Factors influencing options in primary breast cancer treatment

Determinants of Breast-Conserving Therapy in the Asian Population: A Systematic Review

BACKGROUND

Treatment guidelines recommend breast-conserving therapy (BCT) for patients with early-stage breast cancer. However, Asian patients choose mastectomy over BCT, and the factors influencing this choice are unknown. This review aimed to identify the factors most frequently reported in the Eastern and Southeastern Asian population influencing the choice of BCT for treatment of early-stage breast cancer.

METHODS

PRISMA guidelines were followed, and PubMed and EMBASE databases were used. The literature search initially identified 4619 articles; abstract screening and full-text screening were performed on 150 and 19 articles, respectively, and 9 articles were finally included in the study.

RESULTS

Selection of BCT was associated with sociodemographic factors, such as high socioeconomic status and education level and young age at diagnosis; clinicopathological factors, such as small tumor size and mammographically detected tumors; and healthcare provider factors, such as treatment from a female doctor or from a breast specialist. However, not selecting BCT was associated with personal factors, such as fear of recurrence and avoidance of further treatment.

CONCLUSIONS

The process of making a treatment decision is complicated and involves many factors influencing patients' choice of surgery type. Exploring these factors helps to elucidate why patients do not choose BCT as their treatment option.

Understanding Patients' Preferences: A Systematic Review of Psychological Instruments Used in Patients' Preference and Decision Studies

BACKGROUND

Research has been mainly focused on how to elicit patient preferences, with less attention on why patients form certain preferences.

OBJECTIVES

To assess which psychological instruments are currently used and which psychological constructs are known to have an impact on patients' preferences and health-related decisions including the formation of preferences and preference heterogeneity.

METHODS

A systematic database search was undertaken to identify relevant studies. From the selected studies, the following information was extracted: study objectives, study population, design, psychological dimensions investigated, and instruments used to measure psychological variables.

RESULTS

Thirty-three studies were identified that described the association between a psychological construct, measured using a validated instrument, and patients' preferences or health-related decisions. We identified 33 psychological instruments and 18 constructs, and categorized the instruments into 5 groups, namely, motivational factors, cognitive factors, individual differences, emotion and mood, and health beliefs.

CONCLUSIONS

This review provides an overview of the psychological factors and related instruments in the context of patients' preferences and decisions in healthcare settings. Our results indicate that measures of health literacy, numeracy, and locus of control have an impact on health-related preferences and decisions. Within the category of constructs that could explain preference and decision heterogeneity, health locus of control is a strong predictor of decisions in several healthcare contexts and is useful to consider when designing a patient preference study. Future research should continue to explore the association of psychological constructs with preference formation and heterogeneity to build on these initial recommendations.

Self-Reported Sexual Function Measures Administered to Female Cancer Patients: A Systematic Review, 2008-2014

A systematic review was conducted to identify and characterize self-reported sexual function (SF) measures administered to women with a history of cancer. Using 2009 PRISMA guidelines, we searched electronic bibliographic databases for quantitative studies published January 2008-September 2014 that used a self-reported measure of SF, or a quality of life (QOL) measure that contained at least 1 item pertaining to SF. Of 1,487 articles initially identified, 171 were retained. The studies originated in 36 different countries with 23% from US-based authors. Most studies focused on women treated for breast, gynecologic, or colorectal cancer. About 70% of the articles examined SF as the primary focus; the remaining examined QOL, menopausal symptoms, or compared treatment modalities. We identified 37 measures that assessed at least one domain of SF, eight of which were dedicated SF measures developed with cancer patients. Almost one third of the studies used EORTC QLQ modules to assess SF, and another third used the Female Sexual Function Inventory. There were few commonalities among studies, though nearly all demonstrated worse SF after cancer treatment or compared to healthy controls. QOL measures are better suited to screening while dedicated SF questionnaires provide data for more in depth assessment. This systematic review will assist oncology clinicians and researchers in their selection of measures of SF and encourage integration of this quality of life domain in patient care.

