

educated

Patient who knew Bernie Fisherrsquos brother was named

Ed

Patient wanted the details on the calibration schedule

for our gamma probe for her sentinel node

Patient asked whether the Myriad Genetics

technology looking for BRCA gene mutations would

reveal gene silencing through promoter methylation

Less invasive is NOT

always better in the long

runhellip Multiple coronary artery stents vs CABG

(advantage CABG)

EVARS (elective) of abdominal aortic aneurysm

vs open definitive repair

Long term benefits of tissue transfer

reconstruction vs implant reconstruction

Transanal vs Total Mesorectal Excision of rectal

cancer

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Of course too many mastectomies are being done There is too much breast cancer

Too Many Mastectomies

Argument is that the

ratio of mastectomy to

breast conservation in

patients with cancer

(when everything else

is equal) is too high

Debated topic

suggests that the

choice is the surgeonrsquos

choice rather than the

patientrsquos choice

Assumes

The surgeon is

directing the patient

towards mastectomy

The surgeon has

placed a value on the

breast

The surgeonrsquos

valuation of the

breast is more

important than the

patientrsquos valuation Who has the autonomy to make this

decision ndash surgeon or patient

Too Many Mastectomies

Ratio of mastectomy to

breast conservation in

patients with cancer

(when everything else

is equal) is too high

Debated topic

suggests that the

choice is the surgeonrsquos

choice rather than the

patientrsquos choice

Assumes

THAT THE PATIENT

IS ILL-EQUIPPED TO

MAKE THE

DECISION HERSELF

Patients who choose

mastectomy regret

the decision

Assumptions in Favor of

BCT Advantages to BCT

Survival advantage

Better local regional

control (lower local

regional recurrence

rate)

ALL PATIENTS are

willing to receive

radiation therapy in

exchange for

preserving the breast

ALL PATIENTS are

willing to undergo a

lifetime of vigilance

Disadvantages to

Mastectomy

Irrevocable change in body

image

Psychologically traumatic

Painful

Total skin sparing with

excellent reconstruction

does not soften the blow

Women define their self

image at least partially by

their breasts

National Prophylactic

Mastectomy Registry 1995-

2005 1240 women identified from US lay media

All had one or both breasts removed

prophylactically

All followed yearly

Extensively questioned

ldquoDO YOU REGRET YOUR DECISIONrsquo

4 SAID YEShellipWOULD NOT DO IT AGAIN

COMMON DENOMINATOR WAS PHYSICIAN

TALKING PATIENT INTO PROCEDURE

Borgen Tran Montgomery et al Cancer 23 220 2005

Survival Implications Associated with

Variation in Mastectomy Rates for

Early-Staged Breast Cancer John M Brooks1 Elizabeth A Chrischilles2 Mary Beth

Landrum3 Kara B Wright2 Gang Fang4 Eric P Winer5 and Nancy L

Keating36

1992ndash2002 SEER-Medicare databases 69140

patients with stage I or II breast cancer that were

enrolled in Medicare

1 percentage point increase in the mastectomy

rate would reduce the 7-year survival rate by 1

percentage points

International Journal of Surgical

OncologyVolume 2012 (2012) Article ID 127854 9

pages

Conclusion

These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage

Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients

Impact of four quarter amputations

on the hearing acuity of the frog

Background of Authors

bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2

bull College of Public Health University of Iowa Iowa City IA 52242 USA3

bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4

bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5

bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6

bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA

Patients are Educated

Patients are educated

Website hits by patients on breast cancer repeat

hits

Lifelong learning relatives with cancer

Media crunch ndash super high exposure

1 degree of separation with women and breast

cancer

Many have considered her options before getting

the disease

Patients are often REALLY

educated

Patient who knew Bernie Fisherrsquos brother was named

Ed

Patient wanted the details on the calibration schedule

for our gamma probe for her sentinel node

Patient asked whether the Myriad Genetics

technology looking for BRCA gene mutations would

reveal gene silencing through promoter methylation

Less invasive is NOT

always better in the long

runhellip Multiple coronary artery stents vs CABG

(advantage CABG)

