In recognition of breast cancer awareness month, Oliver Wyman is sharing recent research conducted by Practicing WiselyTM on a key treatment decision in the breast cancer patient journey. There are many critical choices both patients and physicians face when deciding upon treatment options. We hope that our focus on one of these pivotal moments will raise physician understanding of how their clinical recommendations compare with that of their peers and ultimately improve patient wellbeing.
Examining Choices Behind the Full Versus Partial Mastectomy Decision
After hearing the dreaded words, “you have breast cancer,” patients with early-stage breast cancer are being given greater discretion to contribute to their medical decision-making. One of the decisions many recently-diagnosed women face is the choice between a mastectomy (removal of the breast) and a lumpectomy (removal of only the tumor and rim of normal tissue around it) followed by radiation therapy. Significant evidence shows that lumpectomy followed by radiation therapy has a lower risk of complications and quicker recovery time while delivering similar outcomes to mastectomy. Despite the advantages of lumpectomy, the number of women choosing mastectomy has increased by 34% over the past decade.
One reported factor contributing to this spike is women wanting to avoid a prolonged treatment – surgery and radiation therapy. Many women also express concern over radiation’s side effects and the anxiety that accompanies treatment over an extended period of time. Thanks to advances in radiation therapy, there are ways to address these concerns so that patients can comfortably consider breast conservation.
High Quality, Less Burdensome Cancer Treatment is The New Reality
For women who would prefer breast-conserving surgery but want to avoid the hassles of the conventional radiation treatment, there is high-quality evidence supporting a shorter course of radiation therapy. Accelerated radiation therapy delivers a slightly higher radiation dose each day, thereby compressing the total course of radiation to 3-4 weeks instead of the standard 5-7 weeks. Multiple clinical studies have proven that accelerated radiation treatment prevents breast cancer recurrence as effectively as does the conventional radiation regimen while decreasing the frequency and severity of side effects. In addition to reducing inconvenience, accelerated radiation produces less fatigue, pain, skin peeling, and breast thickening.
Another benefit is savings. The average reported cost of accelerated treatment is 25% less than conventional therapy, saving an average of about $4,000 per patient. This translates into hundreds of millions of dollars in annual savings in the United States. