Facing breast cancer far from radiation therapy centres
CMAJ 1997;157:251-2
See response by: V. Goel, C. Sawka, I. Olivotto
We read with interest the article "Patterns of initial management of node-negative breast cancer in two Canadian provinces" (CMAJ 1997;156:25-35 [abstract / résumé]), by Dr. Vivek Goel and associates, and the accompanying editorial "A surgical subculture: the use of mastectomy to treat breast cancer" (CMAJ 1997;156:43-45 [abstract / résumé]), by Dr. Adalei Starreveld. We would like to provide a different perspective, as surgeons in a community where facilities for radiation therapy are not readily accessible to patients with breast cancer. Our point of view is not unique; specialists in communities similar to ours likely encounter the same obstacles. These obstacles must be considered before formulating guidelines, with all of their inherent medicolegal consequences.
Breast-conserving surgery (BCS) followed by radiation therapy is clearly equivalent to mastectomy in terms of survival and disease-free survival. However, since radiation therapy is essential to the success of this strategy, contraindications to radiation therapy or unwillingness to undergo radiation therapy are usually contraindications to BCS. It is not our experience that mastectomy is an outdated treatment, as there are still many patients who prefer mastectomy to BCS and a course of radiation therapy.
Let us describe our practice setting and the women we often encounter who may have a tendency to choose mastectomy over BCS. Williams Lake is a community with a population of approximately 15 000 (surgical service area of 45 000) about 6 hours' drive from Vancouver. It is surrounded by numerous ranches, many as far as 400 km away from any hospital. These ranches require considerable dedication to operate, and economic pressures preclude most family members from travelling major distances to centres with radiation therapy facilities for several weeks. Furthermore, many of the people living in the small, isolated villages and aboriginal communities in the area are also resistant to travelling to major centres. As much as we would like to impose our own values in supporting BCS, many patients whom we have encountered would not consider this option, for a variety of personal and economic reasons.
Canada is a vast country with a scattered population; this demographic factor may ultimately prove to be the major obstacle to instituting guidelines for management of early-stage breast cancer. In Ontario, only 6.0% of women considered in the study by Goel and associates lived more than 2 hours' travel time from a radiation therapy facility. This level of service is impressive indeed. Unfortunately, it is doubtful that other provinces can provide that level of service. Thus, provincial cancer agencies must decide which is more important: providing a specialized, progressive service in a few centres at the risk of losing some patients to management strategies that are not state-of-the-art, or providing a less-specialized service in more centres to capture all patients. Frankly, a cancer agency that adopts the latter strategy is not likely to excel at data collection or to remain at the cutting edge of cancer treatment. Furthermore, it is not difficult to predict which strategy is more attractive to fiscally driven bureaucrats. In light of these realities, we cannot deliver state-of-the-art treatment to all patients. We must therefore be careful not to label other regimens as "outdated."
Most studies suggest that patients who have undergone mastectomy experience more intense and persistently negative feelings about their bodies than do women who undergo BCS, but BCS does not categorically eliminate psychologic morbidity.1 Furthermore, conservatively treated patients have a greater concern that the cancer will recur.2,3 Although these studies of the psychologic consequences of various treatments of breast cancer are valuable, a number of inherent limitations may preclude their translation to the clinical realm. For instance, in one trial, patients were randomly assigned to mastectomy or BCS, then evaluated for the degree of distress resulting from not being in control of events in their lives.1 Although this study protocol ensures that the populations being compared are equal, it is unlikely that any patient randomly assigned to one group or the other will feel that she is in control of the events in her life. Most of the studies of the psychologic consequences of therapy for breast cancer recruit patients that have all treatment options readily available to them. These populations are unlikely to choose the same treatment and respond in the same way as others who may be inconvenienced by BCS. To a Canadian clinician, it is more important to know the determinants of a woman's decision to choose one treatment over the other. The most relevant studies of the psychologic sequelae of various treatments of breast cancer are those involving women in a large variety of social circumstances who have chosen whether to undergo mastectomy or BCS.
We do not intend to downplay the role of BCS in the treatment of early-stage breast cancer. Rather, it is our intention to remind those who provide guidelines that women's needs differ depending on a number of factors, including race, culture, religion and geographic location. Cosmetic factors may be a high priority for some; for others, limiting the effect of cancer on their lifestyle may be more important. Before we call BCS the "standard of care," perhaps the population at risk should be surveyed to learn what the priorities of its members are. A less partisan approach to management of breast cancer, resisting the temptation to impose our values on our patients, would ultimately serve our patients better.
Oliver F. Bathe, MD, MSc
Daniel T. Brosseuk, MD
Cariboo Memorial Hospital
Williams Lake, BC
References
- Schain WS, d'Angelo TM, Dunn ME, Lichter AS, Pierce O. Mastectomy versus conservative surgery and radiation therapy: psychosocial consequences. Cancer 1994;73:1221-8.
- Fallowfield LJ. Psychosocial adjustment after treatment for early breast cancer. Oncology 1990;4:89-97.
- Fallowfield LJ, Hall A. Psychosocial and sexual impact of diagnosis and treatment of breast cancer. Br Med Bull 1991;47:388-99.
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