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 journalArticlepeer-review

166 Scopus citations

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

ASJC Scopus subject areas

  • Medicine(all)

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