Annals of Surgical Oncology

, Volume 15, Issue 3, pp 854–862 | Cite as

The Influence of Age on the Breast Surgery Decision-Making Process

  • Richard J. BleicherEmail author
  • Paul Abrahamse
  • Sarah T. Hawley
  • Steven J. Katz
  • Monica Morrow
Breast Oncology



Mastectomy rates have been assumed to be a function of physician recommendations, although they correlate with patient involvement in decision making. The influence of age on the decision-making process and treatment choice is poorly described.


All women with ductal carcinoma in situ (DCIS) and a random sample with invasive breast cancer were identified from two Surveillance Epidemiology and End Results (SEER) program registries and surveyed 6 months postoperatively. Women older than 79 years with noninvasive or localized invasive breast cancer diagnosed in 2002 were included. Women with breast-conserving therapy (BCT) contraindications were excluded. Women were questioned about involvement in surgical decision-making, inquiring if this decision was patient-based, surgeon-based, or shared. Knowledge and concerns were assessed.


The response rate was 77.0%. There were 1,259 patients who met the study eligibility criteria and age data was available for 1,131. Median patient age was 59.9 years. The frequency of patient-based decisions did not vary with age (p = 0.20), but older women had less knowledge for decision making. The mastectomy rate overall was 19.7%, with no differences in mastectomy choice by age (p = 0.18). In logistic regression for the likelihood of undergoing mastectomy, patient involvement (p < 0.0001), larger tumor size (p < 0.0001), lower education (p = 0.0002), number of surgeons consulted (p = 0.0005), and nonwhite race origin (p = 0.011) were significant predictors, while age, invasion, and comorbidities were not significant.


Older women participate equally in breast cancer surgical decision making and are equally likely to select mastectomy, but use less knowledge to make the decision. The impact of education and ethnic origin on mastectomy use indicates the need for improved educational strategies for these groups.


Breast neoplasms Carcinoma Decision making Mastectomy Segmental mastectomy Patient participation 



Funded by a grant from the National Cancer Institute (R01CA8837-AI).