EVARS (elective) of abdominal aortic aneurysm

vs open definitive repair

Long term benefits of tissue transfer

reconstruction vs implant reconstruction

Transanal vs Total Mesorectal Excision of rectal

cancer

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Too Many Mastectomies

Argument is that the

ratio of mastectomy to

breast conservation in

patients with cancer

(when everything else

is equal) is too high

Debated topic

suggests that the

choice is the surgeonrsquos

choice rather than the

patientrsquos choice

Assumes

The surgeon is

directing the patient

towards mastectomy

The surgeon has

placed a value on the

breast

The surgeonrsquos

valuation of the

breast is more

important than the

patientrsquos valuation Who has the autonomy to make this

decision ndash surgeon or patient

Too Many Mastectomies

Ratio of mastectomy to

breast conservation in

patients with cancer

(when everything else

is equal) is too high

Debated topic

suggests that the

choice is the surgeonrsquos

choice rather than the

patientrsquos choice

Assumes

THAT THE PATIENT

IS ILL-EQUIPPED TO

MAKE THE

DECISION HERSELF

Patients who choose

mastectomy regret

the decision

Assumptions in Favor of

BCT Advantages to BCT

Survival advantage

Better local regional

control (lower local

regional recurrence

rate)

ALL PATIENTS are

willing to receive

radiation therapy in

exchange for

preserving the breast

ALL PATIENTS are

willing to undergo a

lifetime of vigilance

Disadvantages to

Mastectomy

Irrevocable change in body

image

Psychologically traumatic

Painful

Total skin sparing with

excellent reconstruction

does not soften the blow

Women define their self

image at least partially by

their breasts

National Prophylactic

Mastectomy Registry 1995-

2005 1240 women identified from US lay media

All had one or both breasts removed

prophylactically

All followed yearly

Extensively questioned

ldquoDO YOU REGRET YOUR DECISIONrsquo

4 SAID YEShellipWOULD NOT DO IT AGAIN

COMMON DENOMINATOR WAS PHYSICIAN

TALKING PATIENT INTO PROCEDURE

Borgen Tran Montgomery et al Cancer 23 220 2005

Survival Implications Associated with

Variation in Mastectomy Rates for

Early-Staged Breast Cancer John M Brooks1 Elizabeth A Chrischilles2 Mary Beth

Landrum3 Kara B Wright2 Gang Fang4 Eric P Winer5 and Nancy L

Keating36

1992ndash2002 SEER-Medicare databases 69140

patients with stage I or II breast cancer that were

enrolled in Medicare

1 percentage point increase in the mastectomy

rate would reduce the 7-year survival rate by 1

percentage points

International Journal of Surgical

OncologyVolume 2012 (2012) Article ID 127854 9

pages

Conclusion

These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage

Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients

Impact of four quarter amputations

on the hearing acuity of the frog

Background of Authors

bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2

bull College of Public Health University of Iowa Iowa City IA 52242 USA3

bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4

bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5

bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6

bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA

Patients are Educated

Patients are educated

Website hits by patients on breast cancer repeat

hits

Lifelong learning relatives with cancer

Media crunch ndash super high exposure

1 degree of separation with women and breast

cancer

Many have considered her options before getting

the disease

Patients are often REALLY

educated

Patient who knew Bernie Fisherrsquos brother was named

Ed

Patient wanted the details on the calibration schedule

for our gamma probe for her sentinel node

Patient asked whether the Myriad Genetics

technology looking for BRCA gene mutations would

reveal gene silencing through promoter methylation

Less invasive is NOT

always better in the long

runhellip Multiple coronary artery stents vs CABG

(advantage CABG)

