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Comparative Study
. 2014 Sep 3;312(9):902-14.
doi: 10.1001/jama.2014.10707.

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

Allison W Kurian  1 , Daphne Y Lichtensztajn  2 , Theresa H M Keegan  3 , David O Nelson  3 , Christina A Clarke  3 , Scarlett L Gomez  3
Affiliations
Comparative Study

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

Allison W Kurian et al. JAMA. .

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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Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Clarke and Dr Gomez reported receiving grants from Genentech outside the submitted work. No other authors reported disclosures.

Figures

Figure 1
Figure 1
Joinpoint Analysis Showing Time Trends in Use of Bilateral Mastectomy, Breast-Conserving Surgery With Radiation, and Unilateral Mastectomy, According to Patient Age in Years at Breast Cancer Diagnosis Data points indicate observed data.
Figure 2
Figure 2
Propensity-Weighted Kaplan-Meier Plots of Estimated Mortality Among All Patients if Surgical Procedure Had Been Randomly Assigned and of Estimated Mortality if a Different Surgical Procedure Had Been Performed Among Patients Who Had Undergone a Specific Surgical Procedure A, Estimated mortality among all patients if surgical procedure were randomly assigned (analysis of average treatment effect). B–D, Estimated mortality from another surgical procedure among patients who had a specific surgical procedure (analysis of average treatment effect for those treated). B, For patients receiving breast-conserving surgery with radiation, bilateral mastectomy would have resulted in marginally higher mortality, on average, and unilateral mastectomy in higher mortality. C, For patients receiving unilateral mastectomy, bilateral mastectomy would have resulted in unchanged mortality and breast-conserving surgery with radiation in lower mortality. D, For patients receiving bilateral mastectomy, breast-conserving surgery with radiation would have resulted in unchanged mortality and unilateral mastectomy in higher mortality.
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Comment in

References

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