Breast cancer: How insurance cover is driving American women to choose mastectomy over lumpectomy

Breast cancer: How insurance cover is driving American women to choose mastectomy over lumpectomy
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Insurance cover could be driving a vast majority of American breast cancer patients to opt for the more invasive mastectomy, where doctors remove the entire breast, over a milder treatment option called 'breast preservation therapy or lumpectomy, a new study has found.

This trend in the US is different from that observed in Europe and Asia: about 55% of patients underwent breast-conserving therapy in the US, as opposed to 80% in Europe and Asia.

"We also found that US patients are nearly three times more likely than patients in Europe or Asia to undergo contralateral mastectomy, or removal of the unaffected breast, even if they tested negative for a genetic mutation that predisposes women to breast and ovarian cancer. To me, this is a profound difference," says corresponding author Dr. Mehra Golshan, Dr. Abdul Mohsen and Sultana Al-Tuwaijri Distinguished Chair in Surgical Oncology at the Brigham and director of the Breast Surgical Oncology Fellowship.

Lumpectomy Vs Mastectomy

During lumpectomy, doctors preserve the breast, while only surgically removing the tumor and any affected surrounding tissue. A mastectomy, on the other hand, involves removing the entire breast. 

Although both treatments are equally effective, may women who are eligible for a lumpectomy -- including 26% of those who tested negative for a genetic mutation for breast cancer -- still underwent a mastectomy, says the study. 

However, people who undergo lumpectomy face a higher risk of relapse, when compared to mastectomy. But if patients choose the latter, they will need more post-operative care. This has not deterred patients from choosing mastectomy, the study explains.

Genetic testing and mastectomy gained spotlight after Angelina Jolie, an actress, filmmaker, and humanitarian wrote an open editorial in May 2013, recounting her journey after she tested positive for a BRCA1 mutation, which increased her chances of breast and ovarian cancer. She underwent a risk-reducing bilateral mastectomy procedure with reconstruction to reduce her risk. 

Since then, the US has seen an uptick in genetic testing, which may have cost the health system $14 million in unnecessary tests, according to an earlier analysis.

An earlier study has suggested that removing both breasts is not usually helpful when women have breast cancer in one breast, experts say. The American Society of Breast Surgeons issued a statement to discourage women with one-sided, or unilateral, breast cancer who don’t have a genetic or family risk for the disease from undergoing a double, or contralateral, mastectomy.

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"Our goal here is not to say whether women should have had a lumpectomy instead. The decision isn't wrong -- I've been through cancer treatment myself, and it's a very personal process in decision making. However, it's important to recognize that based on the same medical information, patients in different countries are making very different decisions. The next question to ask is: why?", Golshan explains. 

The findings

In this current study, the team of researchers wanted to test whether American women would choose the milder lumpectomy or mastectomy after undergoing Neoadjuvant systemic therapy (NST), a treatment strategy to shrink tumor size, including chemotherapy. 

"Today, the vast majority of breast cancer patients have options," says Golshan. "New drugs and therapies are becoming available that allow us to shrink tumors prior to surgery, but we need to better understand how patients and surgeons perceive risk of disease and how this may factor into the surgical decision-making process."

So they analyzed data collected on 600 women with operable, clinical stage II and III triple-negative breast cancer from 145 centers in 15 countries, who were a part of BrighTNess, a phase III clinical trial.

All these women received different chemotherapy treatments. After treatment, 53% of the patients deemed ineligible before treatment became eligible for breast-conserving therapy.

Overall, 68% of the women who were eligible for breast-conserving therapy underwent a lumpectomy. But this trend varied, with patients from Europe and Asia preferring lumpectomy.

This trend is driven by costs and insurance cover. In Europe or Asia, patients have no insurance cover for mastectomies, which means patients will have to shell out their own money to remove the unaffected breast and reconstruct the breast unless they have a genetic mutation that puts them at risk.

On the other hand, in the US, such procedures are more frequently covered. The authors acknowledge a limitation in their study: they could not confirm from the participants of the study whether insurance had something to do with their choices.

The study gas has been published in JAMA surgery.

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