Breast-conserving therapy on the rise, but off-limits to some
The first national review of breast-conserving therapy (BCT) shows that over the last 13 years, rates of this treatment for early-stage breast cancer have increased at a steady pace. However, the review also highlights demographic factors that impact whether or not a patient will have access to BCT. MD Anderson researchers found that disparities related to age, treatment facility type and geographic region, are declining. But they also identified several socioeconomic factors including health insurance coverage, income and travel distance to treatment centers as barriers to BCT.
Published online in JAMA Surgery, the researchers used the National Cancer Data Base (NCDB) to examine the surgical choices of women with stage T1 or T2 breast cancer treated between 1998 and 2011. The NCDB is a nationwide oncology outcomes database that includes approximately 70% of all newly diagnosed cases of cancer in the U.S. Of the nearly 728,000 women included in the analysis, the percentage undergoing BCT increased from 54.3% in 1998 to 59.7% in 2006, and then remained relatively constant, landing at 60.1% in 2011.
However, the rates of BCT — also called lumpectomy — varied based on patient demographics, including insurance status and income, and treating facility variables such as facility type, location and travel distance for the patient.
“Looking at the big picture, strides have been made to reduce disparities in the use of this very effective treatment for women with early-stage breast cancer. But despite significant progress by the medical community, there are significant pockets of women where this therapy is underutilized,” said principal investigator Isabelle Bedrosian, M.D., associate professor of Surgical Oncology and medical director of the Nellie B. Connally Breast Center at MD Anderson. “The socioeconomic barriers are unlikely to be erased without health policy changes.”
Elaborating on the findings, she added that lower rates of BCT among women who live farthest from treatment facilities may be attributed to patients’ ability or willingness to travel for daily radiation therapy, a standard follow-up to lumpectomy. This may also account for lower rates of BCT in the South, where women often have disproportionately greater travel distances to treatment facilities. Income and insurance status also play a significant role in surgical choice, as a woman from a low-income family may be unable to commit to the length of time needed for the weeks of radiotherapy.
Most women with breast cancer have some type of surgery to remove the tumor, usually opting for BCT or mastectomy. With BCT, only the part of the breast containing the cancer and some surrounding tissue are removed. The National Institutes of Health issued a consensus statement in 1990 in support of BCT that led to a substantial decline in mastectomy rates and widespread acceptance of BCT as an appropriate and effective treatment for early-stage breast cancer. However, in the past decade, technical advances and other societal changes — including genetic testing for BRCA1 and BRCA2 mutations, advances in reconstruction techniques, breast magnetic resonance imaging and contralateral prophylactic mastectomy — have garnered increased patient interest.
According to Dr. Bedrosian, this study confirms that the majority of women are choosing BCT, a “reassuring finding that patients and physicians recognize that this less invasive therapy is a good course of treatment for early-stage breast cancer.” However, she added, “These data also demonstrate the breadth of the socioeconomic factors that need to be considered to adequately address the disparate use of BCT across demographic groups.”