Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011

Allison W. Kurian, Daphne Y. Lichtensztajn, Theresa H Keegan, David O. Nelson, Christina A. Clarke, Scarlett L. Gomez

Research output: Contribution to journalArticle

148 Citations (Scopus)

Abstract

IMPORTANCE: Bilateral mastectomy is increasingly used to treat unilateral breast cancer. Because it may have medical and psychosocial complications, a better understanding of its use and outcomes is essential to optimizing cancer care. OBJECTIVE: To compare use of and mortality after bilateral mastectomy, breast-conserving therapy with radiation, and unilateral mastectomy. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study within the population-based California Cancer Registry; participants were women diagnosed with stages 0-III unilateral breast cancer in California from 1998 through 2011, with median follow-up of 89.1 months. MAIN OUTCOMES AND MEASURES: Factors associated with surgery use (from polytomous logistic regression); overall and breast cancer-specific mortality (from propensity score weighting and Cox proportional hazards analysis). RESULTS: Among 189 734 patients, the rate of bilateral mastectomy increased from 2.0% (95%CI, 1.7%-2.2%) in 1998 to 12.3%(95%CI, 11.8%-12.9%) in 2011, an annual increase of 14.3%(95%CI, 13.1%-15.5%); among women younger than 40 years, the rate increased from 3.6%(95%CI, 2.3%-5.0%) in 1998 to 33%(95%CI, 29.8%-36.5%) in 2011. Bilateral mastectomy was more often used by non-Hispanic white women, those with private insurance, and those who received care at a National Cancer Institute (NCI)-designated cancer center (8.6%[95%CI, 8.1%-9.2%] among NCI cancer center patients vs 6.0% [95% CI, 5.9%-6.1%] among non-NCI cancer center patients; odds ratio [OR], 1.13 [95%CI, 1.04-1.22]); in contrast, unilateral mastectomy was more often used by racial/ethnic minorities (Filipina, 52.8%[95%CI, 51.6%-54.0%]; OR, 2.00 [95%CI, 1.90-2.11] and Hispanic, 45.6%[95%CI, 45.0%-46.2%]; OR, 1.16 [95%CI, 1.13-1.20] vs non-Hispanic white, 35.2% [95%CI, 34.9%-35.5%]) and those with public/Medicaid insurance (48.4%[95%CI, 47.8%-48.9%]; OR, 1.08 [95%CI, 1.05-1.11] vs private insurance, 36.6%[95%CI, 36.3%-36.8%]). Compared with breast-conserving surgery with radiation (10-year mortality, 16.8%[95%CI, 16.6%-17.1%]), unilateral mastectomy was associated with higher all-cause mortality (hazard ratio [HR], 1.35 [95%CI, 1.32-1.39]; 10-year mortality, 20.1%[95%CI, 19.9%-20.4%]). There was no significant mortality difference compared with bilateral mastectomy (HR, 1.02 [95%CI, 0.94-1.11]; 10-year mortality, 18.8% [95%CI, 18.6%-19.0%]). Propensity analysis showed similar results. CONCLUSIONS AND RELEVANCE: Use of bilateral mastectomy increased significantly throughout California from 1998 through 2011 and was not associated with lower mortality than that achieved with breast-conserving surgery plus radiation. Unilateral mastectomy was associated with higher mortality than were the other 2 surgical options.

Original languageEnglish (US)
Pages (from-to)902-914
Number of pages13
JournalJAMA - Journal of the American Medical Association
Volume312
Issue number9
DOIs
StatePublished - Sep 3 2014
Externally publishedYes

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Mastectomy
Breast Neoplasms
Mortality
Insurance
Odds Ratio
Therapeutics
Neoplasms
Segmental Mastectomy
National Cancer Institute (U.S.)
Radiation
Propensity Score
Medicaid
Hispanic Americans
Observational Studies
Registries
Breast
Cohort Studies
Radiotherapy
Logistic Models

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011. / Kurian, Allison W.; Lichtensztajn, Daphne Y.; Keegan, Theresa H; Nelson, David O.; Clarke, Christina A.; Gomez, Scarlett L.

In: JAMA - Journal of the American Medical Association, Vol. 312, No. 9, 03.09.2014, p. 902-914.