Surgeon's recommendation, perceived operative efficacy and age dictate treatment choice by Chinese women facing breast cancer surgery

PURPOSE

to identify factors influencing Chinese women's choices between breast-conserving therapy (BCT), mastectomy (MRM) or MRM followed by breast reconstruction (MRM+R).

METHODS

of 405/443 Hong Kong Chinese women receiving surgery for early breast cancer who were interviewed one week post-surgery about their pre-surgical consultation, available treatment alternatives, whether their surgeons had indicated a surgical preference, perceived efficacy of the surgical options and considerations influencing their treatment decisions (TDM), 198 (49%) reported they were offered a choice of surgery.

RESULTS

among women offered a choice of surgery, BCT was chosen by 34/43 (79%) of women whose surgeons recommended BCT but by only 34/96 (37%) of women whose surgeons expressed no treatment recommendation. Multivariate adjustment showed women choosing MRM were influenced more by avoiding both cancer recurrence (p = 0.003) and further treatment (p = 0.009) when choosing surgical option than women choosing BCT. In contrast, women choosing MRM+R and BCT, placed more emphasis on appearance (p < 0.001) and body image (p < 0.001) concerns as influencing treatment choice than did women who chose MRM.

CONCLUSION

survival concerns rather than physical appearance, age and lack of recommendation push Chinese women to choose MRM as BCT is, incorrectly often seen as less efficacious. Recommending BCT increases BCT choice.

The effect of ipsilateral whole breast ultrasonography on the surgical management of breast carcinoma

BACKGROUND

Patients can be selected for breast conservation therapy using mammography and physical examination. Whole breast ultrasonography has been shown to identify lesions not seen on mammography. This study sought to determine how often whole breast ultrasonography changes the surgical management of breast cancer.

METHODS

All patients with stage 1 and 2 breast cancer undergoing whole breast ultrasonography were identified. A change in surgical management was defined as the identification by ultrasonography alone of foci of carcinoma greater than 1 cm from the primary tumor site or in another quadrant of the breast.

RESULTS

There were 1385 breast cancer patients; 31% had ultrasonography. Eighteen percent of patients had abnormalities identified by ultrasonography alone. Changes in management occurred in 2.8%. The additional lesions led to four wider resections and eight mastectomies. Patients with ultrasonography abnormalities were significantly younger, and more likely to have histologic grade 2 or 3 disease.

CONCLUSIONS

These findings do not support the routine use of ultrasonography in all breast cancer patients. Significant abnormalities were more commonly seen among younger patients with higher grade lesions.

A population-based study on variations in the use of adjuvant systemic therapy on postmenopausal patients with early stage breast cancer

PURPOSE

To assess adherence to treatment recommendations regarding adjuvant systemic therapy of postmenopausal patients with early stage breast cancer.

METHODS

A population-based cohort of women from Eastern Thuringia/Germany with first diagnosis of breast cancer in 1995-2000 was studied. The use of adjuvant therapy was assessed separately for patients with positive and negative nodal status fitting polytomous logistic regression models.

RESULTS

Among 396 women with positive lymph nodes and 832 with negative lymph nodes, 92.9% and 87.3% received an adjuvant systemic treatment, respectively. Age, comorbidity, hormone receptor status, histological grading, and additionally, in nodal positives, the number of involved lymph nodes, were associated with treatment patterns. Age had the strongest impact on treatment decision. Older women more often received hormone- or no adjuvant therapy. However, 26.3% of the women with lymph node involvement and positive hormone receptor status received no hormone therapy, whereas 35.7% of women with negative hormone receptor status received hormone therapy.

CONCLUSION

The number of patients with adjuvant systemic therapy is high in women with positive and those with negative lymph nodes, reflecting adherence to the recommendations. Better outcome could be expected if hormone therapy was used adequately in receptor positives. Further follow-up is required to monitor the outcome and changes in adherence to treatment recommendations.

