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American Surgeons are Often Slower to Adopt Newer and Better TreatmentsSAN ANTONIO, Texas-U.S. surgeons lag behind their British colleagues in adopting breast-conserving surgery as the standard of care for breast cancer, a new study suggests. Data from one of the largest breast cancer trials ever undertaken reveal that women in the United States are more likely than British women to undergo a full mastectomy, rather than breast conserving therapy (BCT), for early stage breast cancer (odds ratio [OR], 1.44). Of 3,228 British women enrolled in the study, 42% had a mastectomy. In contrast, 51% of the 2,222 U.S. women in the trial underwent complete breast removal. The high mastectomy rate in the United States goes against recent studies and a National Cancer Institute consensus supporting BCT as the preferred approach for breast cancer. This fall, the National Surgical Adjuvant Breast and Bowel Project published a massive 20-year study, which showed lumpectomy to be as effective long term as total mastectomy (N Engl J Med 2002; 347:1233-1241). "Only 10 years ago, there was much discussion about how the British were somewhat behind the rest of the world in the treatment of breast cancer. And now, when it came to choice of surgery, I was surprised that we were the laggards," said primary investigator Gershon Y Locker, MD, professor of medicine, Feinberg School of Medicine, Northwestern University, Evanston, Ill. "Even for patients coming from U.S. centers that are involved in clinical research, centers that we all assume are the most attuned to the state-of-the-art cancer therapies, too many are getting mastectomies," he said. Dr. Locker presented the findings this past December at the San Antonio Breast Cancer Symposium. Results showed wide variations in mastectomy rates in different countries. This prompted Dr. Locker to conduct a retrospective analysis to find out whether tumor pathology, patient characteristics and other treatments, or the experience of the enrolling center could explain the disparities.
Univariate analysis showed that predictors for mastectomy included tumor size (2 cm or larger) (68%; OR, 2.81), having 4 or more positive nodes (74%; OR, 3.94), age 70 or older (59%; OR, 2.05), poorly differentiated tumors (55%; OR, 2.14) and the use of adjuvant chemotherapy (60%; OR, 1.90). Predictors for BCT were tumors that were estrogen receptor-positive (54%; OR, 0.60) or patient weight more than 70 kg (54%; OR, 0.87). The study also showed a volume performance relationship. Patients from low volume centers (<40 patients) were more likely to get mastectomy than those from the higher volume sites that enrolled more than 40 patients.
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