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Increasing Mastectomy Rates—The Effect of Environmental Factors on the Choice for Mastectomy: A Comparative Analysis Between Canada and the United States

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Purpose

Unilateral mastectomy (UM) and contralateral prophylactic mastectomy (CPM) for early-stage breast cancer (ESBC) have been increasing. Numerous etiological factors for this rise have been suggested, including increasing use of magnetic resonance imaging (MRI) and reconstruction, surgeon’s preference, and patient’s choice. We conducted a qualitative study to explore what role the surgeon and their practice environment play in the increasing rates.

Methods

Semi-structured interviews were conducted with general surgeons to explore their current approach to treating ESBC and their experience with women requesting mastectomy. Purposive sampling identified surgeons across Ontario, Canada, and the United States (US). Constant comparative analysis identified key concepts.

Results

Data saturation was achieved after 45 interviews. ‘The effect of external factors on rising mastectomy rates’ was the dominant theme. All surgeons described increasing mastectomy rates over the last 5 years, and all surgeons discussed breast-conserving therapy (BCT) and UM as equivalent options. However, US surgeons discussed reconstruction early in the consultation process, reflecting legislative requirements. In contrast, Ontario surgeons discussed reconstruction only when a patient was considering mastectomy. Ontario surgeons often recommended BCT, whereas US surgeons rarely made a direct recommendation regarding the extent of surgery. Neither US nor Canadian surgeons recommended the use of UM + CPM in average-risk ESBC, and all surgeons described women initiating this request. MRI use and access to immediate breast reconstruction also impacted the choice for mastectomy.

Conclusions

Use of MRI, access to reconstruction, and legislative requirements regarding information disclosure, appeared to influence the surgical consultation process and the patient’s request for CPM.

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Acknowledgment

With sincere thanks to all of the participating surgeons who offered their time and shared their experiences. Dr. Covelli received a research fellowship from the Canadian Breast Cancer Foundation, Roche Physician Fellowship Program, and 1 year of salary support from the Clinical Investigator Program, Ontario Ministry of Health salary support program. Dr. Covelli also received a travel grant from the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, to present work related to this research. The Surgeon Scientist Training Program provided indirect financial support to Dr. Covelli through programs delivered to surgeon scientists-in-training in the Department of Surgery at the University of Toronto. Dr. Baxter holds the Cancer Care Ontario Chair Health Services Research Chair.

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Authors and Affiliations

  1. Division of General Surgery, University of Toronto, Toronto, ON, Canada

    Andrea M. Covelli MD, PhD(c), Nancy N. Baxter MD, PhD & Frances C. Wright MD, MEd

  2. Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

    Andrea M. Covelli MD, PhD(c), Nancy N. Baxter MD, PhD & Frances C. Wright MD, MEd

  3. Department of Surgery and Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada

    Andrea M. Covelli MD, PhD(c) & Nancy N. Baxter MD, PhD

  4. Odette Cancer Centre, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    Margaret I. Fitch MScN, PhD & Frances C. Wright MD, MEd

  5. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada

    Margaret I. Fitch MScN, PhD

  6. Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    Frances C. Wright MD, MEd

Authors
  1. Andrea M. Covelli MD, PhD(c)
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  2. Nancy N. Baxter MD, PhD
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  3. Margaret I. Fitch MScN, PhD
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Corresponding author

Correspondence to Andrea M. Covelli MD, PhD(c).

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Covelli, A.M., Baxter, N.N., Fitch, M.I. et al. Increasing Mastectomy Rates—The Effect of Environmental Factors on the Choice for Mastectomy: A Comparative Analysis Between Canada and the United States. Ann Surg Oncol 21, 3173–3184 (2014). https://doi.org/10.1245/s10434-014-3955-4

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  • DOI: https://doi.org/10.1245/s10434-014-3955-4

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