EVARS (elective) of abdominal aortic aneurysm

vs open definitive repair

Long term benefits of tissue transfer

reconstruction vs implant reconstruction

Transanal vs Total Mesorectal Excision of rectal

cancer

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Too Many Mastectomies

Ratio of mastectomy to

breast conservation in

patients with cancer

(when everything else

is equal) is too high

Debated topic

suggests that the

choice is the surgeonrsquos

choice rather than the

patientrsquos choice

Assumes

THAT THE PATIENT

IS ILL-EQUIPPED TO

MAKE THE

DECISION HERSELF

Patients who choose

mastectomy regret

the decision

Assumptions in Favor of

BCT Advantages to BCT

Survival advantage

Better local regional

control (lower local

regional recurrence

rate)

ALL PATIENTS are

willing to receive

radiation therapy in

exchange for

preserving the breast

ALL PATIENTS are

willing to undergo a

lifetime of vigilance

Disadvantages to

Mastectomy

Irrevocable change in body

image

Psychologically traumatic

Painful

Total skin sparing with

excellent reconstruction

does not soften the blow

Women define their self

image at least partially by

their breasts

National Prophylactic

Mastectomy Registry 1995-

2005 1240 women identified from US lay media

All had one or both breasts removed

prophylactically

All followed yearly

Extensively questioned

ldquoDO YOU REGRET YOUR DECISIONrsquo

4 SAID YEShellipWOULD NOT DO IT AGAIN

COMMON DENOMINATOR WAS PHYSICIAN

TALKING PATIENT INTO PROCEDURE

Borgen Tran Montgomery et al Cancer 23 220 2005

Survival Implications Associated with

Variation in Mastectomy Rates for

Early-Staged Breast Cancer John M Brooks1 Elizabeth A Chrischilles2 Mary Beth

Landrum3 Kara B Wright2 Gang Fang4 Eric P Winer5 and Nancy L

Keating36

1992ndash2002 SEER-Medicare databases 69140

patients with stage I or II breast cancer that were

enrolled in Medicare

1 percentage point increase in the mastectomy

rate would reduce the 7-year survival rate by 1

percentage points

International Journal of Surgical

OncologyVolume 2012 (2012) Article ID 127854 9

pages

Conclusion

These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage

Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients

Impact of four quarter amputations

on the hearing acuity of the frog

Background of Authors

bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2

bull College of Public Health University of Iowa Iowa City IA 52242 USA3

bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4

bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5

bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6

bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA

Patients are Educated

Patients are educated

Website hits by patients on breast cancer repeat

hits

Lifelong learning relatives with cancer

Media crunch ndash super high exposure

1 degree of separation with women and breast

cancer

Many have considered her options before getting

the disease

Patients are often REALLY

educated

Patient who knew Bernie Fisherrsquos brother was named

Ed

Patient wanted the details on the calibration schedule

for our gamma probe for her sentinel node

Patient asked whether the Myriad Genetics

technology looking for BRCA gene mutations would

reveal gene silencing through promoter methylation

Less invasive is NOT

always better in the long

runhellip Multiple coronary artery stents vs CABG

(advantage CABG)

EVARS (elective) of abdominal aortic aneurysm

vs open definitive repair

Long term benefits of tissue transfer

reconstruction vs implant reconstruction

Transanal vs Total Mesorectal Excision of rectal

cancer

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Assumptions in Favor of

BCT Advantages to BCT

Survival advantage

Better local regional

control (lower local

regional recurrence

rate)