Patient choice of breast cancer treatment: impact on health state preferences

BACKGROUND

Multiple treatment options exist for many medical conditions. The extent to which physicians should involve the patient in the choice the treatment to be delivered is not well understood.

OBJECTIVE

To test the impact of breast cancer treatment choice on patients' health state preferences.

DESIGN AND SETTING

A cohort from 29 hospitals (primarily referral centers) in Massachusetts, Texas, Washington DC, and New York. Subjects were surveyed at 5 months, 1 year, and 2 years following surgery and asked whether they had a choice in the type of treatment received.

SUBJECTS

Women age 67 or older treated in 1996 to 1997 for localized breast cancer (n = 683).

MEASURES

Patient preferences for current health state, assessed with patient valuations using the visual analogue scale (VAS) from the EuroQol instrument and with general public valuations using the Health Utilities Index (HUI), and 1-year medical costs.

RESULTS

For the adjusted analysis at 5 months, the adjusted mean VAS score was 78.7 for women who reported a choice and 75.3 for women who reported no choice, a difference of 3.4 (P = 0.03). The difference in the HUI score was 3.6 (P= 0.10) and the difference in the 1-year medical costs was -4363 dollars (P = 0.01). There were no statistically significant differences at the 1-year and 2-year interviews.

CONCLUSIONS

A woman's perception of choice of surgical treatment for breast cancer is associated with a short-term benefit on her preference of health state, suggesting choice helps with recovery, but does not provide long-term benefits.

Quality of life in patients with early and advanced carcinoma of the breast

AIM

Emotional disturbances are known to occur in patients suffering from malignant diseases even after treatment. This is mainly because of a fear of death which modifies quality of life (QOL). QOL has gained an important place in the management of cancer in industrialized nations, with the increase in survival. However, in developing countries like India, very little attention has been paid to this issue. Developing countries have poor infrastructure and lack proper treatment facilities at most centres, this leads to poor survival rates and hence much emphasis is on attaining quantity of life rather than quality. This study was carried out to assess the quality of life determinant in patients with breast cancer and the impact of treatment on quality of life indices.

METHODS

We carried out QOL assessment in 50 patients with breast cancer using the modified linear analogue scale for self assessment (LASA).

RESULTS

Significant deterioration was seen in health-related parameters in terms of recreation (P=0.01), social life (P=0.002), mobility (P=0.03), physical activity (P=0.4) and sleep and appetite (P=0.05). Treatment related parameters deteriorated in both early and advanced carcinoma. Similarly, weight loss was seen in both the groups, however, this was not statistically significant. Self-care and recreation were found to be the most important parameters influencing the QOL in breast cancer patients.

CONCLUSIONS

Breast cancer detection programs, health education and better awareness among women in industrialized nations has helped in downstaging of the disease, thus improving overall survival. It has not been so in developing countries, where the majority of patients present with advanced disease (T3 and T4). These are usually managed with surgery and adjuvant chemotherapy, which duly interferes with general health-related parameters and the social life of these patients, thereby adversely affecting the QOL.

Low rate of breast conservation surgery in large urban hospital serving the medically indigent

BACKGROUND

Breast conservation surgery (BCS) with radiation therapy is an acceptable treatment for stage I and II breast carcinoma. The purpose of this study was to measure the use of BCS in a large, urban, university-affiliated hospital serving primarily medically indigent patients.

METHODS

A chart review of patients receiving operative treatment for breast carcinoma during 1995 and 1996 was done. Patients with stage I or II disease were selected. Data were analyzed for clinical stage, surgical treatment, age, and ethnic origin.

RESULTS

Of patients eligible, only 16% received BCS. There were slight trends for younger women to receive BCS and for decreased use of BCS with stage II disease. No differences in surgical treatment were seen across ethnic groups.

CONCLUSIONS

We suggest that poverty, poor education, and cultural differences may play a role in selection of surgical treatment for breast carcinoma. Further investigation is needed to facilitate best treatment.

