Skip to main content
NCBI home page
Canadian Journal of Public Health = Revue Canadienne de Santé Publique logoLink to Canadian Journal of Public Health = Revue Canadienne de Santé Publique
. 2004 Sep 1;95(5):336–340. doi: 10.1007/BF03405141

Declining Use of Mastectomy for Invasive Breast Cancer in Canada, 1981–2000

Leslie A Gaudette 13,✉, Ru-Nie Gao 13, Andrea Spence 23, Fan Shi 33, Helen Johansen 43, Ivo A Olivotto 53
PMCID: PMC6975738  PMID: 15490921

Abstract

Objective: To evaluate the rate and magnitude of change in surgical practice for breast cancer in Canada in relation to publication dates of clinical trials and consensus conferences.

Methods: Hospital separations with a diagnosis of invasive breast cancer were extracted from the Hospital Morbidity File from 1981 to 2000. Age-standardized rates of in-patient procedures for breast-conserving surgery and mastectomy were analyzed by province and age group and by geographic region.

Results: In Canada, mastectomy rates decreased from 62.2 to 37.9 per 100,000 between 1981 and 2000; declines were largest between 1984 and 1985, following publication of the NSABP B-06 clinical trial in March 1985, and between 1991 and 1993, after the US NIH Consensus Conference in February 1991. Mastectomy rates plateaued between 1985 and 1991, and from 1993 to 2000; the transitory peak in 1988 corresponded to publicity surrounding Nancy Reagan’s choice of mastectomy in 1987. Regional variations from the main pattern led to increasingly divergent mastectomy rates over time. Women aged 80+ were less likely to be treated by any surgery.

Interpretation: Publication of clinical trial results and consensus conferences were associated with changes in surgical treatment for breast cancer in Canada. However, divergent mastectomy rates among Canadian regions point to inconsistent adoption of less invasive therapy despite a publicly-funded health care system and national consensus guidelines.

Footnotes

Acknowledgements: The authors acknowledge the support of the Canadian Breast Cancer Initiative, and thank Dr. C. Ineke Neutel for consultation and assistance.