ALL PATIENTS are

willing to receive

radiation therapy in

exchange for

preserving the breast

ALL PATIENTS are

willing to undergo a

lifetime of vigilance

Disadvantages to

Mastectomy

Irrevocable change in body

image

Psychologically traumatic

Painful

Total skin sparing with

excellent reconstruction

does not soften the blow

Women define their self

image at least partially by

their breasts

National Prophylactic

Mastectomy Registry 1995-

2005 1240 women identified from US lay media

All had one or both breasts removed

prophylactically

All followed yearly

Extensively questioned

ldquoDO YOU REGRET YOUR DECISIONrsquo

4 SAID YEShellipWOULD NOT DO IT AGAIN

COMMON DENOMINATOR WAS PHYSICIAN

TALKING PATIENT INTO PROCEDURE

Borgen Tran Montgomery et al Cancer 23 220 2005

Survival Implications Associated with

Variation in Mastectomy Rates for

Early-Staged Breast Cancer John M Brooks1 Elizabeth A Chrischilles2 Mary Beth

Landrum3 Kara B Wright2 Gang Fang4 Eric P Winer5 and Nancy L

Keating36

1992ndash2002 SEER-Medicare databases 69140

patients with stage I or II breast cancer that were

enrolled in Medicare

1 percentage point increase in the mastectomy

rate would reduce the 7-year survival rate by 1

percentage points

International Journal of Surgical

OncologyVolume 2012 (2012) Article ID 127854 9

pages

Conclusion

These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage

Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients

Impact of four quarter amputations

on the hearing acuity of the frog

Background of Authors

bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2

bull College of Public Health University of Iowa Iowa City IA 52242 USA3

bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4

bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5

bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6

bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA

Patients are Educated

Patients are educated

Website hits by patients on breast cancer repeat

hits

Lifelong learning relatives with cancer

Media crunch ndash super high exposure

1 degree of separation with women and breast

cancer

Many have considered her options before getting

the disease

Patients are often REALLY

educated

Patient who knew Bernie Fisherrsquos brother was named

Ed

Patient wanted the details on the calibration schedule

for our gamma probe for her sentinel node

Patient asked whether the Myriad Genetics

technology looking for BRCA gene mutations would

reveal gene silencing through promoter methylation

Less invasive is NOT

always better in the long

runhellip Multiple coronary artery stents vs CABG

(advantage CABG)

EVARS (elective) of abdominal aortic aneurysm

vs open definitive repair

Long term benefits of tissue transfer

reconstruction vs implant reconstruction

Transanal vs Total Mesorectal Excision of rectal

cancer

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

National Prophylactic

Mastectomy Registry 1995-

2005 1240 women identified from US lay media

All had one or both breasts removed

prophylactically

All followed yearly

Extensively questioned

ldquoDO YOU REGRET YOUR DECISIONrsquo

4 SAID YEShellipWOULD NOT DO IT AGAIN

COMMON DENOMINATOR WAS PHYSICIAN

TALKING PATIENT INTO PROCEDURE

Borgen Tran Montgomery et al Cancer 23 220 2005

Survival Implications Associated with

Variation in Mastectomy Rates for

Early-Staged Breast Cancer John M Brooks1 Elizabeth A Chrischilles2 Mary Beth

Landrum3 Kara B Wright2 Gang Fang4 Eric P Winer5 and Nancy L

Keating36

1992ndash2002 SEER-Medicare databases 69140

patients with stage I or II breast cancer that were

enrolled in Medicare

1 percentage point increase in the mastectomy

rate would reduce the 7-year survival rate by 1

percentage points

International Journal of Surgical

OncologyVolume 2012 (2012) Article ID 127854 9

pages

Conclusion

These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage

Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients

Impact of four quarter amputations

on the hearing acuity of the frog

Background of Authors

bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2

bull College of Public Health University of Iowa Iowa City IA 52242 USA3

bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4

bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5

bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6

bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA

Patients are Educated

Patients are educated

Website hits by patients on breast cancer repeat

hits

Lifelong learning relatives with cancer

Media crunch ndash super high exposure

1 degree of separation with women and breast

cancer

Many have considered her options before getting

the disease

Patients are often REALLY

educated

Patient who knew Bernie Fisherrsquos brother was named

Ed

Patient wanted the details on the calibration schedule

for our gamma probe for her sentinel node

Patient asked whether the Myriad Genetics

technology looking for BRCA gene mutations would

reveal gene silencing through promoter methylation

Less invasive is NOT

always better in the long

runhellip Multiple coronary artery stents vs CABG

(advantage CABG)

