are too many mastectomies being done in the...
TRANSCRIPT
Are too many mastectomies being done in the US
Patrick Ivan Borgen MD
Surgeon-in-Chief
Maimonides Medical Center
Brooklyn New York
Of course too many mastectomies are being done There is too much breast cancer
Too Many Mastectomies
Argument is that the
ratio of mastectomy to
breast conservation in
patients with cancer
(when everything else
is equal) is too high
Debated topic
suggests that the
choice is the surgeonrsquos
choice rather than the
patientrsquos choice
Assumes
The surgeon is
directing the patient
towards mastectomy
The surgeon has
placed a value on the
breast
The surgeonrsquos
valuation of the
breast is more
important than the
patientrsquos valuation Who has the autonomy to make this
decision ndash surgeon or patient
Too Many Mastectomies
Ratio of mastectomy to
breast conservation in
patients with cancer
(when everything else
is equal) is too high
Debated topic
suggests that the
choice is the surgeonrsquos
choice rather than the
patientrsquos choice
Assumes
THAT THE PATIENT
IS ILL-EQUIPPED TO
MAKE THE
DECISION HERSELF
Patients who choose
mastectomy regret
the decision
Assumptions in Favor of
BCT Advantages to BCT
Survival advantage
Better local regional
control (lower local
regional recurrence
rate)
ALL PATIENTS are
willing to receive
radiation therapy in
exchange for
preserving the breast
ALL PATIENTS are
willing to undergo a
lifetime of vigilance
Disadvantages to
Mastectomy
Irrevocable change in body
image
Psychologically traumatic
Painful
Total skin sparing with
excellent reconstruction
does not soften the blow
Women define their self
image at least partially by
their breasts
National Prophylactic
Mastectomy Registry 1995-
2005 1240 women identified from US lay media
All had one or both breasts removed
prophylactically
All followed yearly
Extensively questioned
ldquoDO YOU REGRET YOUR DECISIONrsquo
4 SAID YEShellipWOULD NOT DO IT AGAIN
COMMON DENOMINATOR WAS PHYSICIAN
TALKING PATIENT INTO PROCEDURE
Borgen Tran Montgomery et al Cancer 23 220 2005
Survival Implications Associated with
Variation in Mastectomy Rates for
Early-Staged Breast Cancer John M Brooks1 Elizabeth A Chrischilles2 Mary Beth
Landrum3 Kara B Wright2 Gang Fang4 Eric P Winer5 and Nancy L
Keating36
1992ndash2002 SEER-Medicare databases 69140
patients with stage I or II breast cancer that were
enrolled in Medicare
1 percentage point increase in the mastectomy
rate would reduce the 7-year survival rate by 1
percentage points
International Journal of Surgical
OncologyVolume 2012 (2012) Article ID 127854 9
pages
Conclusion
These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage
Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients
Impact of four quarter amputations
on the hearing acuity of the frog
Background of Authors
bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2
bull College of Public Health University of Iowa Iowa City IA 52242 USA3
bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4
bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5
bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6
bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA
Patients are Educated
Patients are educated
Website hits by patients on breast cancer repeat
hits
Lifelong learning relatives with cancer
Media crunch ndash super high exposure
1 degree of separation with women and breast
cancer
Many have considered her options before getting
the disease
Patients are often REALLY
educated
Patient who knew Bernie Fisherrsquos brother was named
Ed
Patient wanted the details on the calibration schedule
for our gamma probe for her sentinel node
Patient asked whether the Myriad Genetics
technology looking for BRCA gene mutations would
reveal gene silencing through promoter methylation
Less invasive is NOT
always better in the long
runhellip Multiple coronary artery stents vs CABG
(advantage CABG)
EVARS (elective) of abdominal aortic aneurysm
vs open definitive repair
Long term benefits of tissue transfer
reconstruction vs implant reconstruction
Transanal vs Total Mesorectal Excision of rectal
cancer
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Of course too many mastectomies are being done There is too much breast cancer
Too Many Mastectomies
Argument is that the
ratio of mastectomy to
breast conservation in
patients with cancer
(when everything else
is equal) is too high
Debated topic
suggests that the
