Factors Influencing Choice of Surgery in the Management of Breast Cancer

A Qualitative and Quantitative Study

Introduction

A significant geographic variation in the rates of Mastectomy and Breast Conservation Surgery (BCS) for the surgical management of early breast carcinoma has long been recognised. This pattern is observed throughout the UK and repeated in Europe, USA and Canada. The Trent region is no different in this respect; as supported by the Trent Breast Screening Program Database and a specific audit project commissioned by the North Trent Breast Cancer Group and analysed by ScHARR in 1998. In agreement with the published work on the subject, Trents variation in Mastectomy and BCS rates are not explained by case-mix alone.

The surgical management of breast cancer has advanced considerably in recent years with the expansion of breast reconstruction surgery. There are now generally considered to be four rather than two surgical treatment options for early breast cancer; BCS, mastectomy and mastectomy with primary or secondary reconstruction. However the majority of women still fall into the first two groups.

Survival Rates

Two historically important prognostic studies were published in 1995. The National Surgical Adjuvant Breast and Bowel Projects Protocol (NSABP) B-06 (Fisher et al. 1995) and a smaller Canadian study performed by the National Cancer institute (Jacobson et al. 1995) reported no statistically significant difference in the survival curves of women with early breast cancer treated by mastectomy or BCS with radiotherapy. These early studies concentrated on tumours less than 2cm in diameter. More recently results of a long term randomised trial, the European Organisation for Research and Treatment of Cancer 10801 Trial (van Dongen et al. 2000) confirmed that in cancers up to 5cm in diameter there was no significant survival advantage of one treatment over the other at 10-years follow up. Interestingly, these trials all confirm a statistically significant difference in local recurrence rates between mastectomy and breast conservation surgery (with ipsilateral radiotherapy); the most recent study reported locoregional recurrence rates of 12% and 20% respectively.

With the availability of survival results, it was widely assumed that when given a choice the majority of women with early stage breast cancer would elect to undergo BCS. Available evidence suggests this has not uniformly been the case.

Aim

The aim of this project is to investigate the influence of the surgical management preferences and consultation skills of specialist breast clinicians (surgeon and nurses) on the surgical choices, decision-making and satisfaction, of women with breast cancer in Trent. The Trent region demonstrating a degree of treatment variation reflective of the widely reported pattern of variation observed within the UK, will be studied to elucidate the factors influencing patient choice in surgical decisions in the management of breast cancer.

We intend to develop a paradigm regarding options for breast cancer surgery that results in a fully informed process of decision-making, thereby promoting best practice in communication and therapeutic intervention.