JCO: Surgeon bias with post-mastectomy radiotherapy brought to light

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According to the results of a study published online March 29 in the Journal of Clinical Oncology, radiotherapy (RT) treatment following breast conserving surgery in all sociodemographic subgroups was consistently high, but not so following mastectomy, despite similar clinical benefit.

The study also found that surgeon involvement in a patient’s case plays a strong role on whether or not an individual will undergo RT following surgery and even in patients with strong indications that the treatment would be beneficial, where not found to have undergone RT, reported lead author Reshma Jagsi, MD, from the University of Michigan Comprehensive Cancer Center in Ann Arbor, Mich., and colleagues.

“Radiation can be a life-saving treatment,” said Jagsi. “A substantial number of breast cancer patients are being undertreated. One in five women with strong indications for radiation after mastectomy failed to receive it.”

Utilizing patient self-reports, the researchers considered the data submitted from 2,260 survey respondents between the ages of 20 to 79 years who were diagnosed with nonmetastatc breast cancer between July 2005 and February 2007 in Detroit and Los Angeles and reported to Surveillance, Epidemiology and End Results (SEER) registries. The survey responses were then merged with SEER data, explained the researchers. Self-reports were used to “provide more valid estimates of whether RT is underutilized than possible with registry data, as well as to evaluate for disparities and the influence of preferences and provider interactions,” wrote the authors.

Rates of RT administration among groups of patients undergoing both BCS and mastectomy with indications for RT (i.e., positive lymph nodes or T3-4 tumors) were assessed by Jagsi and colleagues.

The authors found that 95.4 percent of the 904 patients undergoing BCS with strong indications for RT received the treatment and 77.6 percent of the 135 patients undergoing mastectomy with strong indications for RT underwent the therapy. Moreover, among the 114 patients undergoing BCS with weaker indications (i.e., elderly) for RT, 80 percent of the patients received treatment compared to the 47.5 percent of the 164 patients undergoing mastectomy with weaker indications.

In addition to surgery type and indication strength, patient desire to avoid RT and the level of surgeon involvement in decisions to undergo the therapy, as well as SEER site were significantly associated with likelihood of RT receipt. The authors wrote that the patients who reported that their surgeon was involved in the decision regarding whether or not to undergo RT were more likely to receive the treatment, even in the subgroup of patients who wished to avoid RT, than those patients whose surgeon was less involved.

“We need to do a better job of educating both patients and physicians regarding the benefits of radiation after mastectomy in certain circumstances and we need to encourage physicians to help their patients as they make these important decisions," Jagsi concluded.