Research output: Contribution to journalArticle

Kurian, Allison W. ; Lichtensztajn, Daphne Y. ; Keegan, Theresa H ; Nelson, David O. ; Clarke, Christina A. ; Gomez, Scarlett L. / Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011. In: JAMA - Journal of the American Medical Association. 2014 ; Vol. 312, No. 9. pp. 902-914.
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title = "Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011",
abstract = "IMPORTANCE: Bilateral mastectomy is increasingly used to treat unilateral breast cancer. Because it may have medical and psychosocial complications, a better understanding of its use and outcomes is essential to optimizing cancer care. OBJECTIVE: To compare use of and mortality after bilateral mastectomy, breast-conserving therapy with radiation, and unilateral mastectomy. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study within the population-based California Cancer Registry; participants were women diagnosed with stages 0-III unilateral breast cancer in California from 1998 through 2011, with median follow-up of 89.1 months. MAIN OUTCOMES AND MEASURES: Factors associated with surgery use (from polytomous logistic regression); overall and breast cancer-specific mortality (from propensity score weighting and Cox proportional hazards analysis). RESULTS: Among 189 734 patients, the rate of bilateral mastectomy increased from 2.0{\%} (95{\%}CI, 1.7{\%}-2.2{\%}) in 1998 to 12.3{\%}(95{\%}CI, 11.8{\%}-12.9{\%}) in 2011, an annual increase of 14.3{\%}(95{\%}CI, 13.1{\%}-15.5{\%}); among women younger than 40 years, the rate increased from 3.6{\%}(95{\%}CI, 2.3{\%}-5.0{\%}) in 1998 to 33{\%}(95{\%}CI, 29.8{\%}-36.5{\%}) in 2011. Bilateral mastectomy was more often used by non-Hispanic white women, those with private insurance, and those who received care at a National Cancer Institute (NCI)-designated cancer center (8.6{\%}[95{\%}CI, 8.1{\%}-9.2{\%}] among NCI cancer center patients vs 6.0{\%} [95{\%} CI, 5.9{\%}-6.1{\%}] among non-NCI cancer center patients; odds ratio [OR], 1.13 [95{\%}CI, 1.04-1.22]); in contrast, unilateral mastectomy was more often used by racial/ethnic minorities (Filipina, 52.8{\%}[95{\%}CI, 51.6{\%}-54.0{\%}]; OR, 2.00 [95{\%}CI, 1.90-2.11] and Hispanic, 45.6{\%}[95{\%}CI, 45.0{\%}-46.2{\%}]; OR, 1.16 [95{\%}CI, 1.13-1.20] vs non-Hispanic white, 35.2{\%} [95{\%}CI, 34.9{\%}-35.5{\%}]) and those with public/Medicaid insurance (48.4{\%}[95{\%}CI, 47.8{\%}-48.9{\%}]; OR, 1.08 [95{\%}CI, 1.05-1.11] vs private insurance, 36.6{\%}[95{\%}CI, 36.3{\%}-36.8{\%}]). Compared with breast-conserving surgery with radiation (10-year mortality, 16.8{\%}[95{\%}CI, 16.6{\%}-17.1{\%}]), unilateral mastectomy was associated with higher all-cause mortality (hazard ratio [HR], 1.35 [95{\%}CI, 1.32-1.39]; 10-year mortality, 20.1{\%}[95{\%}CI, 19.9{\%}-20.4{\%}]). There was no significant mortality difference compared with bilateral mastectomy (HR, 1.02 [95{\%}CI, 0.94-1.11]; 10-year mortality, 18.8{\%} [95{\%}CI, 18.6{\%}-19.0{\%}]). Propensity analysis showed similar results. CONCLUSIONS AND RELEVANCE: Use of bilateral mastectomy increased significantly throughout California from 1998 through 2011 and was not associated with lower mortality than that achieved with breast-conserving surgery plus radiation. Unilateral mastectomy was associated with higher mortality than were the other 2 surgical options.",
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TY - JOUR

T1 - Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011

AU - Kurian, Allison W.

AU - Lichtensztajn, Daphne Y.

AU - Keegan, Theresa H

AU - Nelson, David O.

AU - Clarke, Christina A.

AU - Gomez, Scarlett L.

