[Skip to Content]
Sign In
Individual Sign In
Create an Account
Institutional Sign In
OpenAthens Shibboleth
[Skip to Content Landing]
Figure 1.  Annual Nationwide Proportions of Contralateral Prophylactic Mastectomies (CPMs)
Annual Nationwide Proportions of Contralateral Prophylactic Mastectomies (CPMs)

Annual nationwide percentages of CPMs among women with invasive unilateral early-stage breast cancer treated with surgery by age category, 2004-2012. The bars represent the percentage of CPMs among women treated with surgery for unilateral early-stage breast cancer. The vertical error bars represent 95% CIs.

Figure 2.  State Variation in Proportions of Contralateral Prophylactic Mastectomies (CPMs) During the Period From 2010 to 2012
State Variation in Proportions of Contralateral Prophylactic Mastectomies (CPMs) During the Period From 2010 to 2012

A, Percentage of women 20 to 44 years of age with invasive unilateral early-stage breast cancer treated with surgery undergoing a CPM during the period from 2010 to 2012. B, Percentage of women 45 years of age or older with invasive unilateral early-stage breast cancer treated with surgery undergoing a CPM during the period from 2010 to 2012.

Figure 3.  State Variation in Proportions of Reconstructive Surgical Procedures Among Women Undergoing a Contralateral Prophylactic Mastectomy (CPM) During the Period From 2010 to 2012
State Variation in Proportions of Reconstructive Surgical Procedures Among Women Undergoing a Contralateral Prophylactic Mastectomy (CPM) During the Period From 2010 to 2012

A, Percentage of women 20 to 44 years of age who underwent a CPM for invasive unilateral early-stage breast cancer during the period from 2010 to 2012 who also underwent reconstructive surgery. B, Percentage of women 45 years of age or older who underwent a CPM for invasive unilateral early-stage breast cancer during the period from 2010 to 2012 who also underwent reconstructive surgery.