EVARS (elective) of abdominal aortic aneurysm

vs open definitive repair

Long term benefits of tissue transfer

reconstruction vs implant reconstruction

Transanal vs Total Mesorectal Excision of rectal

cancer

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Survival Implications Associated with

Variation in Mastectomy Rates for

Early-Staged Breast Cancer John M Brooks1 Elizabeth A Chrischilles2 Mary Beth

Landrum3 Kara B Wright2 Gang Fang4 Eric P Winer5 and Nancy L

Keating36

1992ndash2002 SEER-Medicare databases 69140

patients with stage I or II breast cancer that were

enrolled in Medicare

1 percentage point increase in the mastectomy

rate would reduce the 7-year survival rate by 1

percentage points

International Journal of Surgical

OncologyVolume 2012 (2012) Article ID 127854 9

pages

Conclusion

These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage

Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients

Impact of four quarter amputations

on the hearing acuity of the frog

Background of Authors

bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2

bull College of Public Health University of Iowa Iowa City IA 52242 USA3

bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4

bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5

bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6

bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA

Patients are Educated

Patients are educated

Website hits by patients on breast cancer repeat

hits

Lifelong learning relatives with cancer

Media crunch ndash super high exposure

1 degree of separation with women and breast

cancer

Many have considered her options before getting

the disease

Patients are often REALLY

educated

Patient who knew Bernie Fisherrsquos brother was named

Ed

Patient wanted the details on the calibration schedule

for our gamma probe for her sentinel node

Patient asked whether the Myriad Genetics

technology looking for BRCA gene mutations would

reveal gene silencing through promoter methylation

Less invasive is NOT

always better in the long

runhellip Multiple coronary artery stents vs CABG

(advantage CABG)

EVARS (elective) of abdominal aortic aneurysm

vs open definitive repair

Long term benefits of tissue transfer

reconstruction vs implant reconstruction

Transanal vs Total Mesorectal Excision of rectal

cancer

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Conclusion

These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage

Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients

Impact of four quarter amputations

on the hearing acuity of the frog

Background of Authors

bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2

bull College of Public Health University of Iowa Iowa City IA 52242 USA3

bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4

bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5

bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6

bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA

Patients are Educated

Patients are educated

Website hits by patients on breast cancer repeat

hits

Lifelong learning relatives with cancer

Media crunch ndash super high exposure

1 degree of separation with women and breast

cancer

Many have considered her options before getting

the disease

Patients are often REALLY

educated

Patient who knew Bernie Fisherrsquos brother was named

Ed

Patient wanted the details on the calibration schedule

for our gamma probe for her sentinel node

Patient asked whether the Myriad Genetics

technology looking for BRCA gene mutations would

reveal gene silencing through promoter methylation

Less invasive is NOT

always better in the long

runhellip Multiple coronary artery stents vs CABG

(advantage CABG)

EVARS (elective) of abdominal aortic aneurysm

vs open definitive repair

Long term benefits of tissue transfer

reconstruction vs implant reconstruction

Transanal vs Total Mesorectal Excision of rectal

cancer

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Impact of four quarter amputations

on the hearing acuity of the frog

Background of Authors

bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2

bull College of Public Health University of Iowa Iowa City IA 52242 USA3

bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4

bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5

bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6

bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA

Patients are Educated

Patients are educated

Website hits by patients on breast cancer repeat

hits

Lifelong learning relatives with cancer

Media crunch ndash super high exposure

1 degree of separation with women and breast

cancer

Many have considered her options before getting

the disease

Patients are often REALLY

educated

Patient who knew Bernie Fisherrsquos brother was named

Ed

Patient wanted the details on the calibration schedule

for our gamma probe for her sentinel node

Patient asked whether the Myriad Genetics

technology looking for BRCA gene mutations would

reveal gene silencing through promoter methylation

Less invasive is NOT

always better in the long

runhellip Multiple coronary artery stents vs CABG

(advantage CABG)

