Baptist Health System General Surgery Residency Program Reasons for Mastectomy in Early Stage Breast Cancer: An Institutional Review Rosebella Agola, MD, MPH Greg Bearden MD, FACS Baptist Health System General Surgery Residency Program

Introduction Early stage breast cancer: cancer that has not spread beyond the breast or axillary lymph nodes Stage 0, I and II based on American Joint Commission on Cancer (AJCC) classification Surgical options for treating early stage breast cancer include Mastectomy: removing entire breast Breast conserving surgery (BCS): removing part of the breast or lumpectomy, followed by radiation therapy. Using breast conserving surgery (BCS) to treat patients with early stage breast cancer is a nationally accepted standard of care. A 50% breast conservation rate is considered the minimum standard in order to meet National Accreditation Program for Breast Centers (NAPBC) compliance Compliance is evaluated annually. Published data shows that most centers exceed the 50% BCS rate. At Princeton Hospital the overall rate of BCS over two years (2010 to 2011) was 54%.

Princeton Hospital BCS Rates Comparing 2010 and 2011 BCS rate fell from 61% to 50%

Objective To find out reasons why patients with stage 0-II breast cancer were treated with mastectomy over breast conserving surgery.

Materials and Methods A retrospective review of data from Princeton Hospital’s Breast Cancer registry was conducted to identify patients with Stage 0, I and II breast cancer who were treated with either mastectomy or BCS between 2010 and 2011 Exclusion criteria included surgery done at an outside facility or incomplete data in the medical chart. Reasons for mastectomy were identified as: Patient choice Surgeon choice Failed BCS (inability to obtain negative margins after lumpectomy) Bilateral breast cancer Previous breast cancer Multicentricity

Material and Methods The medical chart of each patient in the mastectomy group was reviewed to identify reasons for mastectomy. The following data were also reviewed regarding patient and tumor characteristics in each group Race Age Histology Tumor stage Tumor Size Node status Patient and tumor characteristics were then independently compared between the BCS group and the mastectomy group. Odds ratios (ORs) were analyzed to determine association with mastectomy. This was done using MS Excel XLSTAT software.

Results Between January 2010 and December 2011, 218 patients had surgery for early stage breast cancer. 28 patients were excluded based on our exclusion criteria. A total of 190 patients were identified as either having had a mastectomy or BCS at Princeton Hospital 89 patients in the mastectomy group 101 patients in the BCS group. Patient and tumor characteristics were reviewed and compared according to surgery type.

Results Results of medical chart review of mastectomy group 79% (70 out of 89) of patients in the mastectomy group had identifiable reasons for mastectomy. Patient choice (31% ) Surgeon choice( 3% ) Failed BCS(28%) Previous breast cancer (15%) Bilateral breast cancer (9%) Multicentricity (8%)

Mastectomy Group

Results 21% (19 out of 89) patients in the mastectomy group had unknown reasons for mastectomy. Characteristics of this group Mean age of 63. All had invasive cancer. 63% (12 out of 19) had tumor stage II. 68% (13 out of 19) had tumor size < 3cm. 68% (13 out of 19) had negative node status.

Results Patient and tumor characteristics were analyzed to determine if they were positively associated with mastectomy. Neither race nor age showed a statistically significant association with increased likelihood of mastectomy (P>0.05, respectively). Invasive cancer (OR 3.4), positive node status (OR 2.5) tumor stage II (2.23) and tumor size >3cm (OR 3.17) were all independently associated with an increased likelihood of mastectomy over BCS (p<0.05, respectively).

Conclusion Patient choice was the most common reason for mastectomy . These patients were candidates for BCS on initial evaluation Patients likely opted out based on personal perceptions of increased risk, family history or for “peace of mind.” Published studies have also shown patient choice to be a significant determinant of mastectomy rates. Patients with bilateral breast cancer, history of previous breast cancer, and multicentricity contributed to the overall mastectomy rate but were not candidates for BCS on initial evaluation. Failed BCS included patients who initially opted for BCS Surgeon choice/influence has been reported as a significant predictor of BCS versus mastectomy rates in other studies

Conclusion Shortcomings of study based on chart documentation Unless explicitly stated in the chart it was difficult to determine precise reasons for opting for mastectomy. We suggest a prospective analysis where specific reasons for choosing mastectomy versus BCS are documented in the breast cancer registry. Can be used to accurately track and analyze specific determinants of breast conservation versus mastectomy rates. This information can also be used to improve compliance with NAPBC standards. Future directions Further analysis of patient and tumor characteristics to determine true predictors of BCS versus mastectomy Analysis of surgeon characteristics and association with BCT versus mastectomy

Acknowledgements Dr Greg Bearden, MD, FACS Judy Lang, Cancer/Trauma Registry Coordinator, Princeton Baptist Medical Center

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