Table 1.  Patient Demographic and Tumor Characteristics
Patient Demographic and Tumor Characteristics
Table 2.  Proportion of Patients Receiving a Contralateral Prophylactic Mastectomy (CPM) by State and Year Among Women 20 to 44 Years of Age
Proportion of Patients Receiving a Contralateral Prophylactic Mastectomy (CPM) by State and Year Among Women 20 to 44 Years of Age
1.
Siegel  RL, Miller  KD, Jemal  A.  Cancer statistics, 2015.  CA Cancer J Clin. 2015;65(1):5-29.PubMedGoogle ScholarCrossref
2.
Pesce  CE, Liederbach  E, Czechura  T, Winchester  DJ, Yao  K.  Changing surgical trends in young patients with early stage breast cancer, 2003 to 2010: a report from the National Cancer Data Base.  J Am Coll Surg. 2014;219(1):19-28.PubMedGoogle ScholarCrossref
3.
Tuttle  TM, Jarosek  S, Habermann  EB,  et al.  Increasing rates of contralateral prophylactic mastectomy among patients with ductal carcinoma in situ.  J Clin Oncol. 2009;27(9):1362-1367.PubMedGoogle ScholarCrossref
4.
Yao  K, Stewart  AK, Winchester  DJ, Winchester  DP.  Trends in contralateral prophylactic mastectomy for unilateral cancer: a report from the National Cancer Data Base, 1998-2007.  Ann Surg Oncol. 2010;17(10):2554-2562.PubMedGoogle ScholarCrossref
5.
Bedrosian  I, Hu  CY, Chang  GJ.  Population-based study of contralateral prophylactic mastectomy and survival outcomes of breast cancer patients.  J Natl Cancer Inst. 2010;102(6):401-409.PubMedGoogle ScholarCrossref
6.
Brewster  AM, Bedrosian  I, Parker  PA,  et al.  Association between contralateral prophylactic mastectomy and breast cancer outcomes by hormone receptor status.  Cancer. 2012;118(22):5637-5643.PubMedGoogle ScholarCrossref
7.
Kurian  AW, Lichtensztajn  DY, Keegan  THM, Nelson  DO, Clarke  CA, Gomez  SL.  Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011.  JAMA. 2014;312(9):902-914.PubMedGoogle ScholarCrossref
8.
Pesce  C, Liederbach  E, Wang  C, Lapin  B, Winchester  DJ, Yao  K.  Contralateral prophylactic mastectomy provides no survival benefit in young women with estrogen receptor-negative breast cancer.  Ann Surg Oncol. 2014;21(10):3231-3239.PubMedGoogle ScholarCrossref
9.
Yao  K, Winchester  DJ, Czechura  T, Huo  D.  Contralateral prophylactic mastectomy and survival: report from the National Cancer Data Base, 1998-2002.  Breast Cancer Res Treat. 2013;142(3):465-476.PubMedGoogle ScholarCrossref
10.
Hawley  ST, Jagsi  R, Morrow  M,  et al.  Social and clinical determinants of contralateral prophylactic mastectomy.  JAMA Surg. 2014;149(6):582-589.PubMedGoogle ScholarCrossref
11.
Rosenberg  SM, Tracy  MS, Meyer  ME,  et al.  Perceptions, knowledge, and satisfaction with contralateral prophylactic mastectomy among young women with breast cancer: a cross-sectional survey.  Ann Intern Med. 2013;159(6):373-381.PubMedGoogle ScholarCrossref
12.
Fisher  CS, Martin-Dunlap  T, Ruppel  MB, Gao  F, Atkins  J, Margenthaler  JA.  Fear of recurrence and perceived survival benefit are primary motivators for choosing mastectomy over breast-conservation therapy regardless of age.  Ann Surg Oncol. 2012;19(10):3246-3250.PubMedGoogle ScholarCrossref
13.
Tuttle  TM, Habermann  EB, Grund  EH, Morris  TJ, Virnig  BA.  Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment.  J Clin Oncol. 2007;25(33):5203-5209.PubMedGoogle ScholarCrossref
14.
National Cancer Institute. Surveillance, Epidemiology, and End Results Program: about the SEER Program. National Institutes of Health website. https://www.seer.cancer.gov/about. Accessed August 1, 2016.
15.
Bilimoria  KY, Stewart  AK, Winchester  DP, Ko  CY.  The National Cancer Data Base: a powerful initiative to improve cancer care in the United States.  Ann Surg Oncol. 2008;15(3):683-690.PubMedGoogle ScholarCrossref
16.
Lerro  CC, Robbins  AS, Phillips  JL, Stewart  AK.  Comparison of cases captured in the National Cancer Data Base with those in population-based central cancer registries.  Ann Surg Oncol. 2013;20(6):1759-1765.PubMedGoogle ScholarCrossref
17.
Weir  HK, Johnson  CJ, Mariotto  AB,  et al.  Evaluation of North American Association of Central Cancer Registries’ (NAACCR) data for use in population-based cancer survival studies.  J Natl Cancer Inst Monogr. 2014;2014(49):198-209.PubMedGoogle ScholarCrossref
18.
Young  JL.  SEER Summary Staging Manual, 2000: Codes and Coding Instructions. Bethesda, MD: Dept. of Health and Human Services, National Institutes of Health, National Cancer Institute; 2006.
19.
Johnson  CH, ed. SEER Program Coding and Staging Manual 2004, Revision 1. Bethesda, MD: National Cancer Institute; 2004; NIH publication 04-5581.
20.
Brown  LD, Cai  TT, DasGupta  A.  Confidence intervals for a binomial proportion and asymptotic expansions.  Ann Stat. 2002;30(1):160-201. doi:10.1214/aos/1015362189Google ScholarCrossref
21.
Kim  HJ, Fay  MP, Feuer  EJ, Midthune  DN.  Permutation tests for joinpoint regression with applications to cancer rates.  Stat Med. 2000;19(3):335-351.PubMedGoogle ScholarCrossref
22.
Fu  Y, Zhuang  Z, Dewing  M, Apple  S, Chang  H.  Predictors for contralateral prophylactic mastectomy in breast cancer patients.  Int J Clin Exp Pathol. 2015;8(4):3748-3764.PubMedGoogle Scholar
23.
King  TA, Sakr  R, Patil  S,  et al.  Clinical management factors contribute to the decision for contralateral prophylactic mastectomy.  J Clin Oncol. 2011;29(16):2158-2164.PubMedGoogle ScholarCrossref
24.
Morrow  M, Jagsi  R, Alderman  AK,  et al.  Surgeon recommendations and receipt of mastectomy for treatment of breast cancer.  JAMA. 2009;302(14):1551-1556.PubMedGoogle ScholarCrossref
25.
Nelson  JA, Tchou  J, Domchek  S, Sonnad  SS, Serletti  JM, Wu  LC.  Breast reconstruction in bilateral prophylactic mastectomy patients: factors that influence decision making.  J Plast Reconstr Aesthet Surg. 2012;65(11):1481-1489.PubMedGoogle ScholarCrossref
26.
Pinell-White  XA, Kolegraff  K, Carlson  GW.  Predictors of contralateral prophylactic mastectomy and the impact on breast reconstruction.  Ann Plast Surg. 2014;72(6):S153-S157.PubMedGoogle ScholarCrossref
27.
Yi  M, Hunt  KK, Arun  BK,  et al.  Factors affecting the decision of breast cancer patients to undergo contralateral prophylactic mastectomy.  Cancer Prev Res (Phila). 2010;3(8):1026-1034.PubMedGoogle ScholarCrossref
28.
Gold  LS, Buist  DS, Loggers  ET,  et al.  Advanced diagnostic breast cancer imaging: variation and patterns of care in Washington state.  J Oncol Pract. 2013;9(5):e194-e202.PubMedGoogle ScholarCrossref