choice is the surgeonrsquos
choice rather than the
patientrsquos choice
Assumes
The surgeon is
directing the patient
towards mastectomy
The surgeon has
placed a value on the
breast
The surgeonrsquos
valuation of the
breast is more
important than the
patientrsquos valuation Who has the autonomy to make this
decision ndash surgeon or patient
Too Many Mastectomies
Ratio of mastectomy to
breast conservation in
patients with cancer
(when everything else
is equal) is too high
Debated topic
suggests that the
choice is the surgeonrsquos
choice rather than the
patientrsquos choice
Assumes
THAT THE PATIENT
IS ILL-EQUIPPED TO
MAKE THE
DECISION HERSELF
Patients who choose
mastectomy regret
the decision
Assumptions in Favor of
BCT Advantages to BCT
Survival advantage
Better local regional
control (lower local
regional recurrence
rate)
ALL PATIENTS are
willing to receive
radiation therapy in
exchange for
preserving the breast
ALL PATIENTS are
willing to undergo a
lifetime of vigilance
Disadvantages to
Mastectomy
Irrevocable change in body
image
Psychologically traumatic
Painful
Total skin sparing with
excellent reconstruction
does not soften the blow
Women define their self
image at least partially by
their breasts
National Prophylactic
Mastectomy Registry 1995-
2005 1240 women identified from US lay media
All had one or both breasts removed
prophylactically
All followed yearly
Extensively questioned
ldquoDO YOU REGRET YOUR DECISIONrsquo
4 SAID YEShellipWOULD NOT DO IT AGAIN
COMMON DENOMINATOR WAS PHYSICIAN
TALKING PATIENT INTO PROCEDURE
Borgen Tran Montgomery et al Cancer 23 220 2005
Survival Implications Associated with
Variation in Mastectomy Rates for
Early-Staged Breast Cancer John M Brooks1 Elizabeth A Chrischilles2 Mary Beth
Landrum3 Kara B Wright2 Gang Fang4 Eric P Winer5 and Nancy L
Keating36
1992ndash2002 SEER-Medicare databases 69140
patients with stage I or II breast cancer that were
enrolled in Medicare
1 percentage point increase in the mastectomy
rate would reduce the 7-year survival rate by 1
percentage points
International Journal of Surgical
OncologyVolume 2012 (2012) Article ID 127854 9
pages
Conclusion
These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage
Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients
Impact of four quarter amputations
on the hearing acuity of the frog
Background of Authors
bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2
bull College of Public Health University of Iowa Iowa City IA 52242 USA3
bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4
bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5
bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6
bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA
Patients are Educated
Patients are educated
Website hits by patients on breast cancer repeat
hits
Lifelong learning relatives with cancer
Media crunch ndash super high exposure
1 degree of separation with women and breast
cancer
Many have considered her options before getting
the disease
Patients are often REALLY
educated
Patient who knew Bernie Fisherrsquos brother was named
Ed
Patient wanted the details on the calibration schedule
for our gamma probe for her sentinel node
Patient asked whether the Myriad Genetics
technology looking for BRCA gene mutations would
reveal gene silencing through promoter methylation
Less invasive is NOT
always better in the long
runhellip Multiple coronary artery stents vs CABG
(advantage CABG)
EVARS (elective) of abdominal aortic aneurysm
vs open definitive repair
Long term benefits of tissue transfer
reconstruction vs implant reconstruction
Transanal vs Total Mesorectal Excision of rectal
cancer
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Too Many Mastectomies
Argument is that the
ratio of mastectomy to
breast conservation in
patients with cancer
(when everything else
is equal) is too high
Debated topic
suggests that the
choice is the surgeonrsquos
choice rather than the
patientrsquos choice
Assumes
The surgeon is
directing the patient
towards mastectomy
The surgeon has
placed a value on the
breast
The surgeonrsquos
valuation of the
breast is more
important than the
patientrsquos valuation Who has the autonomy to make this
decision ndash surgeon or patient
Too Many Mastectomies
Ratio of mastectomy to
breast conservation in
patients with cancer
(when everything else
is equal) is too high
Debated topic
suggests that the
choice is the surgeonrsquos
choice rather than the