Breast cancer outcomes at the Strathfield Breast Centre

BACKGROUND

Breast cancer is the most commonly diagnosed cancer and the most common cause of cancer death in women. This report presents outcomes from a multidisciplinary breast clinic established in 1989 with the specific aim of providing a rapid, integrated assessment service for patients with breast disease.

METHODS

A prospective data collection and analysis using a Microsoft Access (Microsoft Corp., North Ryde, NSW, Australia) database was established and has collected information on all patients presenting for diagnosis or ongoing management of breast cancer. Data on survival were obtained by routine follow-up visits or contact with the patient's general practitioner.

RESULTS

Patient age, mode of presentation and histopathology were similar to other population-based studies in Australia. Ninety-three per cent of the patients had a diagnosis confirmed on the day of consultation. The average time between diagnosis and surgery was 11.9 days. Breast preserving surgery was attempted in 68% and achieved in 50% of cases, 67% of patients had one stage surgery. Five-year disease-free survival was 74% and is comparable with other reports.

CONCLUSIONS

The centralization of services and expertise has enabled us to provide efficient service and achieve internationally comparable outcomes.

Concern about aspects of body image and adjustment to early stage breast cancer

OBJECTIVE

Several authors have suggested that patients adjust more poorly to breast cancer if they are heavily invested in body image as a source of their sense of self-worth. This prospective study examined this possibility, looking at two aspects of concern about body image as predictors of several indices of adjustment over the first postoperative year.

METHODS

At diagnosis (and again a year later) 66 women with early stage breast cancer reported how much they valued a) a sense of body integrity (or intactness) and b) a good physical appearance. The day before surgery, a week afterward, and at 3-month, 6-month, and 12-month follow ups, they reported on their mood. At presurgery and at follow ups they also rated their attractiveness and sexual desirability and reported on frequency of sexual interaction. At follow-ups they also indicated how much their illness and treatment were interfering with social and recreational activities.

RESULTS

Initial investment in appearance was related to distress across the postsurgical year. In contrast, investment in appearance made women more resilient against deterioration in their perceptions of attractiveness. Concern about body integrity did not strongly predict emotional distress, but it related to adverse impact on social and recreational activities in the follow-up period, to deterioration in feelings of sexual desirability, and to feelings of alienation from the self (feeling "not like yourself anymore").

CONCLUSIONS

Body image is often thought of in terms of physical appearance, but there is also a body image pertaining to integrity, wholeness, and normal functioning. People who are greatly concerned about either aspect of their body image are vulnerable to poorer psychosocial adjustment when confronting treatment for breast cancer. The poorer adjustment takes a different form, however, depending on the nature of the patient's body-image concern.

Women's use of resources in decision-making for early-stage breast cancer: results of a community-based survey

BACKGROUND

The majority of women with stage I/II breast cancer may choose between mastectomy and breast-conserving therapy (BCT). A survey was designed to examine the resources women used in making this decision.

METHODS

From 1990 to 1994, 261 patients were diagnosed with or treated for stage I/II breast cancer at Washington Hospital (Fremont, CA). One-hundred seventy-six surviving patients received a questionnaire asking them to anonymously rank various medical and nonmedical persons, audio and visual materials, and decision criteria on a 5-point scale with regard to their influence on that individual's choice to undergo BCT or mastectomy. The BCT and mastectomy groups were similar demographically; approximately 50% were college-educated. Statistical significance of the difference in means between groups was assessed with the t test. The response rate to the survey was 65%.