29.
Sommer  CA, Stitzenberg  KB, Tolleson-Rinehart  S, Carpenter  WR, Carey  TS.  Breast MRI utilization in older patients with newly diagnosed breast cancer.  J Surg Res. 2011;170(1):77-83.PubMedGoogle ScholarCrossref
30.
Sorbero  ME, Dick  AW, Beckjord  EB, Ahrendt  G.  Diagnostic breast magnetic resonance imaging and contralateral prophylactic mastectomy.  Ann Surg Oncol. 2009;16(6):1597-1605.PubMedGoogle ScholarCrossref
31.
Stout  NK, Nekhlyudov  L, Li  L,  et al.  Rapid increase in breast magnetic resonance imaging use: trends from 2000 to 2011.  JAMA Intern Med. 2014;174(1):114-121.PubMedGoogle ScholarCrossref
32.
Wernli  KJ, DeMartini  WB, Ichikawa  L,  et al; Breast Cancer Surveillance Consortium.  Patterns of breast magnetic resonance imaging use in community practice.  JAMA Intern Med. 2014;174(1):125-132.PubMedGoogle ScholarCrossref
33.
Rosenberg  SM, Ruddy  KJ, Tamimi  RM,  et al.  BRCA1 and BRCA2 mutation testing in young women with breast cancer.  JAMA Oncol. 2016;2(6):730-736.PubMedGoogle ScholarCrossref
34.
Birkmeyer  JD, Reames  BN, McCulloch  P, Carr  AJ, Campbell  WB, Wennberg  JE.  Understanding of regional variation in the use of surgery.  Lancet. 2013;382(9898):1121-1129.PubMedGoogle ScholarCrossref
35.
Chassin  MR, Brook  RH, Park  RE,  et al.  Variations in the use of medical and surgical services by the Medicare population.  N Engl J Med. 1986;314(5):285-290.PubMedGoogle ScholarCrossref
36.
Clemens  J, Gottlieb  JD.  Do physicians’ financial incentives affect medical treatment and patient health?  Am Econ Rev. 2014;104(4):1320-1349.PubMedGoogle ScholarCrossref
37.
Welch  WP, Miller  ME, Welch  HG, Fisher  ES, Wennberg  JE.  Geographic variation in expenditures for physicians’ services in the United States.  N Engl J Med. 1993;328(9):621-627.PubMedGoogle ScholarCrossref
38.
Arriagada  R, Lê  MG, Rochard  F, Contesso  G; Institut Gustave-Roussy Breast Cancer Group.  Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow-up data.  J Clin Oncol. 1996;14(5):1558-1564.PubMedGoogle ScholarCrossref
39.
Fisher  B, Anderson  S, Bryant  J,  et al.  Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.  N Engl J Med. 2002;347(16):1233-1241.PubMedGoogle ScholarCrossref
40.
Jacobson  JA, Danforth  DN, Cowan  KH,  et al.  Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer.  N Engl J Med. 1995;332(14):907-911.PubMedGoogle ScholarCrossref
41.
Veronesi  U, Cascinelli  N, Mariani  L,  et al.  Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer.  N Engl J Med. 2002;347(16):1227-1232.PubMedGoogle ScholarCrossref
42.
Farrow  DC, Hunt  WC, Samet  JM.  Geographic variation in the treatment of localized breast cancer.  N Engl J Med. 1992;326(17):1097-1101.PubMedGoogle ScholarCrossref
43.
Nattinger  AB, Gottlieb  MS, Veum  J, Yahnke  D, Goodwin  JS.  Geographic variation in the use of breast-conserving treatment for breast cancer.  N Engl J Med. 1992;326(17):1102-1107.PubMedGoogle ScholarCrossref
44.
Ridao-López  M, García-Armesto  S, Abadía-Taira  B, Peiró-Moreno  S, Bernal-Delgado  E.  Income level and regional policies, underlying factors associated with unwarranted variations in conservative breast cancer surgery in Spain.  BMC Cancer. 2011;11:145.PubMedGoogle ScholarCrossref
45.
Sariego  J.  Regional variation in breast cancer treatment throughout the United States.  Am J Surg. 2008;196(4):572-574.PubMedGoogle ScholarCrossref
46.
Smith  GL, Xu  Y, Shih  YC,  et al.  Breast-conserving surgery in older patients with invasive breast cancer: current patterns of treatment across the United States.  J Am Coll Surg. 2009;209(4):425-433.e2.PubMedGoogle ScholarCrossref
47.
Jerome-D’Emilia  B, Begun  JW.  Diffusion of breast conserving surgery in medical communities.  Soc Sci Med. 2005;60(1):143-151.PubMedGoogle ScholarCrossref
48.
King  MC, Marks  JH, Mandell  JB; New York Breast Cancer Study Group.  Breast and ovarian cancer risks due to inherited mutations in BRCA1 and BRCA2 Science. 2003;302(5645):643-646.PubMedGoogle ScholarCrossref
49.
Yakoub  D, Avisar  E, Koru-Sengul  T,  et al.  Factors associated with contralateral preventive mastectomy.  Breast Cancer (Dove Med Press). 2015;7:1-8.PubMedGoogle Scholar
50.
Hawley  ST, Griggs  JJ, Hamilton  AS,  et al.  Decision involvement and receipt of mastectomy among racially and ethnically diverse breast cancer patients.  J Natl Cancer Inst. 2009;101(19):1337-1347.PubMedGoogle ScholarCrossref
51.
Lee  MK, Noh  DY, Nam  SJ,  et al.  Association of shared decision-making with type of breast cancer surgery: a cross-sectional study.  BMC Health Serv Res. 2010;10:48.PubMedGoogle ScholarCrossref
52.
Waljee  JF, Rogers  MA, Alderman  AK.  Decision aids and breast cancer: do they influence choice for surgery and knowledge of treatment options?  J Clin Oncol. 2007;25(9):1067-1073.PubMedGoogle ScholarCrossref
53.
Kane  HL, Halpern  MT, Squiers  LB, Treiman  KA, McCormack  LA.  Implementing and evaluating shared decision making in oncology practice.  CA Cancer J Clin. 2014;64(6):377-388.PubMedGoogle ScholarCrossref
54.
Margenthaler  JA, Ollila  DW.  Breast conservation therapy versus mastectomy: shared decision-making strategies and overcoming decisional conflicts in your patients.  Ann Surg Oncol. 2016;23(10):3133-3137.PubMedGoogle ScholarCrossref
55.
Rosenberg  SM, Sepucha  K, Ruddy  KJ,  et al.  Local therapy decision-making and contralateral prophylactic mastectomy in young women with early-stage breast cancer.  Ann Surg Oncol. 2015;22(12):3809-3815.PubMedGoogle ScholarCrossref
56.
Katz  SJ, Lantz  PM, Janz  NK,  et al.  Patient involvement in surgery treatment decisions for breast cancer.  J Clin Oncol. 2005;23(24):5526-5533.PubMedGoogle ScholarCrossref
57.
Boughey  JC, Attai  DJ, Chen  SL,  et al.  Contralateral Prophylactic Mastectomy Consensus Statement from the American Society of Breast Surgeons: additional considerations and a framework for shared decision making.  Ann Surg Oncol. 2016;23(10):3106-3111.PubMedGoogle ScholarCrossref
58.
Boughey  JC, Attai  DJ, Chen  SL,  et al.  Contralateral Prophylactic Mastectomy (CPM) Consensus Statement from the American Society of Breast Surgeons: data on CPM outcomes and risks.  Ann Surg Oncol. 2016;23(10):3100-3105.PubMedGoogle ScholarCrossref
Original Investigation
July 2017