patientrsquos choice
Assumes
THAT THE PATIENT
IS ILL-EQUIPPED TO
MAKE THE
DECISION HERSELF
Patients who choose
mastectomy regret
the decision
Assumptions in Favor of
BCT Advantages to BCT
Survival advantage
Better local regional
control (lower local
regional recurrence
rate)
ALL PATIENTS are
willing to receive
radiation therapy in
exchange for
preserving the breast
ALL PATIENTS are
willing to undergo a
lifetime of vigilance
Disadvantages to
Mastectomy
Irrevocable change in body
image
Psychologically traumatic
Painful
Total skin sparing with
excellent reconstruction
does not soften the blow
Women define their self
image at least partially by
their breasts
National Prophylactic
Mastectomy Registry 1995-
2005 1240 women identified from US lay media
All had one or both breasts removed
prophylactically
All followed yearly
Extensively questioned
ldquoDO YOU REGRET YOUR DECISIONrsquo
4 SAID YEShellipWOULD NOT DO IT AGAIN
COMMON DENOMINATOR WAS PHYSICIAN
TALKING PATIENT INTO PROCEDURE
Borgen Tran Montgomery et al Cancer 23 220 2005
Survival Implications Associated with
Variation in Mastectomy Rates for
Early-Staged Breast Cancer John M Brooks1 Elizabeth A Chrischilles2 Mary Beth
Landrum3 Kara B Wright2 Gang Fang4 Eric P Winer5 and Nancy L
Keating36
1992ndash2002 SEER-Medicare databases 69140
patients with stage I or II breast cancer that were
enrolled in Medicare
1 percentage point increase in the mastectomy
rate would reduce the 7-year survival rate by 1
percentage points
International Journal of Surgical
OncologyVolume 2012 (2012) Article ID 127854 9
pages
Conclusion
These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage
Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients
Impact of four quarter amputations
on the hearing acuity of the frog
Background of Authors
bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2
bull College of Public Health University of Iowa Iowa City IA 52242 USA3
bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4
bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5
bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6
bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA
Patients are Educated
Patients are educated
Website hits by patients on breast cancer repeat
hits
Lifelong learning relatives with cancer
Media crunch ndash super high exposure
1 degree of separation with women and breast
cancer
Many have considered her options before getting
the disease
Patients are often REALLY
educated
Patient who knew Bernie Fisherrsquos brother was named
Ed
Patient wanted the details on the calibration schedule
for our gamma probe for her sentinel node
Patient asked whether the Myriad Genetics
technology looking for BRCA gene mutations would
reveal gene silencing through promoter methylation
Less invasive is NOT
always better in the long
runhellip Multiple coronary artery stents vs CABG
(advantage CABG)
EVARS (elective) of abdominal aortic aneurysm
vs open definitive repair
Long term benefits of tissue transfer
reconstruction vs implant reconstruction
Transanal vs Total Mesorectal Excision of rectal
cancer
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Too Many Mastectomies
Ratio of mastectomy to
breast conservation in
patients with cancer
(when everything else
is equal) is too high
Debated topic
suggests that the
choice is the surgeonrsquos
choice rather than the
patientrsquos choice
Assumes
THAT THE PATIENT
IS ILL-EQUIPPED TO
MAKE THE
DECISION HERSELF
Patients who choose
mastectomy regret
the decision
Assumptions in Favor of
BCT Advantages to BCT
Survival advantage
Better local regional
control (lower local
regional recurrence
rate)
ALL PATIENTS are
willing to receive
radiation therapy in
exchange for
preserving the breast
ALL PATIENTS are
willing to undergo a
lifetime of vigilance
Disadvantages to
Mastectomy
Irrevocable change in body
image
Psychologically traumatic
Painful
Total skin sparing with
excellent reconstruction
does not soften the blow
Women define their self
image at least partially by
their breasts
National Prophylactic
Mastectomy Registry 1995-
2005 1240 women identified from US lay media
All had one or both breasts removed
prophylactically
All followed yearly
Extensively questioned
ldquoDO YOU REGRET YOUR DECISIONrsquo
4 SAID YEShellipWOULD NOT DO IT AGAIN
COMMON DENOMINATOR WAS PHYSICIAN
TALKING PATIENT INTO PROCEDURE
Borgen Tran Montgomery et al Cancer 23 220 2005
Survival Implications Associated with
