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Canadian Journal of Public Health

, Volume 95, Issue 5, pp 336–340 | Cite as

Declining Use of Mastectomy for Invasive Breast Cancer in Canada, 1981–2000

  • Leslie A. GaudetteEmail author
  • Ru-Nie Gao
  • Andrea Spence
  • Fan Shi
  • Helen Johansen
  • Ivo A. Olivotto
Article

Abstract

Objective: To evaluate the rate and magnitude of change in surgical practice for breast cancer in Canada in relation to publication dates of clinical trials and consensus conferences.

Methods: Hospital separations with a diagnosis of invasive breast cancer were extracted from the Hospital Morbidity File from 1981 to 2000. Age-standardized rates of in-patient procedures for breast-conserving surgery and mastectomy were analyzed by province and age group and by geographic region.

Results: In Canada, mastectomy rates decreased from 62.2 to 37.9 per 100,000 between 1981 and 2000; declines were largest between 1984 and 1985, following publication of the NSABP B-06 clinical trial in March 1985, and between 1991 and 1993, after the US NIH Consensus Conference in February 1991. Mastectomy rates plateaued between 1985 and 1991, and from 1993 to 2000; the transitory peak in 1988 corresponded to publicity surrounding Nancy Reagan’s choice of mastectomy in 1987. Regional variations from the main pattern led to increasingly divergent mastectomy rates over time. Women aged 80+ were less likely to be treated by any surgery.

Interpretation: Publication of clinical trial results and consensus conferences were associated with changes in surgical treatment for breast cancer in Canada. However, divergent mastectomy rates among Canadian regions point to inconsistent adoption of less invasive therapy despite a publicly-funded health care system and national consensus guidelines.

Résumé

Objectif: Évaluer le taux et l’ampleur du changement que connaît la pratique chirurgicale relativement au traitement du cancer du sein au Canada par rapport aux dates de publication des essais cliniques et de celles des conférences de concertation.

Méthodes: Les diagnostics-congés liés à un diagnostic de cancer du sein envahissant ont été extraits de la base de données sur la morbidité hospitalière de 1981 à 2000. Les taux standardisés selon l’âge relatifs aux procédures d’hospitalisation pour la chirurgie mammaire conservatrice et la mastectomie ont été analysés par province, par groupe d’âge et par région géographique.

Résultats: Au Canada, les taux de mastectomie ont diminué, passant de 62,2 à 37,9 pour 100 000 de 1981 à 2000; les baisses ont été les plus importantes entre 1984 et 1985, à la suite de la publication de l’essai clinique NSABP B-06 en mars 1985 et, de 1991 à 1993, à la suite de la conférence de concertation des National Institutes of Health (NIH) des États-Unis en février 1991. Les taux de mastectomie ont atteint des plateaux de 1985 à 1991 et de 1993 à 2000; le point culminant de la transition en 1988 a coïncidé avec la publicité entourant le choix de Mme Nancy Reagan de subir une mastectomie en 1987. Des variations régionales par rapport à la tendance principale ont mené à des taux de mastectomie de plus en plus divergents au fil du temps. Les femmes de plus de 80 ans étaient moins susceptibles de subir un traitement chirurgical.

Interprétation: La publication des résultats relatifs aux essais cliniques et aux conférences de concertation a été rattachée à des changements dans le traitement chirurgical relatif au cancer du sein au Canada. Cependant, des taux de mastectomie divergents selon les régions canadiennes indiquent que l’adoption d’une thérapie moins envahissante fluctue, et ce, malgré un système de santé public et des lignes directrices nationales de consensus.

