Breast Conservation versus Mastectomy for Early Stage Breast Cancer: How Does the Department of Defense Compare?

William E Sherman, MD1, Benjamin F Stork, MD2, Julie A Rizzo, MD3, Cletus A Arciero, MD1. 1Dwight D. Eisenhower Army Medical Center, 2Naval Aerospace Medical Institute, 3United States Army Institute of Surgical Research

Objectives: The surgical management of early breast cancer is evolving. Breast-conservation therapy (BCT) is utilized more often. Rates of BCT versus mastectomy, however, vary across the country. Previous reports revealed BCT rates in the Department of Defense (DOD) lagged behind national trends. Our objectives were to assess utilization of BCT in the DOD Healthcare System and factors that may have influenced this rate and to compare these findings to civilian institutions.

Methods: The Department of Defense Automated Central Tumor Registry (ACTUR) was queried for women diagnosed with Stage 0, I, or II breast cancer from January 1, 1996 to December 31, 2008. We investigated rates of BCT and factors that may have influenced these rates including age, race, T stage, hospital size, and geographic location. Patients without a complete record of treatment were excluded.

Results: 6471 patients met inclusion criteria. The average rate of BCT over these years was 59%. Initial selection of BCT was significantly influenced by age and T stage. 504 patients (7.88%) scheduled for BCT ultimately underwent mastectomy. These patients were younger with higher T staged tumors. The only factor that significantly correlated with the final cancer procedure was T stage (OR 2.14). Rates of breast conservation were not affected by whether the patient was treated in a community hospital or larger medical center (p=0.318). Patients in the West and Northeast were more likely to undergo breast conservation than those in the Central, Southeast, or outside the continental United States (OCONUS), though significant difference was only found for the Central Region (OR=0.77) the West (OR 1.14) and the Northeast (OR=1.35).

Conclusions: The utilization of BCT in the DOD Health Care System has slightly increased over the 12 years studied with a decrease in 2008. Rates of BCT are similar to civilian institutions. Rates of BCT in the DOD appear to be influenced by stage of the tumor but not race or age. There is equal use of BCT amongst community hospitals and medical centers. There was variation in the use of BCT for different geographic regions; culture variances amongst geographic regions may play the largest role in this difference. Even in the unique environment of the Department of Defense healthcare, the use of BCT is similar to civilian institutions. This suggests that physician preferences and traits may be a less likely barrier to increased use of breast conservation and that patient preference may play a larger role.

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