Variation in Mastectomy Rates for
Early-Staged Breast Cancer John M Brooks1 Elizabeth A Chrischilles2 Mary Beth
Landrum3 Kara B Wright2 Gang Fang4 Eric P Winer5 and Nancy L
Keating36
1992ndash2002 SEER-Medicare databases 69140
patients with stage I or II breast cancer that were
enrolled in Medicare
1 percentage point increase in the mastectomy
rate would reduce the 7-year survival rate by 1
percentage points
International Journal of Surgical
OncologyVolume 2012 (2012) Article ID 127854 9
pages
Conclusion
These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage
Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients
Impact of four quarter amputations
on the hearing acuity of the frog
Background of Authors
bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2
bull College of Public Health University of Iowa Iowa City IA 52242 USA3
bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4
bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5
bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6
bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA
Patients are Educated
Patients are educated
Website hits by patients on breast cancer repeat
hits
Lifelong learning relatives with cancer
Media crunch ndash super high exposure
1 degree of separation with women and breast
cancer
Many have considered her options before getting
the disease
Patients are often REALLY
educated
Patient who knew Bernie Fisherrsquos brother was named
Ed
Patient wanted the details on the calibration schedule
for our gamma probe for her sentinel node
Patient asked whether the Myriad Genetics
technology looking for BRCA gene mutations would
reveal gene silencing through promoter methylation
Less invasive is NOT
always better in the long
runhellip Multiple coronary artery stents vs CABG
(advantage CABG)
EVARS (elective) of abdominal aortic aneurysm
vs open definitive repair
Long term benefits of tissue transfer
reconstruction vs implant reconstruction
Transanal vs Total Mesorectal Excision of rectal
cancer
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Assumptions in Favor of
BCT Advantages to BCT
Survival advantage
Better local regional
control (lower local
regional recurrence
rate)
ALL PATIENTS are
willing to receive
radiation therapy in
exchange for
preserving the breast
ALL PATIENTS are
willing to undergo a
lifetime of vigilance
Disadvantages to
Mastectomy
Irrevocable change in body
image
Psychologically traumatic
Painful
Total skin sparing with
excellent reconstruction
does not soften the blow
Women define their self
image at least partially by
their breasts
National Prophylactic
Mastectomy Registry 1995-
2005 1240 women identified from US lay media
All had one or both breasts removed
prophylactically
All followed yearly
Extensively questioned
ldquoDO YOU REGRET YOUR DECISIONrsquo
4 SAID YEShellipWOULD NOT DO IT AGAIN
COMMON DENOMINATOR WAS PHYSICIAN
TALKING PATIENT INTO PROCEDURE
Borgen Tran Montgomery et al Cancer 23 220 2005
Survival Implications Associated with
Variation in Mastectomy Rates for
Early-Staged Breast Cancer John M Brooks1 Elizabeth A Chrischilles2 Mary Beth
Landrum3 Kara B Wright2 Gang Fang4 Eric P Winer5 and Nancy L
Keating36
1992ndash2002 SEER-Medicare databases 69140
patients with stage I or II breast cancer that were
enrolled in Medicare
1 percentage point increase in the mastectomy
rate would reduce the 7-year survival rate by 1
percentage points
International Journal of Surgical
OncologyVolume 2012 (2012) Article ID 127854 9
pages
Conclusion
These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage
Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients
Impact of four quarter amputations
on the hearing acuity of the frog
Background of Authors
bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2
bull College of Public Health University of Iowa Iowa City IA 52242 USA3
bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4
bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5
bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6
bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA
Patients are Educated
Patients are educated
Website hits by patients on breast cancer repeat
hits
Lifelong learning relatives with cancer
Media crunch ndash super high exposure
1 degree of separation with women and breast
cancer
Many have considered her options before getting
the disease
Patients are often REALLY
educated