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Reference

  1. 1.
    Lazovich D, Solomon CC, Thomas DB, Moe RE, White E. Breast conservation therapy in the United States following the 1990 National Institutes of Health Consensus Development Conference on the treatment of patients with early stage invasive breast carcinoma. Cancer. 1999;86(4):628–37.CrossRefGoogle Scholar
  2. 2.
    Lazovich DA, White E, Thomas DB, Moe RE. Underutilization of breast-conserving surgery and radiation therapy among women with stage I or II breast cances. JAMA. 1991;266(24):3433–38.CrossRefGoogle Scholar
  3. 3.
    Nattinger AB, Hoffmann RG, Howell-Pelz A, Goodwin JS. Effect of Nancy Reagan’s mastectomy on choice of surgery for breast cancer by US women. JAMA. 1998;279(10):762–66.CrossRefGoogle Scholar
  4. 4.
    Du X, Freeman DH, Syblik DA. What drove changes in the use of breast conserving surgery since the early 1980s? The role of the clinical trial, celebrity action and an NIH consensus statemen. Breast Cancer Res Treat. 2000;62(1):71–79.CrossRefGoogle Scholar
  5. 5.
    Morris CR, Cohen R, Schlag R, Wright WE. Increasing trends in the use of breast-conserving surgery in California. Am J Public Healt. 2000;90(2):281–84.CrossRefGoogle Scholar
  6. 6.
    Iscoe NA, Naylor CD, Williams JI, et al. Temporal trends in breast cancer surgery in Ontario: Can one randomized trial make a difference. CMA. 1994;150(7):1109–15.Google Scholar
  7. 7.
    Veronesi U, Saccozzi R, Del Vecchio M, et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breas. N Engl J Med. 1981;305(1):6–11.CrossRefGoogle Scholar
  8. 8.
    Sarrazin D, Le M, Rouesse J, et al. Conservative treatment versus mastectomy in breast cancer tumors with macroscopic diameter of 20 millimeters or less. The experience of the Institut Gustave-Rouss. Cances. 1984;53(5):1209–13.CrossRefGoogle Scholar
  9. 9.
    Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cance. N Engl J Med. 1985;312(11):665–73.CrossRefGoogle Scholar
  10. 10.
    Veronesi U, Banfi A, Salvadori B, et al. Breast conservation is the treatment of choice in small breast cancer: Long-term results of a randomized trial. Eur J Cances. 1990;26(6):668–70.CrossRefGoogle Scholar
  11. 11.
    Blichert-Toft M, Rose C, Andersen JA, et al. Danish randomized trial comparing breast conservation therapy with mastectomy: Six years of life-table analysis. Danish Breast Cancer Cooperative Grou. J Natl Cancer Inst Monog. 1992;11:19–25.Google Scholar
  12. 12.
    Van Dongen JA, Bartelink H, Fentiman IS, et al. Randomized clinical trial to assess the value of breast-conserving therapy in stage I and II breast cancer, EORTC 10801 trial. J Natl Cancer Inst Monog. 1992;11:15–18.Google Scholar
  13. 13.
    Jacobson JA, Danforth DN, Cowan KH, et al. Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cance. N Engl J Med. 1995;332(14):907–11.CrossRefGoogle Scholar
  14. 14.
    Fisher B, Anderson S, Redmond CK, Wolmark N, Wickerham DL, Cronin WM. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cance. N Engl J Med. 1995;333(22):1456–61.CrossRefGoogle Scholar
  15. 15.
    Arriagada R, Le MG, Rochard F, Contesso G. Conservative treatment versus mastectomy in early breast cancer: Patterns of failure with 15 years of follow-up data. Institut Gustave-Roussy Breast Cancer Grou. J Clin Onco. 1996;14(5):1558–64.CrossRefGoogle Scholar
  16. 16.
    Van Dongen JA, Voogd AC, Fentiman IS, et al. Long-term results of a randomized trial comparing breast-conserving therapy with mastectomy: European Organization for Research and Treatment of Cancer 10801 trial. J Natl Cancer Inst. 2000;92(14):1143–50.CrossRefGoogle Scholar
  17. 17.
    Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cance. N Engl J Met. 2002;347(16):1227–32.CrossRefGoogle Scholar
  18. 18.
    Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cance. N Engl J Met. 2002;347(16):1233–41.CrossRefGoogle Scholar
  19. 19.
    Scarth H, Cantin J, Levine M. Clinical practice guidelines for the care and treatment of breast cancer: Mastectomy or lumpectomy? The choice of operation for clinical stages I and II breast cancer (summary of the 2002 update. CMA. 2002;167(2):154–55.Google Scholar
  20. 20.
    Farrow DC, Hunt WC, Samet JM. Geographic variation in the treatment of localized breast cance. N Engl J Med. 1992;326(17):1097–101.CrossRefGoogle Scholar
  21. 21.
    Goel V, Olivotto I, Hislop TG, Sawka C, Coldman A, Holowaty EJ. Patterns of initial management of node-negative breast cancer in two Canadian province. CMA. 1997;156(1):25–35.Google Scholar
  22. 22.
    Iscoe NA, Goel V, Wu K, Fehringer G, Holowaty EJ, Naylor CD. Variation in breast cancer surgery in Ontari. CMA. 1994;150(3):345–52.Google Scholar
  23. 23.
    Nattinger AB, Gottlieb MS, Hoffman RG, Walker AP, Goodwin JS. Minimal increase in use of breast-conserving surgery from 1986 to 199. Med Care. 1996;34(5):479–89.CrossRefGoogle Scholar
  24. 24.
    Gentleman JF, Parsons GF, Walsh MN, Vayda E. High and low surgical procedure rates in Census Divisions across Canad. Health Report. 1994;6(4):403–40.Google Scholar
  25. 25.
    Mayo NE, Scott SC, Ningyan S, Hanley J, Goldberg MS, MacDonald N. Waiting time for breast cancer surgery in Quebec. CMA. 2001;164(8):1133–38.Google Scholar
  26. 26.
    Hebert-Croteau N, Brisson J, Latreille J, Blanchette C, Deschenes L. Variations in the treatment of early-stage breast cancer in Quebec between 1988 and 1999. CMA. 1999;161(8):951–55.Google Scholar
  27. 27.
    Gibbons L, Waters C. Prostate cancer - testing, incidence, surgery and mortalit. Health Report. 2003;14:9–20.Google Scholar
  28. 28.
    Millar WJ. Hysterectomy, 1981/82 to 1996/9. Health Report. 2000;12:9–22.Google Scholar
  29. 29.
    Gaudette LA, Lee J. Cancer Incidence in Canada, 1969–1993. Statistics Canada cat. no. 82–566-XPB. Ottawa, ON: Minister of Industry, 1997.Google Scholar
  30. 30.
    de Koning HJ, van Dongen JA, van der Maas PJ. Changes in use of breast-conserving therapy in years 1978–200. Br J Cances. 1994;70(6):1165–70.CrossRefGoogle Scholar
  31. 31.
    NIH consensus conference. Treatment of early-stage breast cance. JAM. 1991;265(3):391–95.CrossRefGoogle Scholar
  32. 32.
    Clinical practice guidelines for the care and treatment of breast cancer. A Canadian consensus document. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cance. CMA. 1998;158(3(Suppl).Google Scholar
  33. 33.
    Nold RJ, Beamer RL, Helmer SD, McBoyle MF. Factors influencing a woman’s choice to undergo breast-conserving surgery versus modified radical mastectom. Am J Surv. 2000;180(6):413–18.CrossRefGoogle Scholar
  34. 34.
    Tarbox BB, Rockwood JK, Abernathy CM. Are modified radical mastectomies done for T1 breast cancers because of surgeon’s advice or patient’s choice. Am J Surv. 1992;164(5):417–20.CrossRefGoogle Scholar
  35. 35.
    Potosky AL, Merrill RM, Riley GF, et al. Breast cancer survival and treatment in health maintenance organization and fee-for-service setting. J Natl Cancer Inst. 1997;89(22):1683–91.CrossRefGoogle Scholar
  36. 36.
    Whelan T, Levine M, Gafni A, et al. Mastectomy or lumpectomy? Helping women make informed choice. J Clin Oncon. 1999;17(6):1727–35.CrossRefGoogle Scholar
  37. 37.
    Ballard-Barbash R, Potosky AL, Harlan LC, Nayfield SG, Kessler LG. Factors associated with surgical and radiation therapy for early stage breast cancer in older women. J Natl Cancer Inst. 1996;88(11):716–26.CrossRefGoogle Scholar
