Since the early ’90s breast conserving therapy or BCT has become generally accepted as a standard of care in the treatment of breast cancer. Studies have shown that patients who undergo BCT generally have a higher breast cancer-specific survival rate compared with those treated with mastectomy alone or mastectomy with radiation for early-stage invasive ductal carcinoma. But despite its acceptance for early stage breast cancer, barriers still exist that preclude patients from receiving this treatment option. As a result, many patients still opt for a mastectomy instead. [2]
Now, for the first time, researchers at the University of Texas MD Anderson Cancer Center, Houston, Texas, tried to find a reason. Their objective was to provide a comprehensive population based review of the factors that influence the utilization of BCT. [1]
Their results were presented at the 2014 ASCO Breast Cancer Symposium being held September 4 – 6, 2014 in San Francisco, California, shows that those barriers that still exist are socio-economic, rather than medically-influenced. [1][2]
The results were presented by Meeghan Lautner, MD, MSc., formerly a fellow at MD Anderson Cancer Center and now at The University of Texas San Antonio, Texas.
… while overall rates improve, researchers have identify socio-economic barriers that preclude women from receiving breast-conserving therapy…
Standard of Care
Breast conserving therapy or BCT for early stage breast cancer includes breast conserving surgery, followed by six weeks of radiation. It has been the accepted standard of care for early stage breast cancer since 1990 when randomized, prospective clinical trials confirmed its efficacy. The results from these trials led to the National Institute of Health (NIH) issuing a consensus statement. Yet, today, a number of patients still opt for a mastectomy. In hopes of ultimately democratizing care, it was important to look at surgical choices made by women and their association with disparities, explains Isabelle Bedrosian, MD, associate professor, Surgical Oncology at MD Anderson Cancer Center.
Changing landscape
“What’s particularly novel and most meaningful about our study is that we looked at how the landscape has changed over time,” says Bedrosian, the study’s senior author. “We hope this will help us understand where we are and are not making progress, as well as identify the barriers we need to overcome to create equity in the delivery of care for our patients.”
For the retrospective, population-based study, the MD Anderson Cancer Center team used the National Cancer Database, a nation-wide outcomes registry of the American College of Surgeons, the American Cancer Society and the Commission on Cancer that captures approximately 70% of newly-diagnosed cases of cancer in the country. They identified 727,927 women with early-stage breast cancer, all of whom were diagnosed between 1998 and 2011 and had undergone either breast conserving therapyor a mastectomy.
Increasing rates of BCT
Overall, the researchers found that BCT rates increased from 54% in 1998 to 59% in 2006, and stabilized since then. Adjusting for demographic and clinical characteristics, BCT use was more common in women age 52-61 compared to younger or older patients. Higher education level and median income, private insurance, compared to those uninsured and who were treated at an academic medical center versus a community medical center also affected the choose for BCT vs. mastectomy.
Geographic location
The researchers noted that geographically BCT rates were higher in the Northeast than in the South. They also noted that the rate was higher in women who lived within 17 miles of a treatment facility compared to those who lived further away.
An important question to then ask, says Bedrosian, was to compare barriers for women receiving BCT in 1998 to 2011, and understand how have those barriers changed. The researchers found that, overall, usage of BCT has dramatically increased across all demographic and clinical characteristics, however, significant disparities related to insurance, income and distance to a treatment facility still exist.
Insurance disparities
Bedrosian is happy to see that in the areas where physicians and the medical field can make a direct impact, including geographic distribution and practice type, the disparities have equalized over time. However, she notes that factors outside the influence of the medical field, such as insurance type, income and education, still remain. “Of great interest is the insurance disparity,” Bedrosian explains.
“Now with healthcare exchanges providing new insurance coverage options, will we rectify the disparity and overall increase BCT use? We will have wait to see,” she notes. Bedrosian hopes that health policy makers will take note of the findings and barriers related to women receiving BCT and make appropriate changes to democratize care.
For more information:
[1] Lautner MA, Lin HY, Shen Y, Parker C, Kuerer HM, Shaitelman SF, Babiera G, Bedrosian I. Disparities in utilization of breast-conserving therapy among breast cancer patients. 2014 Breast Cancer Symposium. Abstract Number: #104 J Clin Oncol 32, 2014 (suppl 26; abstr 104)[Abstract]
[2] Agarwal S, Pappas L, Neumayer L, Kokeny K, Agarwal J. Effect of breast conservation therapy vs mastectomy on disease-specific survival for early-stage breast cancer. JAMA Surg. 2014 Mar;149(3):267-74. doi: 10.1001/jamasurg.2013.3049.[Article][PubMed]
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