Reference

  • 1.Lazovich D, Solomon CC, Thomas DB, Moe RE, White E. Breast conservation therapy in the United States following the 1990 National Institutes of Health Consensus Development Conference on the treatment of patients with early stage invasive breast carcinoma. Cancer. 1999;86(4):628–37. doi: 10.1002/(SICI)1097-0142(19990815)86:4<628::AID-CNCR11>3.0.CO;2-L. [DOI] [PubMed] [Google Scholar]
  • 2.Lazovich DA, White E, Thomas DB, Moe RE. Underutilization of breast-conserving surgery and radiation therapy among women with stage I or II breast cances. JAMA. 1991;266(24):3433–38. doi: 10.1001/jama.1991.03470240055032. [DOI] [PubMed] [Google Scholar]
  • 3.Nattinger AB, Hoffmann RG, Howell-Pelz A, Goodwin JS. Effect of Nancy Reagan’s mastectomy on choice of surgery for breast cancer by US women. JAMA. 1998;279(10):762–66. doi: 10.1001/jama.279.10.762. [DOI] [PubMed] [Google Scholar]
  • 4.Du X, Freeman DH, Syblik DA. What drove changes in the use of breast conserving surgery since the early 1980s? The role of the clinical trial, celebrity action and an NIH consensus statemen. Breast Cancer Res Treat. 2000;62(1):71–79. doi: 10.1023/A:1006414122201. [DOI] [PubMed] [Google Scholar]
  • 5.Morris CR, Cohen R, Schlag R, Wright WE. Increasing trends in the use of breast-conserving surgery in California. Am J Public Healt. 2000;90(2):281–84. doi: 10.2105/AJPH.90.2.281. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Iscoe NA, Naylor CD, Williams JI, et al. Temporal trends in breast cancer surgery in Ontario: Can one randomized trial make a difference. CMA. 1994;150(7):1109–15. [PMC free article] [PubMed] [Google Scholar]
  • 7.Veronesi U, Saccozzi R, Del Vecchio M, et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breas. N Engl J Med. 1981;305(1):6–11. doi: 10.1056/NEJM198107023050102. [DOI] [PubMed] [Google Scholar]
  • 8.Sarrazin D, Le M, Rouesse J, et al. Conservative treatment versus mastectomy in breast cancer tumors with macroscopic diameter of 20 millimeters or less. The experience of the Institut Gustave-Rouss. Cances. 1984;53(5):1209–13. doi: 10.1002/1097-0142(19840301)53:5<1209::AID-CNCR2820530531>3.0.CO;2-Y. [DOI] [PubMed] [Google Scholar]
  • 9.Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cance. N Engl J Med. 1985;312(11):665–73. doi: 10.1056/NEJM198503143121101. [DOI] [PubMed] [Google Scholar]
  • 10.Veronesi U, Banfi A, Salvadori B, et al. Breast conservation is the treatment of choice in small breast cancer: Long-term results of a randomized trial. Eur J Cances. 1990;26(6):668–70. doi: 10.1016/0277-5379(90)90113-8. [DOI] [PubMed] [Google Scholar]
  • 11.Blichert-Toft M, Rose C, Andersen JA, et al. Danish randomized trial comparing breast conservation therapy with mastectomy: Six years of life-table analysis. Danish Breast Cancer Cooperative Grou. J Natl Cancer Inst Monog. 1992;11:19–25. [PubMed] [Google Scholar]
  • 12.Van Dongen JA, Bartelink H, Fentiman IS, et al. Randomized clinical trial to assess the value of breast-conserving therapy in stage I and II breast cancer, EORTC 10801 trial. J Natl Cancer Inst Monog. 1992;11:15–18. [PubMed] [Google Scholar]
  • 13.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 cance. N Engl J Med. 1995;332(14):907–11. doi: 10.1056/NEJM199504063321402. [DOI] [PubMed] [Google Scholar]
  • 14.Fisher B, Anderson S, Redmond CK, Wolmark N, Wickerham DL, Cronin WM. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cance. N Engl J Med. 1995;333(22):1456–61. doi: 10.1056/NEJM199511303332203. [DOI] [PubMed] [Google Scholar]
  • 15.Arriagada R, Le MG, Rochard F, Contesso G. Conservative treatment versus mastectomy in early breast cancer: Patterns of failure with 15 years of follow-up data. Institut Gustave-Roussy Breast Cancer Grou. J Clin Onco. 1996;14(5):1558–64. doi: 10.1200/JCO.1996.14.5.1558. [DOI] [PubMed] [Google Scholar]