EVARS (elective) of abdominal aortic aneurysm

vs open definitive repair

Long term benefits of tissue transfer

reconstruction vs implant reconstruction

Transanal vs Total Mesorectal Excision of rectal

cancer

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Background of Authors

bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2

bull College of Public Health University of Iowa Iowa City IA 52242 USA3

bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4

bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5

bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6

bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA

Patients are Educated

Patients are educated

Website hits by patients on breast cancer repeat

hits

Lifelong learning relatives with cancer

Media crunch ndash super high exposure

1 degree of separation with women and breast

cancer

Many have considered her options before getting

the disease

Patients are often REALLY

educated

Patient who knew Bernie Fisherrsquos brother was named

Ed

Patient wanted the details on the calibration schedule

for our gamma probe for her sentinel node

Patient asked whether the Myriad Genetics

technology looking for BRCA gene mutations would

reveal gene silencing through promoter methylation

Less invasive is NOT

always better in the long

runhellip Multiple coronary artery stents vs CABG

(advantage CABG)

EVARS (elective) of abdominal aortic aneurysm

vs open definitive repair

Long term benefits of tissue transfer

reconstruction vs implant reconstruction

Transanal vs Total Mesorectal Excision of rectal

cancer

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Patients are Educated

Patients are educated

Website hits by patients on breast cancer repeat

hits

Lifelong learning relatives with cancer

Media crunch ndash super high exposure

1 degree of separation with women and breast

cancer

Many have considered her options before getting

the disease

Patients are often REALLY

educated

Patient who knew Bernie Fisherrsquos brother was named

Ed

Patient wanted the details on the calibration schedule

for our gamma probe for her sentinel node

Patient asked whether the Myriad Genetics

technology looking for BRCA gene mutations would

reveal gene silencing through promoter methylation

Less invasive is NOT

always better in the long

runhellip Multiple coronary artery stents vs CABG

(advantage CABG)

EVARS (elective) of abdominal aortic aneurysm

vs open definitive repair

Long term benefits of tissue transfer

reconstruction vs implant reconstruction

Transanal vs Total Mesorectal Excision of rectal

cancer

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Patients are educated

Website hits by patients on breast cancer repeat

hits

Lifelong learning relatives with cancer

Media crunch ndash super high exposure

1 degree of separation with women and breast

cancer

Many have considered her options before getting

the disease

Patients are often REALLY

educated

Patient who knew Bernie Fisherrsquos brother was named

Ed

Patient wanted the details on the calibration schedule

for our gamma probe for her sentinel node

Patient asked whether the Myriad Genetics

technology looking for BRCA gene mutations would

reveal gene silencing through promoter methylation

Less invasive is NOT

always better in the long

runhellip Multiple coronary artery stents vs CABG

(advantage CABG)

EVARS (elective) of abdominal aortic aneurysm

vs open definitive repair

Long term benefits of tissue transfer

reconstruction vs implant reconstruction

Transanal vs Total Mesorectal Excision of rectal

cancer

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Patients are often REALLY

educated

Patient who knew Bernie Fisherrsquos brother was named

Ed

Patient wanted the details on the calibration schedule

for our gamma probe for her sentinel node

Patient asked whether the Myriad Genetics

technology looking for BRCA gene mutations would

reveal gene silencing through promoter methylation

Less invasive is NOT

always better in the long

runhellip Multiple coronary artery stents vs CABG

(advantage CABG)

EVARS (elective) of abdominal aortic aneurysm

vs open definitive repair

Long term benefits of tissue transfer

reconstruction vs implant reconstruction

Transanal vs Total Mesorectal Excision of rectal

cancer

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Less invasive is NOT

always better in the long

runhellip Multiple coronary artery stents vs CABG

(advantage CABG)

EVARS (elective) of abdominal aortic aneurysm

vs open definitive repair

Long term benefits of tissue transfer

reconstruction vs implant reconstruction

Transanal vs Total Mesorectal Excision of rectal

cancer

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Flawed basic premisehellip

1992 NCI published a consensus statement

Breast conservation (tumor

removal axillary dissection and

radiation therapy is equivalent to

mastectomy but is preferable as it

is less disfiguring

Assumption was made that every

woman would CHOOSE BCT

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Flawed basic premisehellip

As we witnessed the explosion of new breast

centers and new breast programs in the 1990s

and early 2000s centers were actually GRADED

on their utilization of BCT

In some cases thresholds were set

that centers were expected to

reach for percent utilization of

BCT Negative consequences for failing to reach

goals

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment

More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

T0isN0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 (05 invasive) 5 to 20 (3-10

Invasive)

Need for radiation NEVER ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

3 cm of mixed grade DCIS ER+

Margins gt1cm

BRCA negative

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Local Recurrence

Rate

1 to 3 5 to 12

Need for radiation RARE ALWAYS

Need for

reconstruction

Virtually always RARE

Cosmetic Outcome Reasonable facsimile Excellent

SURVIVAL EQUAL EQUAL

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

T2N0M0 Breast Cancer

Outcome Metric Mastectomy Breast Conservation

Clinical Examination Yes Yes

Ipsilat Mammogram NO ALWAYS

Ipsilat US NO Likely

Ipsilat MRI NO Possible

Future ipsilat BIOPSY 3 30

Clinical Trajectory Next 20 years or sohellip

5 - 12 chance of second cancer

Salvage mastectomy

Reconstruction compromised by radiation

therapy

Second sentinel node biopsy

Previous biopsy site may compromise

mastectomy incision planning and cosmesis

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Decision involvement and receipt of

mastectomy among racially and

ethnically diverse breast cancer

patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz

NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer

Excluded Stage III or those with contraindications to breast conservation therapy

The dependent variable was receipt of mastectomy initially

The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making

Conclusions

Concerns about recurrence or radiation effects

were very important in their surgery decision

were more likely to receive mastectomy than

those less concerned (for recurrence concerns

estimated relative risk [RR] = 166 95

confidence interval [CI] = 128 to 210

Conclusions

There was a relationship between TIME SPENT

with the patient and the choice of mastectomy

Greater patient involvement in decision making

was associated with receipt of mastectomy for all

racial and ethnic groups

Patient attitudes about surgery and the opinions

of family and friends contribute to surgical

choices made by women with breast cancer

Summary

Goal should not be to maximize utilization of

BCT

Goal should be to match patient concerns

values priorities with treatment choice

Summary

Maybe patients are different today

Most work

Many single moms

Highly educated and highly informed

Each with her own set of considerations values

priorities worrieshellip

Simply not my place to impose my opinions

regarding the benefits of sparing her breast

Best we can hope for is to establish a

relationship with each patient and provide

accurate information to help them arrive at the

choice that is best for them

To sound smarthellipalways conclude your

presentation by quoting HOMERhellip

Homer Simpson 2005

Facts are meaningless

You could use facts to

prove anything that was

even remotely true

I have concluded that of all cancers I deal with

breast cancer is the most difficult Its diversity of

presentations multiple avenues of metastasis

unpredictable clinical behavior requirement for

significant tissue loss renders it in most cases

virtually impossible to arrive at a reasonable

adjustment for a means to an end

James Ewing MD 1920

Conclusions

There was a relationship between TIME SPENT

with the patient and the choice of mastectomy

Greater patient involvement in decision making

was associated with receipt of mastectomy for all

racial and ethnic groups

Patient attitudes about surgery and the opinions

of family and friends contribute to surgical

choices made by women with breast cancer

Summary

Goal should not be to maximize utilization of

BCT

Goal should be to match patient concerns

values priorities with treatment choice

Summary

Maybe patients are different today

Most work

Many single moms

Highly educated and highly informed

Each with her own set of considerations values

priorities worrieshellip

Simply not my place to impose my opinions

regarding the benefits of sparing her breast

Best we can hope for is to establish a

relationship with each patient and provide

accurate information to help them arrive at the

choice that is best for them

To sound smarthellipalways conclude your

presentation by quoting HOMERhellip

Homer Simpson 2005

Facts are meaningless

You could use facts to

prove anything that was

even remotely true

I have concluded that of all cancers I deal with

breast cancer is the most difficult Its diversity of

presentations multiple avenues of metastasis

unpredictable clinical behavior requirement for

significant tissue loss renders it in most cases

virtually impossible to arrive at a reasonable

adjustment for a means to an end

James Ewing MD 1920

Summary

Goal should not be to maximize utilization of

BCT

Goal should be to match patient concerns

values priorities with treatment choice

Summary

Maybe patients are different today

Most work

Many single moms

Highly educated and highly informed

Each with her own set of considerations values

priorities worrieshellip

Simply not my place to impose my opinions

regarding the benefits of sparing her breast

Best we can hope for is to establish a

relationship with each patient and provide

accurate information to help them arrive at the

choice that is best for them

To sound smarthellipalways conclude your

presentation by quoting HOMERhellip

Homer Simpson 2005

Facts are meaningless

You could use facts to

prove anything that was

even remotely true

I have concluded that of all cancers I deal with

breast cancer is the most difficult Its diversity of

presentations multiple avenues of metastasis

unpredictable clinical behavior requirement for

significant tissue loss renders it in most cases

virtually impossible to arrive at a reasonable

adjustment for a means to an end

James Ewing MD 1920

Summary

Maybe patients are different today

Most work

Many single moms

Highly educated and highly informed

Each with her own set of considerations values

priorities worrieshellip

Simply not my place to impose my opinions

regarding the benefits of sparing her breast

Best we can hope for is to establish a

relationship with each patient and provide

accurate information to help them arrive at the

choice that is best for them

To sound smarthellipalways conclude your

presentation by quoting HOMERhellip

Homer Simpson 2005

Facts are meaningless

You could use facts to

prove anything that was

even remotely true

I have concluded that of all cancers I deal with

breast cancer is the most difficult Its diversity of

presentations multiple avenues of metastasis

unpredictable clinical behavior requirement for

significant tissue loss renders it in most cases

virtually impossible to arrive at a reasonable

adjustment for a means to an end

James Ewing MD 1920

Best we can hope for is to establish a

relationship with each patient and provide

accurate information to help them arrive at the

choice that is best for them

To sound smarthellipalways conclude your

presentation by quoting HOMERhellip

Homer Simpson 2005

Facts are meaningless

You could use facts to

prove anything that was

even remotely true

I have concluded that of all cancers I deal with

breast cancer is the most difficult Its diversity of

presentations multiple avenues of metastasis

unpredictable clinical behavior requirement for

significant tissue loss renders it in most cases

virtually impossible to arrive at a reasonable

adjustment for a means to an end

James Ewing MD 1920

Homer Simpson 2005

Facts are meaningless

You could use facts to

prove anything that was

even remotely true

I have concluded that of all cancers I deal with

breast cancer is the most difficult Its diversity of

presentations multiple avenues of metastasis

unpredictable clinical behavior requirement for

significant tissue loss renders it in most cases

virtually impossible to arrive at a reasonable

adjustment for a means to an end

James Ewing MD 1920

I have concluded that of all cancers I deal with

breast cancer is the most difficult Its diversity of

presentations multiple avenues of metastasis

unpredictable clinical behavior requirement for

significant tissue loss renders it in most cases

virtually impossible to arrive at a reasonable

adjustment for a means to an end

James Ewing MD 1920