PY - 2014/9/3

Y1 - 2014/9/3

N2 - IMPORTANCE: Bilateral mastectomy is increasingly used to treat unilateral breast cancer. Because it may have medical and psychosocial complications, a better understanding of its use and outcomes is essential to optimizing cancer care. OBJECTIVE: To compare use of and mortality after bilateral mastectomy, breast-conserving therapy with radiation, and unilateral mastectomy. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study within the population-based California Cancer Registry; participants were women diagnosed with stages 0-III unilateral breast cancer in California from 1998 through 2011, with median follow-up of 89.1 months. MAIN OUTCOMES AND MEASURES: Factors associated with surgery use (from polytomous logistic regression); overall and breast cancer-specific mortality (from propensity score weighting and Cox proportional hazards analysis). RESULTS: Among 189 734 patients, the rate of bilateral mastectomy increased from 2.0% (95%CI, 1.7%-2.2%) in 1998 to 12.3%(95%CI, 11.8%-12.9%) in 2011, an annual increase of 14.3%(95%CI, 13.1%-15.5%); among women younger than 40 years, the rate increased from 3.6%(95%CI, 2.3%-5.0%) in 1998 to 33%(95%CI, 29.8%-36.5%) in 2011. Bilateral mastectomy was more often used by non-Hispanic white women, those with private insurance, and those who received care at a National Cancer Institute (NCI)-designated cancer center (8.6%[95%CI, 8.1%-9.2%] among NCI cancer center patients vs 6.0% [95% CI, 5.9%-6.1%] among non-NCI cancer center patients; odds ratio [OR], 1.13 [95%CI, 1.04-1.22]); in contrast, unilateral mastectomy was more often used by racial/ethnic minorities (Filipina, 52.8%[95%CI, 51.6%-54.0%]; OR, 2.00 [95%CI, 1.90-2.11] and Hispanic, 45.6%[95%CI, 45.0%-46.2%]; OR, 1.16 [95%CI, 1.13-1.20] vs non-Hispanic white, 35.2% [95%CI, 34.9%-35.5%]) and those with public/Medicaid insurance (48.4%[95%CI, 47.8%-48.9%]; OR, 1.08 [95%CI, 1.05-1.11] vs private insurance, 36.6%[95%CI, 36.3%-36.8%]). Compared with breast-conserving surgery with radiation (10-year mortality, 16.8%[95%CI, 16.6%-17.1%]), unilateral mastectomy was associated with higher all-cause mortality (hazard ratio [HR], 1.35 [95%CI, 1.32-1.39]; 10-year mortality, 20.1%[95%CI, 19.9%-20.4%]). There was no significant mortality difference compared with bilateral mastectomy (HR, 1.02 [95%CI, 0.94-1.11]; 10-year mortality, 18.8% [95%CI, 18.6%-19.0%]). Propensity analysis showed similar results. CONCLUSIONS AND RELEVANCE: Use of bilateral mastectomy increased significantly throughout California from 1998 through 2011 and was not associated with lower mortality than that achieved with breast-conserving surgery plus radiation. Unilateral mastectomy was associated with higher mortality than were the other 2 surgical options.

AB - IMPORTANCE: Bilateral mastectomy is increasingly used to treat unilateral breast cancer. Because it may have medical and psychosocial complications, a better understanding of its use and outcomes is essential to optimizing cancer care. OBJECTIVE: To compare use of and mortality after bilateral mastectomy, breast-conserving therapy with radiation, and unilateral mastectomy. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study within the population-based California Cancer Registry; participants were women diagnosed with stages 0-III unilateral breast cancer in California from 1998 through 2011, with median follow-up of 89.1 months. MAIN OUTCOMES AND MEASURES: Factors associated with surgery use (from polytomous logistic regression); overall and breast cancer-specific mortality (from propensity score weighting and Cox proportional hazards analysis). RESULTS: Among 189 734 patients, the rate of bilateral mastectomy increased from 2.0% (95%CI, 1.7%-2.2%) in 1998 to 12.3%(95%CI, 11.8%-12.9%) in 2011, an annual increase of 14.3%(95%CI, 13.1%-15.5%); among women younger than 40 years, the rate increased from 3.6%(95%CI, 2.3%-5.0%) in 1998 to 33%(95%CI, 29.8%-36.5%) in 2011. Bilateral mastectomy was more often used by non-Hispanic white women, those with private insurance, and those who received care at a National Cancer Institute (NCI)-designated cancer center (8.6%[95%CI, 8.1%-9.2%] among NCI cancer center patients vs 6.0% [95% CI, 5.9%-6.1%] among non-NCI cancer center patients; odds ratio [OR], 1.13 [95%CI, 1.04-1.22]); in contrast, unilateral mastectomy was more often used by racial/ethnic minorities (Filipina, 52.8%[95%CI, 51.6%-54.0%]; OR, 2.00 [95%CI, 1.90-2.11] and Hispanic, 45.6%[95%CI, 45.0%-46.2%]; OR, 1.16 [95%CI, 1.13-1.20] vs non-Hispanic white, 35.2% [95%CI, 34.9%-35.5%]) and those with public/Medicaid insurance (48.4%[95%CI, 47.8%-48.9%]; OR, 1.08 [95%CI, 1.05-1.11] vs private insurance, 36.6%[95%CI, 36.3%-36.8%]). Compared with breast-conserving surgery with radiation (10-year mortality, 16.8%[95%CI, 16.6%-17.1%]), unilateral mastectomy was associated with higher all-cause mortality (hazard ratio [HR], 1.35 [95%CI, 1.32-1.39]; 10-year mortality, 20.1%[95%CI, 19.9%-20.4%]). There was no significant mortality difference compared with bilateral mastectomy (HR, 1.02 [95%CI, 0.94-1.11]; 10-year mortality, 18.8% [95%CI, 18.6%-19.0%]). Propensity analysis showed similar results. CONCLUSIONS AND RELEVANCE: Use of bilateral mastectomy increased significantly throughout California from 1998 through 2011 and was not associated with lower mortality than that achieved with breast-conserving surgery plus radiation. Unilateral mastectomy was associated with higher mortality than were the other 2 surgical options.

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