  • 16.Van Dongen JA, Voogd AC, Fentiman IS, et al. Long-term results of a randomized trial comparing breast-conserving therapy with mastectomy: European Organization for Research and Treatment of Cancer 10801 trial. J Natl Cancer Inst. 2000;92(14):1143–50. doi: 10.1093/jnci/92.14.1143. [DOI] [PubMed] [Google Scholar]
  • 17.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 cance. N Engl J Met. 2002;347(16):1227–32. doi: 10.1056/NEJMoa020989. [DOI] [PubMed] [Google Scholar]
  • 18.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 cance. N Engl J Met. 2002;347(16):1233–41. doi: 10.1056/NEJMoa022152. [DOI] [PubMed] [Google Scholar]
  • 19.Scarth H, Cantin J, Levine M. Clinical practice guidelines for the care and treatment of breast cancer: Mastectomy or lumpectomy? The choice of operation for clinical stages I and II breast cancer (summary of the 2002 update. CMA. 2002;167(2):154–55. [PMC free article] [PubMed] [Google Scholar]
  • 20.Farrow DC, Hunt WC, Samet JM. Geographic variation in the treatment of localized breast cance. N Engl J Med. 1992;326(17):1097–101. doi: 10.1056/NEJM199204233261701. [DOI] [PubMed] [Google Scholar]
  • 21.Goel V, Olivotto I, Hislop TG, Sawka C, Coldman A, Holowaty EJ. Patterns of initial management of node-negative breast cancer in two Canadian province. CMA. 1997;156(1):25–35. [PMC free article] [PubMed] [Google Scholar]
  • 22.Iscoe NA, Goel V, Wu K, Fehringer G, Holowaty EJ, Naylor CD. Variation in breast cancer surgery in Ontari. CMA. 1994;150(3):345–52. [PMC free article] [PubMed] [Google Scholar]
  • 23.Nattinger AB, Gottlieb MS, Hoffman RG, Walker AP, Goodwin JS. Minimal increase in use of breast-conserving surgery from 1986 to 199. Med Care. 1996;34(5):479–89. doi: 10.1097/00005650-199605000-00009. [DOI] [PubMed] [Google Scholar]
  • 24.Gentleman JF, Parsons GF, Walsh MN, Vayda E. High and low surgical procedure rates in Census Divisions across Canad. Health Report. 1994;6(4):403–40. [PubMed] [Google Scholar]
  • 25.Mayo NE, Scott SC, Ningyan S, Hanley J, Goldberg MS, MacDonald N. Waiting time for breast cancer surgery in Quebec. CMA. 2001;164(8):1133–38. [PMC free article] [PubMed] [Google Scholar]
  • 26.Hebert-Croteau N, Brisson J, Latreille J, Blanchette C, Deschenes L. Variations in the treatment of early-stage breast cancer in Quebec between 1988 and 1999. CMA. 1999;161(8):951–55. [PMC free article] [PubMed] [Google Scholar]
  • 27.Gibbons L, Waters C. Prostate cancer - testing, incidence, surgery and mortalit. Health Report. 2003;14:9–20. [PubMed] [Google Scholar]
  • 28.Millar WJ. Hysterectomy, 1981/82 to 1996/9. Health Report. 2000;12:9–22. [Google Scholar]
  • 29.Gaudette LA, Lee J. Cancer Incidence in Canada, 1969–1993. Statistics Canada cat. no. 82–566-XPB. Ottawa, ON: Minister of Industry; 1997. [Google Scholar]
  • 30.de Koning HJ, van Dongen JA, van der Maas PJ. Changes in use of breast-conserving therapy in years 1978–200. Br J Cances. 1994;70(6):1165–70. doi: 10.1038/bjc.1994.466. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.NIH consensus conference. Treatment of early-stage breast cance. JAM. 1991;265(3):391–95. doi: 10.1001/jama.1991.03460030097037. [DOI] [PubMed] [Google Scholar]
  • 32.CMA. 1998.
  • 33.Nold RJ, Beamer RL, Helmer SD, McBoyle MF. Factors influencing a woman’s choice to undergo breast-conserving surgery versus modified radical mastectom. Am J Surv. 2000;180(6):413–18. doi: 10.1016/S0002-9610(00)00501-8. [DOI] [PubMed] [Google Scholar]
  • 34.Tarbox BB, Rockwood JK, Abernathy CM. Are modified radical mastectomies done for T1 breast cancers because of surgeon’s advice or patient’s choice. Am J Surv. 1992;164(5):417–20. doi: 10.1016/S0002-9610(05)81172-9. [DOI] [PubMed] [Google Scholar]
  • 35.Potosky AL, Merrill RM, Riley GF, et al. Breast cancer survival and treatment in health maintenance organization and fee-for-service setting. J Natl Cancer Inst. 1997;89(22):1683–91. doi: 10.1093/jnci/89.22.1683. [DOI] [PubMed] [Google Scholar]