Patient who knew Bernie Fisherrsquos brother was named
Ed
Patient wanted the details on the calibration schedule
for our gamma probe for her sentinel node
Patient asked whether the Myriad Genetics
technology looking for BRCA gene mutations would
reveal gene silencing through promoter methylation
Less invasive is NOT
always better in the long
runhellip Multiple coronary artery stents vs CABG
(advantage CABG)
EVARS (elective) of abdominal aortic aneurysm
vs open definitive repair
Long term benefits of tissue transfer
reconstruction vs implant reconstruction
Transanal vs Total Mesorectal Excision of rectal
cancer
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
National Prophylactic
Mastectomy Registry 1995-
2005 1240 women identified from US lay media
All had one or both breasts removed
prophylactically
All followed yearly
Extensively questioned
ldquoDO YOU REGRET YOUR DECISIONrsquo
4 SAID YEShellipWOULD NOT DO IT AGAIN
COMMON DENOMINATOR WAS PHYSICIAN
TALKING PATIENT INTO PROCEDURE
Borgen Tran Montgomery et al Cancer 23 220 2005
Survival Implications Associated with
Variation in Mastectomy Rates for
Early-Staged Breast Cancer John M Brooks1 Elizabeth A Chrischilles2 Mary Beth
Landrum3 Kara B Wright2 Gang Fang4 Eric P Winer5 and Nancy L
Keating36
1992ndash2002 SEER-Medicare databases 69140
patients with stage I or II breast cancer that were
enrolled in Medicare
1 percentage point increase in the mastectomy
rate would reduce the 7-year survival rate by 1
percentage points
International Journal of Surgical
OncologyVolume 2012 (2012) Article ID 127854 9
pages
Conclusion
These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage
Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients
Impact of four quarter amputations
on the hearing acuity of the frog
Background of Authors
bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2
bull College of Public Health University of Iowa Iowa City IA 52242 USA3
bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4
bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5
bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6
bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA
Patients are Educated
Patients are educated
Website hits by patients on breast cancer repeat
hits
Lifelong learning relatives with cancer
Media crunch ndash super high exposure
1 degree of separation with women and breast
cancer
Many have considered her options before getting
the disease
Patients are often REALLY
educated
Patient who knew Bernie Fisherrsquos brother was named
Ed
Patient wanted the details on the calibration schedule
for our gamma probe for her sentinel node
Patient asked whether the Myriad Genetics
technology looking for BRCA gene mutations would
reveal gene silencing through promoter methylation
Less invasive is NOT
always better in the long
runhellip Multiple coronary artery stents vs CABG
(advantage CABG)
EVARS (elective) of abdominal aortic aneurysm
vs open definitive repair
Long term benefits of tissue transfer
reconstruction vs implant reconstruction
Transanal vs Total Mesorectal Excision of rectal
cancer
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Survival Implications Associated with
Variation in Mastectomy Rates for
Early-Staged Breast Cancer John M Brooks1 Elizabeth A Chrischilles2 Mary Beth
Landrum3 Kara B Wright2 Gang Fang4 Eric P Winer5 and Nancy L
Keating36
1992ndash2002 SEER-Medicare databases 69140
patients with stage I or II breast cancer that were
enrolled in Medicare
1 percentage point increase in the mastectomy
rate would reduce the 7-year survival rate by 1
percentage points
International Journal of Surgical
OncologyVolume 2012 (2012) Article ID 127854 9
pages
Conclusion
These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage
Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients
Impact of four quarter amputations
on the hearing acuity of the frog
Background of Authors
bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2
bull College of Public Health University of Iowa Iowa City IA 52242 USA3
bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4
bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5
bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6
bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA
Patients are Educated
Patients are educated
Website hits by patients on breast cancer repeat
hits
Lifelong learning relatives with cancer
Media crunch ndash super high exposure
