A recent article in the Seattle Times references the 2012 Dartmouth Atlas Report: Improving Patient Decision-Making in Health Care. Unfortunately their take home line, "A new report that found wide geographical variation in the use of elective surgical procedures in Pacific states reflects the preferences of physicians – not what patients want or need, the authors say,” oversimplifies a complicated situation.
On my reading of the report, it stresses the values that an individual woman brings to the decision:
“Different women will prefer one option or the other, depending upon how much they value preserving their breast, their willingness to undergo radiation or more invasive surgery, and the level of uncertainty they are willing to live with in terms of their cancer recurring.”
As a breast surgeon who has practiced in Seattle for almost 40 years, I don’t believe that “the preferences of physicians” are the driving factor. I have a few observations to make.
It is clear that wide variations in treatment of early stage breast cancer can be seen across the USA, as the Dartmouth-Atlas data confirms. Some factors that influence this are physician related – for example, what % of their surgical practice involves treating women with breast cancer. Specialists in breast cancer or general surgeons who treat large numbers of women with breast cancer are motivated to be current in their practice patterns and to make sure that their patients are making considered decisions. The utilization of breast MRI has been shown to influence the mastectomy rates and there is regional variation in the use of that study. Distance to a radiation oncology treatment center is a factor for some women as are potential differences in out of pocket costs between mastectomy and breast conservation.
All of the local breast surgeons that I know strongly value shared decision making with their patients. We all work hard to present treatment options fairly and as neutrally as possible. If we have a patient that we think is choosing mastectomy over breast conservation out of fear – for example, fear of radiation therapy – we will encourage her to consult with a radiation oncology specialist prior to making a final decision. We believe that one of our roles is to help our patients make informed decisions. If there are clear medical reasons why one treatment is preferred, we will state that but otherwise encourage the patient to make the best decision for herself.
For example, breast surgeons have been aware of an increasing trend of women choosing total mastectomy and frequently wanting to have both breasts removed. We have detailed conversations with our patients about the pros and cons of mastectomy – both treatment and prophylactic. We may encourage slowing down of the decision making process to allow her to absorb the information more thoroughly. We may encourage consultation with radiation oncologists, medical oncologists and plastic surgeons to better inform her decision. We may emphasize the similar survival rates between the two surgeries. However, some women will still elect to have mastectomies. A study reported at the recent American Society of Clinical Oncology Quality Care Symposium explored why the rate of double mastectomies is on the rise. They found that women who reported being “very worried” about recurrence were about twice as likely to have bilateral mastectomies as those who reported being “somewhat worried” or “not at all worried.”
We can try to decrease the level of worry with information and reassurance but as the statement from the Dartmouth-Atlas report confirms: “Different women will prefer one option or the other…” This is not to say that we shouldn’t continue to work hard on reducing regional variations but let’s not make it less complicated than it is.