Morrow Monica, Jagsi Reshma, Alderman Amy K, Griggs Jennifer J, Hawley Sarah T, Hamilton Ann S, Graff John J, Katz Steven J
Breast Surgery Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA.
JAMA. 2009 Oct 14;302(14):1551-6. doi: 10.1001/jama.2009.1450.
There is concern that mastectomy is overused in the United States.
To evaluate the association of patient-reported initial recommendations by surgeons and those given when a second opinion was sought with receipt of initial mastectomy; and to assess the use of mastectomy after attempted breast-conserving surgery (BCS).
DESIGN, SETTING, AND PATIENTS: A survey of women aged 20 to 79 years with intraductal or stage I and II breast cancer diagnosed between June 2005 and February 2007 and reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results registries for the metropolitan areas of Los Angeles, California, and Detroit, Michigan. Patients were identified using rapid case ascertainment, and Latinas and blacks were oversampled. Of 3133 patients sent surveys, 2290 responded (73.1%). A mailed survey was completed by 96.5% of respondents and 3.5% completed a telephone survey. The final sample included 1984 female patients (502 Latinas, 529 blacks, and 953 non-Hispanic white or other).
The rate of initial mastectomy and the perceived reason for its use (surgeon recommendation, patient driven, medical contraindication) and the rate of mastectomy after attempted BCS.
Of the 1984 patients, 1468 had BCS as an initial surgical therapy (75.4%) and 460 had initial mastectomy, including 13.4% following surgeon recommendation and 8.8% based on patient preference. Approximately 20% of patients (n = 378) sought a second opinion; this was more common for those patients advised by their initial surgeon to undergo mastectomy (33.4%) than for those advised to have BCS (15.6%) or for those not receiving a recommendation for one procedure over another (21.2%) (P < .001). Discordance in treatment recommendations between surgeons occurred in 12.1% (n = 43) of second opinions and did not differ on the basis of patient race/ethnicity, education, or geographic site. Among the 1459 women for whom BCS was attempted, additional surgery was required in 37.9% of patients, including 358 with reexcision (26.0%) and 167 with mastectomy (11.9%). Mastectomy was most common in patients with stage II cancer (P < .001).
Breast-conserving surgery was recommended by surgeons and attempted in the majority of patients evaluated, with surgeon recommendation, patient decision, and failure of BCS all contributing to the mastectomy rate.
在美国，人们担心乳房切除术被过度使用。
评估患者报告的外科医生最初建议与寻求第二意见时给出的建议与接受初次乳房切除术之间的关联；并评估尝试保乳手术（BCS）后乳房切除术的使用情况。
设计、地点和患者：对2005年6月至2007年2月期间诊断为导管内癌或I期和II期乳腺癌且向美国国家癌症研究所的监测、流行病学和最终结果登记处报告的加利福尼亚州洛杉矶市和密歇根州底特律市大都市区20至79岁的女性进行调查。通过快速病例确定来识别患者，拉丁裔和黑人被过度抽样。在发送调查问卷的3133名患者中，2290名做出了回应（73.1%）。96.5%的受访者通过邮寄方式完成了调查，3.5%通过电话调查完成。最终样本包括1984名女性患者（502名拉丁裔、529名黑人以及953名非西班牙裔白人或其他种族）。
初次乳房切除术的发生率及其使用的感知原因（外科医生建议、患者驱动、医学禁忌）以及尝试保乳手术后乳房切除术的发生率。
在1984名患者中，1468名最初接受了保乳手术作为手术治疗（75.4%），460名接受了初次乳房切除术，其中13.4%是根据外科医生的建议，8.8%是基于患者的偏好。约20%的患者（n = 378）寻求了第二意见；对于那些最初的外科医生建议进行乳房切除术的患者来说，这种情况更为常见（33.4%），而对于那些被建议进行保乳手术的患者（15.6%）或那些未收到关于一种手术优于另一种手术建议的患者（21.2%）则不然（P <.001）。外科医生之间治疗建议的不一致在12.1%（n = 43）的第二意见中出现，并且在患者种族/民族、教育程度或地理位置方面没有差异。在1459名尝试保乳手术的女性中，37.9%的患者需要额外的手术，包括358名进行再次切除（26.0%）和167名进行乳房切除术（11.9%）。乳房切除术在II期癌症患者中最为常见（P <.001）。
外科医生建议进行保乳手术，并且在大多数接受评估的患者中尝试进行了保乳手术，外科医生的建议、患者的决定以及保乳手术的失败都导致了乳房切除术的发生率。