State Variation in the Receipt of a Contralateral Prophylactic Mastectomy Among Women Who Received a Diagnosis of Invasive Unilateral Early-Stage Breast Cancer in the United States, 2004-2012

Author Affiliations
  • 1Rollins School of Public Health, Emory University, Atlanta, Georgia
  • 2Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
  • 3Dana-Farber Cancer Institute, Boston, Massachusetts
  • 4Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Surg. 2017;152(7):648-657. doi:10.1001/jamasurg.2017.0115
Key Points

Question  Does the proportion of contralateral prophylactic mastectomies vary by state?

Findings  In this cohort study of more than 1.2 million women who received a diagnosis of invasive unilateral early-stage breast cancer treated with surgery, the proportion of contralateral prophylactic mastectomies varied substantially by state. The proportion among women 20 to 44 years of age during the period from 2010 to 2012 ranged from 15.7% in Hawaii to 42.8% to 48.5% in 5 contiguous Midwestern states.

Meaning  Patients should be educated about the benefit and harm of a contralateral prophylactic mastectomy for informed decision making.

Abstract

Importance  The use of contralateral prophylactic mastectomies (CPMs) among patients with invasive unilateral breast cancer has increased substantially during the past decade in the United States despite the lack of evidence for survival benefit. However, whether this trend varies by state or whether it is correlated with changes in proportions of reconstructive surgery among these patients is unclear.

Objective  To determine state variation in the temporal trend and in the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery.

Design, Setting, and Participants  A retrospective cohort study of 1.2 million women 20 years of age or older diagnosed with invasive unilateral early-stage breast cancer and treated with surgery from January 1, 2004, through December 31, 2012, in 45 states and the District of Columbia as compiled by the North American Association of Central Cancer Registries. Data analysis was performed from August 1, 2015, to August 31, 2016.

Exposure  Contralateral prophylactic mastectomy.

Main Outcomes and Measures  Temporal changes in the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery by age and state, overall and in relation to changes in the proportions of those who underwent reconstructive surgery.

Results  Among the 1 224 947 women with early-stage breast cancer treated with surgery, the proportion who underwent a CPM nationally increased between 2004 and 2012 from 3.6% (4013 of 113 001) to 10.4% (12 890 of 124 231) for those 45 years or older and from 10.5% (1879 of 17 862) to 33.3% (5237 of 15 745) for those aged 20 to 44 years. The increase was evident in all states, although the magnitude of the increase varied substantially across states. For example, among women 20 to 44 years of age, the proportion who underwent a CPM from 2004-2006 to 2010-2012 increased from 14.9% (317 of 2121) to 24.8% (436 of 1755) (prevalence ratio [PR], 1.66; 95% CI, 1.46-1.89) in New Jersey compared with an increase from 9.8% (162 of 1657) to 32.2% (495 of 1538) (PR, 3.29; 95% CI, 2.80-3.88) in Virginia. In this age group, CPM proportions for the period from 2010 to 2012 were over 42% in the contiguous states of Nebraska, Missouri, Colorado, Iowa, and South Dakota. From 2004 to 2012, the proportion of reconstructive surgical procedures among women aged 20 to 44 years who were diagnosed with early-stage breast cancer and received a CPM increased in many states; however, it did not correlate with the proportion of women who received a CPM.

Conclusions and Relevance  The increase in the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery varied substantially across states. Notably, in 5 contiguous Midwest states, nearly half of young women with invasive early-stage breast cancer underwent a CPM from 2010 to 2012. Future studies should examine the reasons for the geographic variation and increasing trend in the use of CPMs.