1 degree of separation with women and breast
cancer
Many have considered her options before getting
the disease
Patients are often REALLY
educated
Patient who knew Bernie Fisherrsquos brother was named
Ed
Patient wanted the details on the calibration schedule
for our gamma probe for her sentinel node
Patient asked whether the Myriad Genetics
technology looking for BRCA gene mutations would
reveal gene silencing through promoter methylation
Less invasive is NOT
always better in the long
runhellip Multiple coronary artery stents vs CABG
(advantage CABG)
EVARS (elective) of abdominal aortic aneurysm
vs open definitive repair
Long term benefits of tissue transfer
reconstruction vs implant reconstruction
Transanal vs Total Mesorectal Excision of rectal
cancer
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Conclusion
These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage
Our results suggest that reducing the mastectomy rate in favor of BCSR may yield positive survival gains for higher-staged older ESBC patients
Impact of four quarter amputations
on the hearing acuity of the frog
Background of Authors
bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2
bull College of Public Health University of Iowa Iowa City IA 52242 USA3
bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4
bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5
bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6
bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA
Patients are Educated
Patients are educated
Website hits by patients on breast cancer repeat
hits
Lifelong learning relatives with cancer
Media crunch ndash super high exposure
1 degree of separation with women and breast
cancer
Many have considered her options before getting
the disease
Patients are often REALLY
educated
Patient who knew Bernie Fisherrsquos brother was named
Ed
Patient wanted the details on the calibration schedule
for our gamma probe for her sentinel node
Patient asked whether the Myriad Genetics
technology looking for BRCA gene mutations would
reveal gene silencing through promoter methylation
Less invasive is NOT
always better in the long
runhellip Multiple coronary artery stents vs CABG
(advantage CABG)
EVARS (elective) of abdominal aortic aneurysm
vs open definitive repair
Long term benefits of tissue transfer
reconstruction vs implant reconstruction
Transanal vs Total Mesorectal Excision of rectal
cancer
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Impact of four quarter amputations
on the hearing acuity of the frog
Background of Authors
bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2
bull College of Public Health University of Iowa Iowa City IA 52242 USA3
bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4
bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5
bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6
bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA
Patients are Educated
Patients are educated
Website hits by patients on breast cancer repeat
hits
Lifelong learning relatives with cancer
Media crunch ndash super high exposure
1 degree of separation with women and breast
cancer
Many have considered her options before getting
the disease
Patients are often REALLY
educated
Patient who knew Bernie Fisherrsquos brother was named
Ed
Patient wanted the details on the calibration schedule
for our gamma probe for her sentinel node
Patient asked whether the Myriad Genetics
technology looking for BRCA gene mutations would
reveal gene silencing through promoter methylation
Less invasive is NOT
always better in the long
runhellip Multiple coronary artery stents vs CABG
(advantage CABG)
EVARS (elective) of abdominal aortic aneurysm
vs open definitive repair
Long term benefits of tissue transfer
reconstruction vs implant reconstruction
Transanal vs Total Mesorectal Excision of rectal
cancer
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Background of Authors
bull College of Pharmacy University of Iowa Iowa City IA 52242 USA2
bull College of Public Health University of Iowa Iowa City IA 52242 USA3
bull Department of Health Care Policy Harvard Medical School Boston MA 02115 USA4
bull Eshelman School of Pharmacy University of North Carolina Chapell Hill NC 27599 USA5
bull Department of Medical Oncology Dana Farber Cancer Institute Boston MA 02115 USA6
bull Division of General Internal Medicine Harvard Medical School Brigham and Womenrsquos Hospital Boston MA 02120 USA