  • 36.Whelan T, Levine M, Gafni A, et al. Mastectomy or lumpectomy? Helping women make informed choice. J Clin Oncon. 1999;17(6):1727–35. doi: 10.1200/JCO.1999.17.6.1727. [DOI] [PubMed] [Google Scholar]
  • 37.Ballard-Barbash R, Potosky AL, Harlan LC, Nayfield SG, Kessler LG. Factors associated with surgical and radiation therapy for early stage breast cancer in older women. J Natl Cancer Inst. 1996;88(11):716–26. doi: 10.1093/jnci/88.11.716. [DOI] [PubMed] [Google Scholar]
  • 38.Hislop TG, Olivotto IA, Coldman AJ, et al. Variations in breast conservation surgery for women with axillary lymph node negative breast cancer in British Columbia. Can J Public Healt. 1996;87(6):390–94. [PubMed] [Google Scholar]
  • 39.Nattinger AB, Gottlieb MS, Veum J, Yahnke D, Goodwin JS. Geographic variation in the use of breast-conserving treatment for breast cance. N Engl J Med. 1992;326(17):1102–7. doi: 10.1056/NEJM199204233261702. [DOI] [PubMed] [Google Scholar]
  • 40.Samet JM, Hunt WC, Farrow DC. Determinants of receiving breast-conserving surgery. The Surveillance, Epidemiology, and End Results Program, 1983–1986. Cances. 1994;73(9):2344–51. doi: 10.1002/1097-0142(19940501)73:9<2344::AID-CNCR2820730917>3.0.CO;2-V. [DOI] [PubMed] [Google Scholar]
  • 41.Hebert-Croteau N, Brisson J, Latreille J, Blanchette C, Deschenes L. Compliance with consensus recommendations for the treatment of early stage breast carcinoma in elderly women. Cances. 1999;85(5):1104–13. doi: 10.1002/(SICI)1097-0142(19990301)85:5<1104::AID-CNCR14>3.0.CO;2-1. [DOI] [PubMed] [Google Scholar]
  • 42.Health Canada. Organized breast cancer screening programs in Canada: 1997 and 1998 report. Minister of Public Works and Government Services Canada. 2001. [Google Scholar]
  • 43.Truong PT, Bernstein V, Wai E, Chua B, Speers C, Olivotto IA. Age-related variations in the use of axillary dissection: A survival analysis of 8038 women with T1-ST2 breast cance. Int J Radiat Oncol Biol Phys. 2002;54(3):794–803. doi: 10.1016/S0360-3016(02)02973-5. [DOI] [PubMed] [Google Scholar]
  • 44.Turner NJ, Haward RA, Mulley GP, Selby PJ. Cancer in old age—is it inadequately investigated and treate. BM. 1999;319(7205):309–12. doi: 10.1136/bmj.319.7205.309. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Hughes M. A Disease-based Comparison of Health Systems. Paris: Organization of Economic Cooperation and Development; 2003. Summary of results from breast cancer disease study. Chapter 4. I; pp. 77–94. [Google Scholar]
  • 46.Neutel CI, Gao R-N, Gaudette LA, Johansen HL. Decreasing length of hospital stay for female breast cancer patients in Canada. 1981. [Google Scholar]
  • 47.Whelan T, Olivotto I, Levine M. Clinical practice guideline for the care and treatment of breast cancer: Breast radiotherapy after breast-conserving surgery (summary of 2003 update. CMA. 2003;168(4):437–39. [PMC free article] [PubMed] [Google Scholar]
  • 48.Nattinger AB, Hoffmann RG, Kneusel RT, Schapira MM. Relation between appropriateness of primary therapy for early-stage breast carcinoma and increased use of breast-conserving surger. Lances. 2000;356(9236):1148–53. doi: 10.1016/S0140-6736(00)02757-4. [DOI] [PubMed] [Google Scholar]
  • 49.Olivotto A, Coldman AJ, Hislop TG, et al. Compliance with practice guidelines for node-negative breast cances. J Clin Oncol. 1997;15(1):216–22. doi: 10.1200/JCO.1997.15.1.216. [DOI] [PubMed] [Google Scholar]
  • 50.Paszat LF, Mackillop WJ, Groome PA, Zhang-Salomons J, Schulze K, Holowaty E. Radiotherapy for breast cancer in Ontario: Rate variation associated with region, age and incom. Clin Invest Med. 1998;21(3):125–34. [PubMed] [Google Scholar]

Articles from Canadian Journal of Public Health = Revue Canadienne de Santé Publique are provided here courtesy of Springer

RESOURCES