Introduction

Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death among women in the United States.1 Treatment for breast cancer varies by hormone and human epidermal growth factor receptor 2 status, stage, and histologic type and may include a combination of surgery, chemotherapy, hormonal therapy, and radiotherapy. Several studies in the United States have reported a marked increase in the use of contralateral prophylactic mastectomies (CPMs) for women who receive a diagnosis of early-stage unilateral breast cancer, particularly for patients younger than 45 years of age,2-4 despite a lack of evidence for survival benefit.5-9 The reasons for this increasing pattern are unclear but are thought to include the fear of developing a second breast cancer and the desire for breast symmetry following reconstructive surgery.10-12

Two previous studies based on the Surveillance, Epidemiology, and End Results (SEER) database13 and the National Cancer Data Base (NCDB)2 reported regional variation in the proportions of CPMs. However, these studies were limited because the SEER database (a population-based cancer registry) covers only 28% of the US population14 and because the NCDB (a hospital-based cancer registry) coverage in some states (eg, 27% in Arizona) is too low to provide representative state-specific estimates.15,16

We examined temporal trends by state and age in the proportion of patients who received CPMs among women diagnosed with invasive unilateral early-stage breast cancer and treated with surgery from 2004 through 2012. We used nationwide population-based incidence data as collected by the SEER program and the National Program of Cancer Registries and compiled by the North American Association of Central Cancer Registries (NAACCR).17 Using these data, we also examined whether the temporal changes in the proportion of women receiving a CPM by state were correlated with changes in the proportion of women undergoing reconstructive surgery following a CPM.

Methods
Data Source and Variables

Demographic and clinical information for women 20 years of age or older who received a diagnosis of primary invasive unilateral breast cancer between January 1, 2004, and December 31, 2012 (n = 1 404 411), was obtained from the NAACCR database for the District of Columbia and all states except for the nonconsenting states of Illinois, Maryland, and Vermont and owing to a lack of readily available data in Kansas and Minnesota. This project was reviewed and approved by the NAACCR institutional review board and was exempt from informed consent of individual study participants because it used only deidentified patient data.

Surgical interventions were categorized as breast-conserving surgery (BCS), unilateral mastectomy (UM) with or without reconstruction, or CPM with or without reconstruction. Stage was categorized as local or regional according to the 2000 SEER Summary Staging Manual.18 Patients not undergoing surgery (123 007 [8.8%]) and those with unknown or unclear surgical procedures (21 728 [1.5%]) were excluded from analyses, as were patients with distant (27 444 [2.0%]) or unknown stage (7285 [0.5%]), resulting in a final sample size of 1 224 947 patients.

Tumor size was grouped into 3 categories: less than 2 cm, 2 to 4.9 cm, and 5 to 20 cm; cases with a likely erroneously recorded tumor size of more than 20 cm (n = 1262) were classified as missing tumor size. Tumor grade was categorized as well differentiated, moderately differentiated, poorly differentiated, or undifferentiated. Race/ethnicity was categorized as non-Hispanic white, non-Hispanic black, non-Hispanic other, and Hispanic based on self-identified race and Hispanic origin.19 Age at diagnosis was categorized in 10-year age groups to compare CPMs with other surgical procedures at the national level. To investigate CPM trends temporally and geographically, age at diagnosis was collapsed into 2 categories: 20 to 44 years of age and 45 years of age or older, with a particular emphasis on women 20 to 44 years of age, for whom a CPM is more common.

Statistical Analysis

Statistical analysis was performed from August 1, 2015, to August 31, 2016. For each state, we calculated the proportion of patients undergoing a CPM among all women with early-stage unilateral breast cancer treated with surgery (BCS, UM, or CPM) by age (20-44 vs ≥45 years) and year of diagnosis averaged across 3 years (2004-2006, 2007-2009, and 2010-2012). We aggregated data across 3 years so that all state-specific estimates were based on at least 10 cases. Temporal trends in the proportion of patients undergoing a CPM between the first (2004-2006) and last (2010-2012) 3-year period were calculated as a prevalence ratio (PR) with asymptotic 95% CIs.20 To illustrate variation by state, maps of the United States were created in ArcMap, version 10.3.1 (ESRI). To show changes in the temporal trend over time for each of the 2 age groups (20-44 and ≥45 years), we used a joinpoint model, with a maximum of 1 joinpoint allowed. A log-transformed model was used to approximate a fixed annual percent change (APC) to account for the skewed distribution over time. In this method, the APC is calculated by fitting a least-squares regression line to the natural logarithm of the proportion, using year of diagnosis as the regressor variable.21 In the presence of a significant joinpoint, 2 values for APC were calculated, preceding and following the identified joinpoint.

Multivariable analysis was conducted using binary logistic regression, in which the outcome variable was CPM vs other surgery (UM or BCS). A second logistic regression model was fitted restricted only to patients who underwent a mastectomy (CPM vs UM). For both of these analyses, a single model was fit to the data, and the results were reported as odds ratios adjusted for the effect of the other covariates and 95% CIs. Statistical analyses were performed using SAS, version 9.4 (SAS Institute Inc), and joinpoint analysis was performed using Joinpoint Regression Program, version 4.2.0.2 (NCI). P = .05 (2-tailed) was considered significant.

We also examined state-specific trends in reconstructive surgery by age (20-44 years and ≥45 years) and year of diagnosis for women who underwent a CPM or a UM. We correlated the proportion of CPMs among women 20 to 44 years of age with early-stage unilateral breast cancer treated with surgery during the most recent period (2010-2012) with the proportion of reconstructive surgical procedures among women who were diagnosed with early-stage breast cancer and received a CPM by state, as well as the relative percent change in the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery between 2004-2006 and 2010-2012 with the corresponding relative percent change in reconstructive surgery, using the Pearson correlation coefficient. We repeated these correlation analyses with proportions of reconstructive surgical procedures among women who were diagnosed with early-stage breast cancer and received a mastectomy (either a UM or a CPM).

Results

Of 1 224 947 patients with unilateral early-stage breast cancer who underwent surgery between 2004 and 2012 and met the inclusion criteria, 715 914 (58.4%) had BCS, 402 434 (32.9%) had a UM, and 106 599 (8.7%) had a CPM (Table 1). Nationally, the proportion of patients undergoing a CPM monotonically increased with younger age from 2.4% (7891 of 330 698) for those 70 years or older to 29.3% (1896 of 6464) for those 20 to 29 years of age and with later years of diagnosis from 5.1% (20 037 of 391 393) in 2004-2006 to 11.9% (49 592 of 416 030) in 2010-2012.

Multivariable analysis also showed that the odds of undergoing a CPM compared with other surgery (BCS or UM) were significantly higher for younger patients (eTable 1 in the Supplement). In binary logistic regression, the odds of undergoing a CPM compared with other surgery ranged from 2.5 (95% CI, 2.5-2.6) for patients 60 to 69 years of age to 18.6 (95% CI, 17.4-19.8) for patients 20 to 29 years of age compared with patients 70 years of age or older. In addition, the odds of undergoing a CPM compared with other surgical procedures were significantly higher for patients who received a diagnosis of node-positive regional stage disease than for patients who received a diagnosis of local stage disease and were higher for patients with lobular carcinoma than for patients with ductal carcinoma, as well as for white vs nonwhite patients and for privately insured vs uninsured or non–privately insured patients. In contrast, in analyses restricted to patients receiving a mastectomy, the odds of undergoing a CPM compared with a UM were lower for patients who received a diagnosis of regional stage disease than for patients who received a diagnosis of local stage disease and were lower for patients with large tumors (≥2 cm) than for patients with small tumors (<2 cm) (eTable 1 in the Supplement).