RESULTS

The average survey ranking was > 1.0 for the following: surgeon (4.5), primary care physician (2.8), spouse (2.4), radiation oncologist (1.7), medical oncologist (1.5), American Cancer Society brochure (1.4), and children (1.2). The ranking of children (p = 0.08), friends (p = 0.08), parents (p = 0.09), and spouse (p = 0.13) was higher in the mastectomy group; the ranking of the radiation oncologist (p = 0.001) and ACS brochure (p = 0.03) was higher in the BCT group. The majority of patients consulted only with the surgeon (96%), primary care physician (64%), and spouse (55% overall, 75% among married patients) before making a treatment choice. Decision criteria were ranked as follows: chance for cure (4.5), physician recommendation (3.7), potential side effects (1.7), cosmetic appearance (1.3), sexual attractiveness (1.1), treatment convenience (1.0), and desire to avoid mastectomy (1.5). Desire to avoid mastectomy was higher in the BCT group (p < 0.0001); ranking of chance for cure was higher in the mastectomy group (p = 0.12). Overall satisfaction was higher in the BCT group; 87% of these patients were "very satisfied" with their decision versus 68% for the mastectomy group (p = 0.005). Review of the admitting records for 125 patients treated with mastectomy indicated that 46% had clear medical or personal contra-indications to BCT, but that the remainder might have benefitted from specialty consultation.

CONCLUSIONS

The surgeon's recommendation and the patient's perception of chance for cure were the most influential factors affecting treatment decision. There was a limited use of specialty consultation or written and audiovisual materials in this educated patient population. The survey results suggest potential areas of intervention to improve rates of BCT, namely use of up-front multidisciplinary evaluation, further education of primary care physicians, and greater attention to concerns of family members.

A comparative study of post-operative psychosocial function in women with primary operable breast cancer randomized to breast conservation therapy or mastectomy

In a randomized patient series of 184 women suffering from primary operable breast carcinoma, psychosocial adjustment to breast-conserving therapy (BCT) vs mastectomy (M) was analysed retrospectively, including: (i) a comparison of intergroup characteristics; (ii) patient experience of the quality of professional pre-operative information; and (iii) the extent to which influence on choice of treatment was required. Using LASA (Linear Analogue Self-Assessment Scale), STAI (State-Trait Anxiety Inventory), and a semi-structured interview, no psychosocial benefits were found in BCT compared with M. Mean observation time was 31 months (range: 15-65). Body image was less impaired in BCT than in M. Both groups scored highly on professional information, but reported reduced ability to take in such information in the peri-operative period. Both groups tended to depend on the surgeon when choosing between surgical options. Irrespective of primary therapy, women must still confront the fact that they have had cancer, a life-threatening disease which may recur. A need for further research into peri-operative information procedures was demonstrated, and some suggestions were derived concerning the surgeon's role in deciding on surgical options.

Offering choice of surgical treatment to women with breast cancer

Much has been written about the psychosocial and sexual dysfunction associated with the diagnosis and treatment of breast cancer. Hopes that breast conserving techniques would lead to a reduction in some of the psychosocial morbidity experienced, have not materialised. Most of the methodologically sound studies reported to date demonstrate few differences in quality of life domains between women whatever their primary surgical treatment. Some researchers suggested that if women were offered an opportunity to select the surgical option they preferred, then two things would occur: (1) women would choose breast-conserving techniques, and (2) choice in itself would prevent psychosocial morbidity. Despite strong support for both of these assumptions, neither have been borne out. Significant numbers of women, when offered choice, opt for mastectomy and choice in itself does not convey protection from psychological morbidity. The majority of women seem to welcome being given clear information about the options available, together with the reasons as to why a clinician would advise one policy rather than another. However, fewer women than expected wish to take a major role in decision-making about their breast cancer treatment.

Counseling Needs of Women With Breast Cancer: What the Women Tell Us

Research has demonstrated that some women treated for breast cancer are at risk for significant and persistent emotional distress and disrupted quality of life. Factors identified that appear to make women psychologically vulnerable include younger age at diagnosis, a history of high life stress or depression prior to diagnosis, and more advanced disease. Research has quickly moved to develop and implement psychological interventions to help these women, although little is known about the patients' perceptions of their need for, and use of, such services. This article presents research that focuses on the perceptions of the women themselves using a survey technique.

Patient selection for breast conservation therapy with magnification mammography

BACKGROUND

Breast-conserving therapy (BCT) is an appropriate treatment for women with breast carcinoma of limited extent. This study was undertaken to determine the ability of microfocal spot magnification mammography to identify women with multifocal or multicentric breast carcinoma who were unlikely to have all gross carcinoma removed with a limited breast resection.