Patients are Educated
Patients are educated
Website hits by patients on breast cancer repeat
hits
Lifelong learning relatives with cancer
Media crunch ndash super high exposure
1 degree of separation with women and breast
cancer
Many have considered her options before getting
the disease
Patients are often REALLY
educated
Patient who knew Bernie Fisherrsquos brother was named
Ed
Patient wanted the details on the calibration schedule
for our gamma probe for her sentinel node
Patient asked whether the Myriad Genetics
technology looking for BRCA gene mutations would
reveal gene silencing through promoter methylation
Less invasive is NOT
always better in the long
runhellip Multiple coronary artery stents vs CABG
(advantage CABG)
EVARS (elective) of abdominal aortic aneurysm
vs open definitive repair
Long term benefits of tissue transfer
reconstruction vs implant reconstruction
Transanal vs Total Mesorectal Excision of rectal
cancer
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Patients are Educated
Patients are educated
Website hits by patients on breast cancer repeat
hits
Lifelong learning relatives with cancer
Media crunch ndash super high exposure
1 degree of separation with women and breast
cancer
Many have considered her options before getting
the disease
Patients are often REALLY
educated
Patient who knew Bernie Fisherrsquos brother was named
Ed
Patient wanted the details on the calibration schedule
for our gamma probe for her sentinel node
Patient asked whether the Myriad Genetics
technology looking for BRCA gene mutations would
reveal gene silencing through promoter methylation
Less invasive is NOT
always better in the long
runhellip Multiple coronary artery stents vs CABG
(advantage CABG)
EVARS (elective) of abdominal aortic aneurysm
vs open definitive repair
Long term benefits of tissue transfer
reconstruction vs implant reconstruction
Transanal vs Total Mesorectal Excision of rectal
cancer
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Patients are educated
Website hits by patients on breast cancer repeat
hits
Lifelong learning relatives with cancer
Media crunch ndash super high exposure
1 degree of separation with women and breast
cancer
Many have considered her options before getting
the disease
Patients are often REALLY
educated
Patient who knew Bernie Fisherrsquos brother was named
Ed
Patient wanted the details on the calibration schedule
for our gamma probe for her sentinel node
Patient asked whether the Myriad Genetics
technology looking for BRCA gene mutations would
reveal gene silencing through promoter methylation
Less invasive is NOT
always better in the long
runhellip Multiple coronary artery stents vs CABG
(advantage CABG)
EVARS (elective) of abdominal aortic aneurysm
vs open definitive repair
Long term benefits of tissue transfer
reconstruction vs implant reconstruction
Transanal vs Total Mesorectal Excision of rectal
cancer
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Patients are often REALLY
educated
Patient who knew Bernie Fisherrsquos brother was named
Ed
Patient wanted the details on the calibration schedule
for our gamma probe for her sentinel node
Patient asked whether the Myriad Genetics
technology looking for BRCA gene mutations would
reveal gene silencing through promoter methylation
Less invasive is NOT
always better in the long
runhellip Multiple coronary artery stents vs CABG
(advantage CABG)
EVARS (elective) of abdominal aortic aneurysm
vs open definitive repair
Long term benefits of tissue transfer
reconstruction vs implant reconstruction
Transanal vs Total Mesorectal Excision of rectal
cancer
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Less invasive is NOT
always better in the long
runhellip Multiple coronary artery stents vs CABG
(advantage CABG)
EVARS (elective) of abdominal aortic aneurysm
vs open definitive repair
Long term benefits of tissue transfer
reconstruction vs implant reconstruction
Transanal vs Total Mesorectal Excision of rectal
cancer
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Flawed basic premisehellip
1992 NCI published a consensus statement
Breast conservation (tumor
removal axillary dissection and
radiation therapy is equivalent to
mastectomy but is preferable as it
is less disfiguring
Assumption was made that every
woman would CHOOSE BCT
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Flawed basic premisehellip