Figure 1 depicts the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery by each year of diagnosis from 2004 to 2012 for all patients (≥20 years) and for the collapsed age categories (20-44 and ≥45 years) nationally. The proportion nationally increased between 2004 and 2012 from 3.6% (4013 of 113 001) to 10.4% (12 890 of 124 231) for those 45 years or older and from 10.5% (1879 of 17 862) to 33.3% (5237 of 1574) for those aged 20 to 44 years. Joinpoint analysis of the temporal trend showed that the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery significantly increased by an APC of 22% per year from 2004 through 2008 and by 11% per year from 2008 through 2012 for women 20 to 44 years of age (P < .05). Similarly, APCs preceding and following the 2008 joinpoint in women 45 years of age or older were 22% and 10%, respectively (P < .05) (eFigure in the Supplement).

The proportions of CPMs among women 20 to 44 years of age with early-stage unilateral breast cancer treated with surgery by state and year of diagnosis are presented in Table 2 (eTable 2 in the Supplement contains data from 2007 to 2009). From 2004-2006 to 2010-2012, the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery significantly increased in every state except Wyoming, with the magnitude of the increase varying by state. For example, between 2004-2006 and 2010-2012, the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery increased by about 3-fold in Virginia (PR, 3.29; 95% CI, 2.80-3.88) and Kentucky (PR, 3.03; 95% CI, 2.51-3.66), while it increased less than 2-fold in several states, such as New Jersey (PR, 1.66; 95% CI, 1.46-1.89). During the most recent time period (2010-2012), the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery substantially varied by state, from about 15% in Hawaii and the District of Columbia to greater than 42% in South Dakota, Iowa, Colorado, Missouri, and Nebraska (Table 2 and Figure 2). South Dakota also registered the highest proportion of women who underwent a CPM during the period from 2004 to 2006 (29.9% [41 of 137]), and West Virginia (6.0% [19 of 319]) and Utah (5.8% [21 of 364]) registered the lowest proportions.

The corresponding proportions of CPMs among women 45 years or older with early-stage unilateral breast cancer treated with surgery are presented in eTable 3 in the Supplement and Figure 2. Similar to the results seen among the younger age group, the proportion of CPMs among women 45 years or older with early-stage unilateral breast cancer treated with surgery significantly increased from 2004-2006 to 2010-2012 in all states except the District of Columbia, where the proportion of CPMs among women 45 years or older with early-stage unilateral breast cancer treated with surgery remained unchanged (2004-2006, 3.3% [25 of 759]; 2010-2012, 3.2% [26 of 810]). Prevalence ratios ranged from about 1.7 in South Dakota and Colorado to greater than 3.5 in Missouri, West Virginia, and Utah (eTable 3 in the Supplement). Likewise, the proportion of CPMs among women 45 years or older with early-stage unilateral breast cancer treated with surgery substantially varied across states in each time period. For example, during the period from 2010 to 2012, the proportions of patients who underwent a CPM ranged from less than 5% in Massachusetts, Hawaii, and Rhode Island to more than 16% in Colorado (eTable 3 in the Supplement). In general, the highest proportions of women 45 years of age or older who underwent a CPM were observed in select Southern and Midwestern states, and the lowest proportions were found in Northeast and Western states (Figure 2).

Nationally, the proportion of reconstructive surgical procedures among patients 20 years of age or older with early-stage unilateral breast cancer from 2004 to 2012 increased from 11.6% (5618 of 48 289) to 21.5% (8741 of 40 595) among patients with a UM and from 39.5% (2328 of 5892) to 54.8% (9930 of 18 127) among patients with a CPM (eTable 4 in the Supplement). Reconstructive surgery during this period was more common among younger than older patients for both CPM and UM. In 2012, 37.4% of patients 20 to 44 years of age with a UM (1776 of 4748) and 66.8% with a CPM (3499 of 5237) had reconstructive surgery. The corresponding proportions of patients 45 years of age or older were 19.4% (6965 of 35 847) and 49.9% (6431 of 12 890), respectively.

The proportion of reconstructive surgical procedures among those 20 to 44 years of age who received a CPM from 2004-2006 to 2010-2012 significantly increased in more than half of the states (26 of 45), with the magnitude of the relative increase ranging from 18% in Florida (PR, 1.18; 95% CI, 1.07-1.30) to a 2-fold increase in Virginia (PR, 2.01; 95% CI, 1.63-2.47) (eTable 5 in the Supplement). During the most recent time period (2010-2012), the proportion of reconstructive surgical procedures among patients 20 to 44 years of age who received a CPM ranged from 30.0% (54 of 180) in Oklahoma to 82.1% (252 of 307) in Massachusetts (Figure 3 and eTable 5 in the Supplement). Similarly, among patients 45 years of age or older who received a CPM, the proportion of reconstructive surgical procedures significantly increased in two-thirds of the states, and during the most recent time period, the proportion varied from 20.4% (109 of 534) in Oklahoma to 66.9% (599 of 895) in New Jersey (eTable 6 in the Supplement). Receipt of reconstructive surgery among patients who received a CPM and use of CPMs by state were not correlated cross-sectionally (r = 0.19; P = .21) or temporally (r = –0.09; P = .57).

The proportion of reconstructive surgical procedures also increased among patients who received a UM during the study period in most states. During the most recent time period (2010-2012), the proportion of reconstructive surgical procedures among women 20 to 44 years of age receiving a UM ranged from less than 20% in Washington, Oklahoma, New Mexico, and Hawaii to 66% in Massachusetts (eTable 7 in the Supplement). Among women 45 years of age or older receiving a UM, the proportion of reconstructive surgical procedrues ranged from about 7% in Alaska (7.2% [19 of 265]), Idaho (6.4% [35 of 548]), and Oklahoma (6.8% [108 of 1592]) to 35.9% (806 of 2243) in Massachusetts. The proportion of reconstructive surgical procedures among patients 20 to 44 years of age who underwent either a UM or a CPM during the period from 2010 to 2012 was correlated with CPM proportions (r = 0.42; P = .005), but the changes in CPM proportions from 2004-2006 to 2010-2012 were not correlated with the corresponding changes in reconstruction proportions among patients who underwent a mastectomy (r = 0.06; P = .68).

Discussion

Using a nationwide population-based cancer database, we found that the proportion of CPMs among patients 20 years or older with early-stage unilateral breast cancer treated with surgery significantly increased from 2004 to 2012 in almost all states, with the absolute proportions substantially higher among patients 20 to 44 years of age than among those 45 years of age or older and in some Midwestern and Southern states than in Western and Northeastern states. In 5 contiguous Midwestern states (South Dakota, Colorado, Nebraska, Iowa, and Missouri), nearly half of the young women who underwent surgery for early-stage unilateral breast cancer during the period from 2010 to 2012 underwent a CPM.