METHODS

Two hundred sixty-three women with mammographically visible ductal carcinoma in situ and stage 1 and 2 carcinoma who were clinical candidates for BCT were evaluated with magnification mammography before undergoing definitive local therapy. Biopsy specimens of additional abnormalities thought to have a greater than 2% risk of malignancy were obtained.

RESULTS

Forty-seven women had other abnormalities in the index breast requiring intervention, and 216 had only the primary tumor identified. Mean age, cancer presentation, disease stage, and histologic tumor type did not differ between groups. BCT was successful in 97.2% of women without mammographic abnormalities versus 38% of women with abnormalities (p = 0.001). Clinical characteristics did not differ between patients undergoing successful BCT and those requiring mastectomy. Synchronous contralateral carcinoma was identified in 2.4% of women at risk.

CONCLUSIONS

Magnification mammography allows accurate preoperative identification of patients requiring mastectomy or quadrantectomy and should be performed before diagnostic biopsy is done.

Chronic pain and depression: is social support relevant?

This study examined the relationship between social support and depression for 70 patients with chronic back pain. We also explored whether the family environments of these patients related to depression and whether the patients' depression predicted outcome subsequent to involvement in a functional restoration program. The patients completed a battery of psychological questionnaires to assess depression, social support, and family environment. Outcome of a rehabilitation program was measured in terms of physical gains, vocational gains, and progress made toward program goals. Analysis indicated that the 25 depressed and 23 nondepressed patients differed as to perceived social support and quality of family environment; however, no association was found between depression and rehabilitation outcome. Implications for family interventions are discussed.

Conservation surgery for breast cancer: selection criteria and technical considerations

Patients with stage I or II breast cancer are candidates for either modified radical mastectomy or breast preservation therapy involving limited resection of the primary tumor, axillary dissection, and breast irradiation. The overall survival rates of both these approaches are comparable according to retrospective reviews and ongoing clinical trials, and long-term follow-up confirms the earlier findings. Thus, patients should be given the choice between these two options by surgeons, radiation therapists, and other physicians involved in their care. However, not all breast cancer patients will choose breast preservation surgery, and because of tumor-related and other factors not all patients are candidates. The patient selection criteria are discussed herein and the optimal surgical techniques are reviewed.

Mastectomy versus conservative surgery and radiation therapy. Psychosocial consequences

BACKGROUND

Clinical trials comparing mastectomy to conservative surgery plus radiation therapy in the treatment of breast cancer have provided an opportunity to increase understanding of the biology of this disease and the psychological adaptation of the breast cancer patient. Because these local treatments appear to be equal in terms of survival, the question remains as to whether conservative surgery plus radiation therapy confers a measure of psychological comfort superior to that of mastectomy for women diagnosed with early-stage breast cancer.

METHODS

One hundred forty-two women participating in a clinical trial randomizing patients to mastectomy or lumpectomy and radiation therapy were prospectively evaluated for psychological response to their respective local therapy. A baseline assessment before randomization and subsequent questionnaires at 6, 12, and 24 months after treatment were completed by patients entered in the clinical trial.

RESULTS

At 6 months, mastectomy patients reported significantly less control over events in their lives (P = 0.003) and more problems with sexual relations (P = 0.021) than did their conservatively treated counterparts. In addition, there were marked differences between mastectomy patients and lumpectomy and radiation therapy patients in the degree of distress over their nude bodies, with P = 0.001 at 6 months, P = 0.019 at 12 months, and P = 0.057 at 24 months.

CONCLUSIONS

From our findings, it appears that breast conservation therapy protects women's perception of their body but does not, over time, contribute to a more positive sexual adjustment.

Surgical treatment for early breast cancer: should the patient decide?