As we witnessed the explosion of new breast
centers and new breast programs in the 1990s
and early 2000s centers were actually GRADED
on their utilization of BCT
In some cases thresholds were set
that centers were expected to
reach for percent utilization of
BCT Negative consequences for failing to reach
goals
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Survey of women surgeons in American College of Surgeons these surgeons treated breast cancer themselves and felt strongly about BCT as their PREFERRED mode of treatment
More than half of them who treated breast cancer said that they would choose a mastectomy for THEMSELVES
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
T0isN0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 (05 invasive) 5 to 20 (3-10
Invasive)
Need for radiation NEVER ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
3 cm of mixed grade DCIS ER+
Margins gt1cm
BRCA negative
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Local Recurrence
Rate
1 to 3 5 to 12
Need for radiation RARE ALWAYS
Need for
reconstruction
Virtually always RARE
Cosmetic Outcome Reasonable facsimile Excellent
SURVIVAL EQUAL EQUAL
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
T2N0M0 Breast Cancer
Outcome Metric Mastectomy Breast Conservation
Clinical Examination Yes Yes
Ipsilat Mammogram NO ALWAYS
Ipsilat US NO Likely
Ipsilat MRI NO Possible
Future ipsilat BIOPSY 3 30
Clinical Trajectory Next 20 years or sohellip
5 - 12 chance of second cancer
Salvage mastectomy
Reconstruction compromised by radiation
therapy
Second sentinel node biopsy
Previous biopsy site may compromise
mastectomy incision planning and cosmesis
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Decision involvement and receipt of
mastectomy among racially and
ethnically diverse breast cancer
patients Hawley ST Griggs JJ Hamilton AS Graff JJ Janz
NK Morrow M Jagsi R Salem B Katz SJ 3133 patients from Detroit and Los Angeles SEER with newly diagnosed breast cancer
Excluded Stage III or those with contraindications to breast conservation therapy
The dependent variable was receipt of mastectomy initially
The primary independent variables were patient involvement in decision making race or ethnicity attitudes about recurrence the effects of radiation the impact of surgery on body image and the role of others in decision making
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Conclusions
Concerns about recurrence or radiation effects
were very important in their surgery decision
were more likely to receive mastectomy than
those less concerned (for recurrence concerns
estimated relative risk [RR] = 166 95
confidence interval [CI] = 128 to 210
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Conclusions
There was a relationship between TIME SPENT
with the patient and the choice of mastectomy
Greater patient involvement in decision making
was associated with receipt of mastectomy for all
racial and ethnic groups
Patient attitudes about surgery and the opinions
of family and friends contribute to surgical
choices made by women with breast cancer
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Summary
Goal should not be to maximize utilization of
BCT
Goal should be to match patient concerns
values priorities with treatment choice
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Summary
Maybe patients are different today
Most work
Many single moms
Highly educated and highly informed
Each with her own set of considerations values
priorities worrieshellip
Simply not my place to impose my opinions
regarding the benefits of sparing her breast
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Best we can hope for is to establish a
relationship with each patient and provide
accurate information to help them arrive at the
choice that is best for them
To sound smarthellipalways conclude your
presentation by quoting HOMERhellip
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
Homer Simpson 2005
Facts are meaningless
You could use facts to
prove anything that was
even remotely true
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920
I have concluded that of all cancers I deal with
breast cancer is the most difficult Its diversity of
presentations multiple avenues of metastasis
unpredictable clinical behavior requirement for
significant tissue loss renders it in most cases
virtually impossible to arrive at a reasonable
adjustment for a means to an end
James Ewing MD 1920