Factors associated with receipt of a CPM that may contribute to variations by state in the proportion of women who underwent a CPM include regional differences in distribution of white race, high socioeconomic status, testing for high-risk genetic mutations, reconstructive surgery for breast symmetry, use of magnetic resonance imaging (MRI), and fear and anxiety surrounding a diagnosis of breast cancer.12,22-27 However, we found no association between the temporal increases in the proportions of reconstructive surgical procedures among patients receiving a CPM by state, nor did we find an association between the 2 proportions by state for the most recent time period. We did find an association among women aged 20 to 44 years between the most recent proportions of CPMs and the proportions of all patients with a mastectomy who underwent reconstruction. Interestingly, the highest proportions of young women undergoing reconstructive surgery among young women who had a CPM were geographically clustered in several Northeastern states (Massachusetts, Maine, New Jersey, Connecticut, New York, and Delaware) rather than in the Midwestern region where we observed the highest proportions of women who underwent a CPM, although high proportions of reconstructive surgical procedures among those who had a CPM were observed in South Dakota and Colorado. The aforementioned Northeastern states also showed the highest proportions of reconstructive surgical procedures among those who had a UM.

Several previous studies in the United States have reported an increase in the use of MRI and high-risk genetic testing among patients with breast cancer, coinciding with the increase in the proportion of patients undergoing a CPM nationally.28-33 However, the use of MRI and high-risk genetic testing among women is unknown by state, and we were unable to assess their contributions to the state variation in the proportions of CPMs among women with breast cancer treated with surgery. One study limited to women 65 years of age or older in the SEER area showed geographic variation in MRI use among SEER registries but without significant difference in mastectomy use between those who underwent MRI and those who did not.29

It has been suggested that regional differences in the use of elective surgical procedures largely reflect geographical differences in physician practice, beliefs, and financial incentives rather than differences in patient factors.34-37 Although BCS has been shown to be an effective and less invasive alternative to mastectomy in the treatment of early-stage breast cancer,38-41 the use of this procedure varies geographically both within and outside of the United States.2,13,42-46 One study47 based on the NCDB found that, in both 1988 and 1994, the proportions of BCS were highest in teaching hospitals and lowest in community hospitals, while 2 later studies2,4 conducted between 1998 and 2010 showed that proportions of CPMs were highest in teaching hospitals and lowest in community hospitals, suggesting that there was a transition in surgical treatment by facility type. However, teaching hospitals comprise only about 20% of the hospitals reporting to the NCDB and contribute only about 35% of the cases.15 Furthermore, our findings do not suggest that state variation in the proportion of women who underwent a CPM reflects geographical differences in the distribution of health care facilities. We found high proportions of CPMs among women with early-stage unilateral breast cancer treated with surgery in both states with mostly community hospitals (eg, South Dakota) and states with many teaching hospitals (eg, Connecticut). We also found lower-than-average proportions of CPMs among women with early-stage unilateral breast cancer treated with surgery in both states with many teaching hospitals (eg, Massachusetts and New York) and in states with very few (eg, Hawaii, Idaho, and Wyoming).

Limitations

To our knowledge, our study is the first to show state-level variation based on population-based data and highlights a contiguous region of states that have substantially higher-than-average proportions of CPMs among women with early-stage unilateral breast cancer treated with surgery. However, a notable limitation of our study is its ecological nature and the lack of individual patient-level or clinician-level data, as well as the lack of health system data to examine reasons for the large state variations in the use of a CPM. Studies have shown that family history, high-risk genetic testing regardless of result, and socioeconomic status are individually associated with receiving a CPM10,22,48,49; however, our study lacked data on these variables. Also lacking in our analytical database were important clinical indicators affecting surgical decisions, such as mammographic patterns of diffuse microcalcifications, presence of multiple tumors, and failed lumpectomy attempts.

Studies examining decision aids have suggested that a mastectomy is less likely for early-stage breast cancer among women who are fully informed about surgical options.50-52 As such, the communication between physicians and patients is a crucial factor affecting decisions about breast cancer surgery, and there is increasing emphasis on shared decision making.53 In circumstances in which there is greater patient involvement in the decision-making process, there is a higher likelihood of patients having a mastectomy or a CPM.54,55 In contrast, patients reporting physician-led decisions were more likely to undergo BCS.50,56 However, variability in physician practices and approaches to decision making with their patients cannot be captured in a study of this nature. Recently, the American Society of Breast Surgeons issued a consensus statement that women with unilateral disease at average risk should be discouraged from undergoing a CPM.57,58 Future studies could examine the effect of this consensus on halting or reversing the rising proportions of CPMs in the United States, especially in some Midwestern states with the highest proportions.

Conclusions

Using a nationwide population-based database, we found substantial geographical variation in the receipt of a CPM among US women with unilateral breast cancer treated with surgery, with nearly 1 in 2 patients 20 to 44 years of age during the period from 2010 to 2012 receiving a CPM in 5 contiguous Midwestern states. This regional variation was partly explained by state variations in reconstructive surgical procedures among all women with a mastectomy but not among women who underwent a CPM. Future studies should examine patient-level, clinician-level, and health system–level factors to provide additional insight into the reasons for temporal changes and regional variation in the receipt of a CPM. In the meantime, however, surgeons and other health care professionals should educate their patients about the benefit, harm, and cost of a CPM to help patients make informed decisions about their treatments.

Back to top
Article Information

Accepted for Publication: January 8, 2017.

Corresponding Author: Ahmedin Jemal, DVM, PhD, Surveillance and Health Services Research, American Cancer Society, 250 Williams St NW, Atlanta, GA 30303 (ahmedin.jemal@cancer.org).

Published Online: March 29, 2017. doi:10.1001/jamasurg.2017.0115

Author Contributions: Ms Nash and Dr Lin had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Lin, Jemal.

Acquisition, analysis, or interpretation of data: Nash, Goodman, Lin, Freedman, Dominici, Ward.

Drafting of the manuscript: Nash, Lin, Dominici, Jemal.

Critical revision of the manuscript for important intellectual content: Goodman, Lin, Freedman, Ward, Jemal.

Statistical analysis: Nash, Ward.

Administrative, technical, or material support: Lin, Ward.

Study supervision: Goodman, Jemal.

Conflict of Interest Disclosures: None reported.

Funding/Support: This project was supported by Intramural Research Funding from the American Cancer Society.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Information: These data are based on the NAACCR December 2014 data submission. Support for cancer registries is provided by the state, province, or territory in which the registry is located. In the United States, registries also participate in the National Cancer Institute’s SEER program or the Centers for Disease Control and Prevention’s National Program of Cancer Registries, or both.