Conservative surgery followed by a course of radiotherapy has been shown to be as effective as mastectomy in terms of survival and disease-free interval. This has led to an increase in the number of surgeons who undertake conservative surgery for early breast cancer. However, some studies have shown that, when offered a choice of surgery, some women elect mastectomy. Such results highlight the need for patients to be fully involved in the decision made about surgery, especially in the circumstances where there is more than one surgical option and a choice of surgery can be offered.

Are modified radical mastectomies done for T1 breast cancers because of surgeon's advice or patient's choice?

Clinical trials show that T1 breast cancers are equally well treated with breast-conserving surgery as with modified radical mastectomy. However, the Colorado Central Cancer Registry indicates that, for the past 5 years, the majority of women (72%) with T1 breast cancer in Colorado have undergone modified radical mastectomies. A questionnaire was sent to 175 general surgeons to determine the reasons for the high number of modified radical mastectomies still being performed. The results indicate that one group of surgeons (34% of those responding) believes each type of surgery has equal survival rates but unknowingly influences the patient to choose modified radical mastectomy, with a subtly biased presentation. Education of both surgeons and patients is needed to increase the number of patients with T1 breast lesions who can benefit from breast-conserving therapy.

Changes in mood state following whole-body hyperthermia

Mood states of cancer patients were assessed pre- and post-41.8 degrees C whole-body hyperthermia using the Profile of Mood States questionnaire. Results demonstrated a statistically significant increase in fatigue associated with decreased vigour which returned to baseline values by 72 h. In contrast, a significant improvement in depression was evident through 72 h following treatment. The relationship of this result to earlier studies of WBH-induced beta-endorphin is discussed.

Is there a role for preference assessments in research on quality of life in oncology?

The development of ways to evaluate interventions that may have an impact on quality of life is a rapidly-developing area of research in clinical oncology, especially within the context of randomized controlled trials. We propose a role for assessments of preferences in such evaluations, including preference studies designed to assess attitudes toward the clinical acceptability of interventions, and preference trials designed to assess choice behaviour in relation to interventions. We suggest that such preference assessments represent a specific case of a more general issue: the need to develop an 'ethics of evidence', that is, standards for the creation, assessment and communication of evidence. We then outline a framework within which an 'ethics of evidence' might be developed, and suggest that the framework also may provide a useful model for the processes involved in the transfer of research results into clinical practice. As an illustration, we consider the problem of decision making in circumstances where the choice of therapy depends primarily on the patient's own preferences, as, for example, in the choice of mastectomy or breast-conserving treatment in early-stage breast cancer. The long-term goal is to develop criteria which might be used to foster shared rational decision making in such circumstances.

Patterns of surgical treatment of breast cancer in Victoria

We analysed data on admissions to Victorian public hospitals for surgical treatment of breast cancer over the period July 1985 to December 1988. Of the 2993 women admitted, 28.7% received breast-preserving surgery. The probability of a woman being treated conservatively was dependent on age, with women aged less than 50 or more than 70 years more likely to receive breast-preserving surgery than women aged 50-69. There was an age-specific change, of marginal statistical significance, in the proportion of women receiving breast-preserving surgery over the period. The public hospitals admissions database is a potentially useful means of monitoring patterns of surgical treatment.

Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial

OBJECTIVES

To assess outside a clinical trial the psychological outcome of different treatment policies in women with early breast cancer who underwent either mastectomy or breast conservation surgery depending on the surgeon's opinion or the patient's choice. To determine whether the extent of psychiatric morbidity reported in women who underwent breast conservation surgery was associated with their participation in a randomised clinical trial.

DESIGN

Prospective, multicentre study capitalising on individual and motivational differences among patients and the different management policies among surgeons for treating patients with early breast cancer.

SETTING

12 District general hospitals, three London teaching hospitals, and four private hospitals.

PATIENTS

269 Women under 75 with a probable diagnosis of stage I or II breast cancer who were referred to 22 different surgeons.

INTERVENTIONS

Surgery and radiotherapy or adjuvant chemotherapy, or both, depending on the individual surgeon's stated preferences for managing early breast cancer.