  38. 38.
    Hislop TG, Olivotto IA, Coldman AJ, et al. Variations in breast conservation surgery for women with axillary lymph node negative breast cancer in British Columbia. Can J Public Healt. 1996;87(6):390–94.Google Scholar
  39. 39.
    Nattinger AB, Gottlieb MS, Veum J, Yahnke D, Goodwin JS. Geographic variation in the use of breast-conserving treatment for breast cance. N Engl J Med. 1992;326(17):1102–7.CrossRefGoogle Scholar
  40. 40.
    Samet JM, Hunt WC, Farrow DC. Determinants of receiving breast-conserving surgery. The Surveillance, Epidemiology, and End Results Program, 1983–1986. Cances. 1994;73(9):2344–51.CrossRefGoogle Scholar
  41. 41.
    Hebert-Croteau N, Brisson J, Latreille J, Blanchette C, Deschenes L. Compliance with consensus recommendations for the treatment of early stage breast carcinoma in elderly women. Cances. 1999;85(5):1104–13.CrossRefGoogle Scholar
  42. 42.
    Health Canada. Organized breast cancer screening programs in Canada: 1997 and 1998 report. Minister of Public Works and Government Services Canada, 2001. Cat.No.HI-9/13-1998.Google Scholar
  43. 43.
    Truong PT, Bernstein V, Wai E, Chua B, Speers C, Olivotto IA. Age-related variations in the use of axillary dissection: A survival analysis of 8038 women with T1-ST2 breast cance. Int J Radiat Oncol Biol Phys. 2002;54(3):794–803.CrossRefGoogle Scholar
  44. 44.
    Turner NJ, Haward RA, Mulley GP, Selby PJ. Cancer in old age—is it inadequately investigated and treate. BM. 1999;319(7205):309–12.CrossRefGoogle Scholar
  45. 45.
    Hughes M. Summary of results from breast cancer disease study. Chapter 4. I. A Disease-based Comparison of Health Systems. Paris: Organization of Economic Cooperation and Development. 2003;77–94.Google Scholar
  46. 46.
    Neutel CI, Gao R-N, Gaudette LA, Johansen HL. Decreasing length of hospital stay for female breast cancer patients in Canada, 1981–2000. Health Report. (in press).Google Scholar
  47. 47.
    Whelan T, Olivotto I, Levine M. Clinical practice guideline for the care and treatment of breast cancer: Breast radiotherapy after breast-conserving surgery (summary of 2003 update. CMA. 2003;168(4):437–39.Google Scholar
  48. 48.
    Nattinger AB, Hoffmann RG, Kneusel RT, Schapira MM. Relation between appropriateness of primary therapy for early-stage breast carcinoma and increased use of breast-conserving surger. Lances. 2000;356(9236):1148–53.CrossRefGoogle Scholar
  49. 49.
    Olivotto A, Coldman AJ, Hislop TG, et al. Compliance with practice guidelines for node-negative breast cances. J Clin Oncol. 1997;15(1):216–22.CrossRefGoogle Scholar
  50. 50.
    Paszat LF, Mackillop WJ, Groome PA, Zhang-Salomons J, Schulze K, Holowaty E. Radiotherapy for breast cancer in Ontario: Rate variation associated with region, age and incom. Clin Invest Med. 1998;21(3):125–34.PubMedGoogle Scholar

Copyright information

© The Canadian Public Health Association 2004

Authors and Affiliations

  • Leslie A. Gaudette
    • 1
    Email author
  • Ru-Nie Gao
    • 1
  • Andrea Spence
    • 2
  • Fan Shi
    • 3
  • Helen Johansen
    • 4
  • Ivo A. Olivotto
    • 5
  1. 1.Chronic Disease Management and Control Division, Centre for Chronic Disease Prevention and ControlHealth CanadaOttawaCanada
  2. 2.Division of Cancer EpidemiologyMcGill UniversityMontrealCanada
  3. 3.Therapeutic Products DirectorateHealth CanadaOttawaCanada
  4. 4.Health Statistics DivisionStatistics CanadaOttawaCanada
  5. 5.BC Cancer Agency, Vancouver Island Centre and University of British ColumbiaVictoriaCanada

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