  1. 1.
    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 cancer. N Engl J Med 2002;347:1233–41PubMedCrossRefGoogle Scholar
  2. 2.
    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 cancer. N Engl J Med 2002;347:1227–32Google Scholar
  3. 3.
    Poggi MM, Danforth DN, Sciuto LC, et al. Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer Institute Randomized Trial. Cancer 2003;98:697–702PubMedCrossRefGoogle Scholar
  4. 4.
    National Cancer Institute. 1973–2001 SEER Public Use DataGoogle Scholar
  5. 5.
    Mandelblatt JS, Berg CD, Meropol NJ, et al. Measuring and predicting surgeons’ practice styles for breast cancer treatment in older women. Med Care 2001;39:228–42PubMedCrossRefGoogle Scholar
  6. 6.
    Mandelblatt JS, Hadley J, Kerner JF, et al. Patterns of breast carcinoma treatment in older women: patient preference and clinical and physical influences. Cancer 2000;89:561–73PubMedCrossRefGoogle Scholar
  7. 7.
    Katz SJ, Lantz PM, Janz NK, et al. Patterns and correlates of local therapy for women with ductal carcinoma-in-situ. J Clin Oncol 2005;23:3001–7PubMedCrossRefGoogle Scholar
  8. 8.
    Surveillance Epidemiology and End Results (SEER) Program. SEER Fast Stats - Breast Cancer, Incidence. In: Institute NC, vol. 2007Google Scholar
  9. 9.
    Katz SJ, Lantz PM, Janz NK, et al. Patient involvement in surgery treatment decisions for breast cancer. J Clin Oncol 2005;23:5526–33PubMedCrossRefGoogle Scholar
  10. 10.
    Morrow M, Mujahid M, Lantz PM, et al. Correlates of breast reconstruction: results from a population-based study. Cancer 2005;104:2340–6PubMedCrossRefGoogle Scholar
  11. 11.
    Katz SJ, Hofer TP, Hawley S, et al. Patterns and correlates of patient referral to surgeons for treatment of breast cancer. J Clin Oncol 2007;25:271–6PubMedCrossRefGoogle Scholar
  12. 12.
    Hawley ST, Lantz PM, Janz NK, et al. Factors associated with patient involvement in surgical treatment decision making for breast cancer. Patient Educ Couns 2007;65(3):387–95PubMedCrossRefGoogle Scholar
  13. 13.
    Dillman DA. Mail and telephone surveys. New York: Wiley; 1978Google Scholar
  14. 14.
    Hawley ST, Lantz PM, Janz NK, et al. Factors associated with patient involvement in surgical treatment decision making for breast cancer. Patient Educ Couns 2007;65:387–95PubMedCrossRefGoogle Scholar
  15. 15.
    Morrow M, Strom EA, Bassett LW, et al. Standard for breast conservation therapy in the management of invasive breast carcinoma. CA Cancer J Clin 2002;52:277–300PubMedGoogle Scholar
  16. 16.
    Morrow M, Strom EA, Bassett LW, et al. Standard for the management of ductal carcinoma in situ of the breast (DCIS). CA Cancer J Clin 2002;52:256–76PubMedCrossRefGoogle Scholar
  17. 17.
    Bickell NA, Aufses AH Jr, Chassin MR. The quality of early-stage breast cancer care. Ann Surg 2000;232:220–4PubMedCrossRefGoogle Scholar
  18. 18.
    Hewitt ME, Simone JV. Institute of Medicine and Commission on Life Sciences, National Research Council report for the National Cancer Policy Board: Ensuring quality cancer care. Washington, D.C.: National Academy Press; 1999. ix, p 246Google Scholar
  19. 19.
    Hiotis K, Ye W, Sposto R, Skinner KA. Predictors of breast conservation therapy: size is not all that matters. Cancer 2005;103:892–9PubMedCrossRefGoogle Scholar
  20. 20.
    Diab SG, Elledge RM, Clark GM. Tumor characteristics and clinical outcome of elderly women with breast cancer. J Natl Cancer Inst 2000;92:550–6PubMedCrossRefGoogle Scholar
  21. 21.
    Martin MA, Meyricke R, O’Neill T, Roberts S. Mastectomy or breast conserving surgery? Factors affecting type of surgical treatment for breast cancer—a classification tree approach. BMC Cancer 2006;6:98PubMedCrossRefGoogle Scholar
  22. 22.
    Wyld L, Garg DK, Kumar ID, Brown H, Reed MW. Stage and treatment variation with age in postmenopausal women with breast cancer: compliance with guidelines. Br J Cancer 2004;90:1486–91PubMedCrossRefGoogle Scholar
  23. 23.
    Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to participate in decision making. A national study of public preferences. J Gen Intern Med 2005;20:531–5PubMedCrossRefGoogle Scholar
  24. 24.
    Falkum E, Forde R. Paternalism, patient autonomy, and moral deliberation in the physician-patient relationship. Attitudes among Norwegian physicians. Soc Sci Med 2001;52:239–48PubMedCrossRefGoogle Scholar
  25. 25.
    Vlastos G, Mirza NQ, Meric F, et al. Breast conservation therapy as a treatment option for the elderly. The M. D. Anderson experience. Cancer 2001;92:1092–100PubMedCrossRefGoogle Scholar
  26. 26.
    Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med 2002;347:567–75PubMedCrossRefGoogle Scholar
  27. 27.
    Collins D, Sepucha K, O’Connor A, et al. Can women with early stage breast cancer make an informed decision for mastectomy? Breast Cancer Res Treat 2006;100:S118Google Scholar
  28. 28.
    Romanek KM, McCaul KD, Sandgren AK. Age differences in treatment decision making for breast cancer in a sample of healthy women: the effects of body image and risk framing. Oncol Nurs Forum 2005;32:799–806PubMedCrossRefGoogle Scholar
  29. 29.
    Nold RJ, Beamer RL, Helmer SD, McBoyle MF. Factors influencing a woman’s choice to undergo breast-conserving surgery versus modified radical mastectomy. Am J Surg 2000;180:413–8PubMedCrossRefGoogle Scholar
  30. 30.
    Schneiderman MA, Axtell LM. Deaths among female patients with carcinoma of the breast treated by a surgical procedure only. Surg Gynecol Obstet 1979;148:193–5PubMedGoogle Scholar
  31. 31.
    Damhuis RA, Meurs CJ, Meijer WS. Postoperative mortality after cancer surgery in octogenarians and nonagenarians: results from a series of 5,390 patients. World J Surg Oncol 2005;3:71PubMedCrossRefGoogle Scholar
  32. 32.
    Sener SF. Breast cancer in older women: screening and selection of locoregional therapy. Semin Surg Oncol 1996;12:328–31PubMedCrossRefGoogle Scholar
  33. 33.
    Samet JM, Hunt WC, Farrow DC. Determinants of receiving breast-conserving surgery. The Surveillance, Epidemiology, and End Results Program, 1983–1986. Cancer 1994;73:2344–51PubMedCrossRefGoogle Scholar
  34. 34.
    Lazovich DA, White E, Thomas DB, Moe RE. Underutilization of breast-conserving surgery and radiation therapy among women with stage I or II breast cancer. J Am Med Assoc 1991;266:3433–8CrossRefGoogle Scholar
  35. 35.
    Cyran EM, Crane LA, Palmer L. Physician sex and other factors associated with type of breast cancer surgery in older women. Arch Surg 2001;136:185–91PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2007

Authors and Affiliations

  • Richard J. Bleicher
    • 1
    Email author
  • Paul Abrahamse
    • 2
  • Sarah T. Hawley
    • 2
  • Steven J. Katz
    • 2
  • Monica Morrow
    • 1
  1. 1.Department of Surgical OncologyFox Chase Cancer CenterPhiladelphiaUSA
  2. 2.Division of General Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborUSA

Personalised recommendations