MAIN OUTCOME MEASURES

Anxiety and depression as assessed by standard methods two weeks, three months, and 12 months after surgery.

RESULTS

Of the 269 women, 31 were treated by surgeons who favoured mastectomy, 120 by surgeons who favoured breast conservation, and 118 by surgeons who offered a choice of treatment. Sixty two of the women treated by surgeons who offered a choice were eligible to choose their surgery, and 43 of these chose breast conserving surgery. The incidences of anxiety, depression, and sexual dysfunction were high in all treatment groups. There were no significant differences in the incidences of anxiety and depression between women who underwent mastectomy and those who underwent lumpectomy. A significant effect of surgeon type on the incidence of depression was observed, with patients treated by surgeons who offered a choice showing less depression than those treated by other surgeons (p = 0.06). There was no significant difference in psychiatric morbidity between women treated by surgeons who offered a choice who were eligible to choose their treatment and those in the same group who were not able to choose. Most of the women (159/244) gave fear of cancer as their primary fear rather than fear of losing a breast. The overall incidences of psychiatric morbidity in women who underwent mastectomy and those who underwent lumpectomy were similar to those found in the Cancer Research Campaign breast conservation study. At 12 months 28% of women who underwent mastectomy in the present study were anxious compared with 26% in the earlier study, and 27% of women in the present study who underwent lumpectomy were anxious compared with 31% in the earlier study. In both the present and earlier study 21% of women who underwent mastectomy were depressed, and 19% of women who underwent lumpectomy in the present study were depressed compared with 27% in the earlier study.)

CONCLUSIONS

There is still no evidence that women with early breast cancer who undergo breast conservation surgery have less psychiatric morbidity after treatment than those who undergo mastectomy. Women who surrender autonomy for decision making by agreeing to participate in randomised clinical trials do not experience any different psychological, sexual, or social problems from those women who are treated for breast cancer outside a clinical trial.

Surgical management of stage I and stage II breast cancer

Patients with Stage I or II breast cancer are candidates for either modified radical mastectomy or breast preservation, with limited resection of the primary, axillary dissection, and breast irradiation. Overall survival rates with these two approaches are comparable in retrospective reviews and in ongoing clinical trials. Longer follow-up has confirmed earlier findings. Patients should be given these options by surgeons, radiation therapists, and other physicians involved in their care. Not all breast cancer patients will choose breast preservation, and not all are candidates for it due to tumor-related and other factors. Patient selection criteria are discussed, and optimal surgical techniques are reviewed.

Does adjuvant radiotherapy have a role in the postmastectomy management of patients with operable breast cancer--revisited

About 2 decades ago, "routine" adjunctive postmastectomy radiotherapy, especially for axillary node-positive patients, was the norm and uncriticized standard against which adequate treatment was measured in most centers. With the advent of cyclic, aggressive, multi-agent chemotherapy and anti-hormones used as adjuvants, especially within the last decade, there has been tremendous reduction in patients referred to the radiation oncologist for consideration of adjunctive postmastectomy radiotherapy. This presentation will attempt to define a role for radiotherapy in at least selected subsets of patients who undergo modified radical mastectomy, based upon published series in the literature. Breast cancer is a protean disease and deserves a multidisciplinary approach to evaluation and treatment. "Routine" adjunctive postmastectomy radiotherapy for all patients with operable breast cancer obviously is not indicated, but there appear to be groups of patients who benefit from radiotherapy, both from the standpoint of disease-free survival and improved quality of life, and . . . in very narrow subsets, absolute survival. In some of these subsets the benefit clinically may be greater than that resulting from chemotherapy or anti-hormone therapy, although, because of sample size, falling short of statistical verification. In response to the posed question, while this remains a controversial issue, there appears to be a role for selective adjunctive postmastectomy radiotherapy in specific subsets of patients, and physicians administering adjunctive breast cancer therapy with sweeping applications of chemotherapy or anti-hormones alone do not appear to be offering their patients optimal therapy.