References
1.
Siegel  RL, Miller  KD, Jemal  A.  Cancer statistics, 2015.  CA Cancer J Clin. 2015;65(1):5-29.PubMedGoogle ScholarCrossref
2.
Pesce  CE, Liederbach  E, Czechura  T, Winchester  DJ, Yao  K.  Changing surgical trends in young patients with early stage breast cancer, 2003 to 2010: a report from the National Cancer Data Base.  J Am Coll Surg. 2014;219(1):19-28.PubMedGoogle ScholarCrossref
3.
Tuttle  TM, Jarosek  S, Habermann  EB,  et al.  Increasing rates of contralateral prophylactic mastectomy among patients with ductal carcinoma in situ.  J Clin Oncol. 2009;27(9):1362-1367.PubMedGoogle ScholarCrossref
4.
Yao  K, Stewart  AK, Winchester  DJ, Winchester  DP.  Trends in contralateral prophylactic mastectomy for unilateral cancer: a report from the National Cancer Data Base, 1998-2007.  Ann Surg Oncol. 2010;17(10):2554-2562.PubMedGoogle ScholarCrossref
5.
Bedrosian  I, Hu  CY, Chang  GJ.  Population-based study of contralateral prophylactic mastectomy and survival outcomes of breast cancer patients.  J Natl Cancer Inst. 2010;102(6):401-409.PubMedGoogle ScholarCrossref
6.
Brewster  AM, Bedrosian  I, Parker  PA,  et al.  Association between contralateral prophylactic mastectomy and breast cancer outcomes by hormone receptor status.  Cancer. 2012;118(22):5637-5643.PubMedGoogle ScholarCrossref
7.
Kurian  AW, Lichtensztajn  DY, Keegan  THM, Nelson  DO, Clarke  CA, Gomez  SL.  Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011.  JAMA. 2014;312(9):902-914.PubMedGoogle ScholarCrossref
8.
Pesce  C, Liederbach  E, Wang  C, Lapin  B, Winchester  DJ, Yao  K.  Contralateral prophylactic mastectomy provides no survival benefit in young women with estrogen receptor-negative breast cancer.  Ann Surg Oncol. 2014;21(10):3231-3239.PubMedGoogle ScholarCrossref
9.
Yao  K, Winchester  DJ, Czechura  T, Huo  D.  Contralateral prophylactic mastectomy and survival: report from the National Cancer Data Base, 1998-2002.  Breast Cancer Res Treat. 2013;142(3):465-476.PubMedGoogle ScholarCrossref
10.
Hawley  ST, Jagsi  R, Morrow  M,  et al.  Social and clinical determinants of contralateral prophylactic mastectomy.  JAMA Surg. 2014;149(6):582-589.PubMedGoogle ScholarCrossref
11.
Rosenberg  SM, Tracy  MS, Meyer  ME,  et al.  Perceptions, knowledge, and satisfaction with contralateral prophylactic mastectomy among young women with breast cancer: a cross-sectional survey.  Ann Intern Med. 2013;159(6):373-381.PubMedGoogle ScholarCrossref
12.
Fisher  CS, Martin-Dunlap  T, Ruppel  MB, Gao  F, Atkins  J, Margenthaler  JA.  Fear of recurrence and perceived survival benefit are primary motivators for choosing mastectomy over breast-conservation therapy regardless of age.  Ann Surg Oncol. 2012;19(10):3246-3250.PubMedGoogle ScholarCrossref
13.
Tuttle  TM, Habermann  EB, Grund  EH, Morris  TJ, Virnig  BA.  Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment.  J Clin Oncol. 2007;25(33):5203-5209.PubMedGoogle ScholarCrossref
14.
National Cancer Institute. Surveillance, Epidemiology, and End Results Program: about the SEER Program. National Institutes of Health website. https://www.seer.cancer.gov/about. Accessed August 1, 2016.
15.
Bilimoria  KY, Stewart  AK, Winchester  DP, Ko  CY.  The National Cancer Data Base: a powerful initiative to improve cancer care in the United States.  Ann Surg Oncol. 2008;15(3):683-690.PubMedGoogle ScholarCrossref
16.
Lerro  CC, Robbins  AS, Phillips  JL, Stewart  AK.  Comparison of cases captured in the National Cancer Data Base with those in population-based central cancer registries.  Ann Surg Oncol. 2013;20(6):1759-1765.PubMedGoogle ScholarCrossref
17.
Weir  HK, Johnson  CJ, Mariotto  AB,  et al.  Evaluation of North American Association of Central Cancer Registries’ (NAACCR) data for use in population-based cancer survival studies.  J Natl Cancer Inst Monogr. 2014;2014(49):198-209.PubMedGoogle ScholarCrossref
18.
Young  JL.  SEER Summary Staging Manual, 2000: Codes and Coding Instructions. Bethesda, MD: Dept. of Health and Human Services, National Institutes of Health, National Cancer Institute; 2006.
19.
Johnson  CH, ed. SEER Program Coding and Staging Manual 2004, Revision 1. Bethesda, MD: National Cancer Institute; 2004; NIH publication 04-5581.
20.
Brown  LD, Cai  TT, DasGupta  A.  Confidence intervals for a binomial proportion and asymptotic expansions.  Ann Stat. 2002;30(1):160-201. doi:10.1214/aos/1015362189Google ScholarCrossref
21.
Kim  HJ, Fay  MP, Feuer  EJ, Midthune  DN.  Permutation tests for joinpoint regression with applications to cancer rates.  Stat Med. 2000;19(3):335-351.PubMedGoogle ScholarCrossref
22.
Fu  Y, Zhuang  Z, Dewing  M, Apple  S, Chang  H.  Predictors for contralateral prophylactic mastectomy in breast cancer patients.  Int J Clin Exp Pathol. 2015;8(4):3748-3764.PubMedGoogle Scholar
23.
King  TA, Sakr  R, Patil  S,  et al.  Clinical management factors contribute to the decision for contralateral prophylactic mastectomy.  J Clin Oncol. 2011;29(16):2158-2164.PubMedGoogle ScholarCrossref
24.
Morrow  M, Jagsi  R, Alderman  AK,  et al.  Surgeon recommendations and receipt of mastectomy for treatment of breast cancer.  JAMA. 2009;302(14):1551-1556.PubMedGoogle ScholarCrossref
25.
Nelson  JA, Tchou  J, Domchek  S, Sonnad  SS, Serletti  JM, Wu  LC.  Breast reconstruction in bilateral prophylactic mastectomy patients: factors that influence decision making.  J Plast Reconstr Aesthet Surg. 2012;65(11):1481-1489.PubMedGoogle ScholarCrossref
26.
Pinell-White  XA, Kolegraff  K, Carlson  GW.  Predictors of contralateral prophylactic mastectomy and the impact on breast reconstruction.  Ann Plast Surg. 2014;72(6):S153-S157.PubMedGoogle ScholarCrossref
27.
Yi  M, Hunt  KK, Arun  BK,  et al.  Factors affecting the decision of breast cancer patients to undergo contralateral prophylactic mastectomy.  Cancer Prev Res (Phila). 2010;3(8):1026-1034.PubMedGoogle ScholarCrossref
28.
Gold  LS, Buist  DS, Loggers  ET,  et al.  Advanced diagnostic breast cancer imaging: variation and patterns of care in Washington state.  J Oncol Pract. 2013;9(5):e194-e202.PubMedGoogle ScholarCrossref
29.
Sommer  CA, Stitzenberg  KB, Tolleson-Rinehart  S, Carpenter  WR, Carey  TS.  Breast MRI utilization in older patients with newly diagnosed breast cancer.  J Surg Res. 2011;170(1):77-83.PubMedGoogle ScholarCrossref
30.
Sorbero  ME, Dick  AW, Beckjord  EB, Ahrendt  G.  Diagnostic breast magnetic resonance imaging and contralateral prophylactic mastectomy.  Ann Surg Oncol. 2009;16(6):1597-1605.PubMedGoogle ScholarCrossref
31.
Stout  NK, Nekhlyudov  L, Li  L,  et al.  Rapid increase in breast magnetic resonance imaging use: trends from 2000 to 2011.  JAMA Intern Med. 2014;174(1):114-121.PubMedGoogle ScholarCrossref
32.
Wernli  KJ, DeMartini  WB, Ichikawa  L,  et al; Breast Cancer Surveillance Consortium.  Patterns of breast magnetic resonance imaging use in community practice.  JAMA Intern Med. 2014;174(1):125-132.PubMedGoogle ScholarCrossref
33.
Rosenberg  SM, Ruddy  KJ, Tamimi  RM,  et al.  BRCA1 and BRCA2 mutation testing in young women with breast cancer.  JAMA Oncol. 2016;2(6):730-736.PubMedGoogle ScholarCrossref
34.
Birkmeyer  JD, Reames  BN, McCulloch  P, Carr  AJ, Campbell  WB, Wennberg  JE.  Understanding of regional variation in the use of surgery.  Lancet. 2013;382(9898):1121-1129.PubMedGoogle ScholarCrossref
35.
Chassin  MR, Brook  RH, Park  RE,  et al.  Variations in the use of medical and surgical services by the Medicare population.  N Engl J Med. 1986;314(5):285-290.PubMedGoogle ScholarCrossref
36.
Clemens  J, Gottlieb  JD.  Do physicians’ financial incentives affect medical treatment and patient health?  Am Econ Rev. 2014;104(4):1320-1349.PubMedGoogle ScholarCrossref
37.
Welch  WP, Miller  ME, Welch  HG, Fisher  ES, Wennberg  JE.  Geographic variation in expenditures for physicians’ services in the United States.  N Engl J Med. 1993;328(9):621-627.PubMedGoogle ScholarCrossref
38.
Arriagada  R, Lê  MG, Rochard  F, Contesso  G; Institut Gustave-Roussy Breast Cancer Group.  Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow-up data.  J Clin Oncol. 1996;14(5):1558-1564.PubMedGoogle ScholarCrossref
39.
Fisher  B, Anderson  S, Bryant  J,  et al.  Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.  N Engl J Med. 2002;347(16):1233-1241.PubMedGoogle ScholarCrossref
40.
Jacobson  JA, Danforth  DN, Cowan  KH,  et al.  Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer.  N Engl J Med. 1995;332(14):907-911.PubMedGoogle ScholarCrossref
41.
Veronesi  U, Cascinelli  N, Mariani  L,  et al.  Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer.  N Engl J Med. 2002;347(16):1227-1232.PubMedGoogle ScholarCrossref
42.
Farrow  DC, Hunt  WC, Samet  JM.  Geographic variation in the treatment of localized breast cancer.  N Engl J Med. 1992;326(17):1097-1101.PubMedGoogle ScholarCrossref
43.
Nattinger  AB, Gottlieb  MS, Veum  J, Yahnke  D, Goodwin  JS.  Geographic variation in the use of breast-conserving treatment for breast cancer.  N Engl J Med. 1992;326(17):1102-1107.PubMedGoogle ScholarCrossref
44.
Ridao-López  M, García-Armesto  S, Abadía-Taira  B, Peiró-Moreno  S, Bernal-Delgado  E.  Income level and regional policies, underlying factors associated with unwarranted variations in conservative breast cancer surgery in Spain.  BMC Cancer. 2011;11:145.PubMedGoogle ScholarCrossref
45.
Sariego  J.  Regional variation in breast cancer treatment throughout the United States.  Am J Surg. 2008;196(4):572-574.PubMedGoogle ScholarCrossref
46.
Smith  GL, Xu  Y, Shih  YC,  et al.  Breast-conserving surgery in older patients with invasive breast cancer: current patterns of treatment across the United States.  J Am Coll Surg. 2009;209(4):425-433.e2.PubMedGoogle ScholarCrossref
47.
Jerome-D’Emilia  B, Begun  JW.  Diffusion of breast conserving surgery in medical communities.  Soc Sci Med. 2005;60(1):143-151.PubMedGoogle ScholarCrossref
48.
King  MC, Marks  JH, Mandell  JB; New York Breast Cancer Study Group.  Breast and ovarian cancer risks due to inherited mutations in BRCA1 and BRCA2 Science. 2003;302(5645):643-646.PubMedGoogle ScholarCrossref
49.
Yakoub  D, Avisar  E, Koru-Sengul  T,  et al.  Factors associated with contralateral preventive mastectomy.  Breast Cancer (Dove Med Press). 2015;7:1-8.PubMedGoogle Scholar
50.
Hawley  ST, Griggs  JJ, Hamilton  AS,  et al.  Decision involvement and receipt of mastectomy among racially and ethnically diverse breast cancer patients.  J Natl Cancer Inst. 2009;101(19):1337-1347.PubMedGoogle ScholarCrossref
51.
Lee  MK, Noh  DY, Nam  SJ,  et al.  Association of shared decision-making with type of breast cancer surgery: a cross-sectional study.  BMC Health Serv Res. 2010;10:48.PubMedGoogle ScholarCrossref
52.
Waljee  JF, Rogers  MA, Alderman  AK.  Decision aids and breast cancer: do they influence choice for surgery and knowledge of treatment options?  J Clin Oncol. 2007;25(9):1067-1073.PubMedGoogle ScholarCrossref
53.
Kane  HL, Halpern  MT, Squiers  LB, Treiman  KA, McCormack  LA.  Implementing and evaluating shared decision making in oncology practice.  CA Cancer J Clin. 2014;64(6):377-388.PubMedGoogle ScholarCrossref
54.
Margenthaler  JA, Ollila  DW.  Breast conservation therapy versus mastectomy: shared decision-making strategies and overcoming decisional conflicts in your patients.  Ann Surg Oncol. 2016;23(10):3133-3137.PubMedGoogle ScholarCrossref
55.
Rosenberg  SM, Sepucha  K, Ruddy  KJ,  et al.  Local therapy decision-making and contralateral prophylactic mastectomy in young women with early-stage breast cancer.  Ann Surg Oncol. 2015;22(12):3809-3815.PubMedGoogle ScholarCrossref
56.
Katz  SJ, Lantz  PM, Janz  NK,  et al.  Patient involvement in surgery treatment decisions for breast cancer.  J Clin Oncol. 2005;23(24):5526-5533.PubMedGoogle ScholarCrossref
57.
Boughey  JC, Attai  DJ, Chen  SL,  et al.  Contralateral Prophylactic Mastectomy Consensus Statement from the American Society of Breast Surgeons: additional considerations and a framework for shared decision making.  Ann Surg Oncol. 2016;23(10):3106-3111.PubMedGoogle ScholarCrossref
58.
Boughey  JC, Attai  DJ, Chen  SL,  et al.  Contralateral Prophylactic Mastectomy (CPM) Consensus Statement from the American Society of Breast Surgeons: data on CPM outcomes and risks.  Ann Surg Oncol. 2016;23(10):3100-3105.PubMedGoogle ScholarCrossref
×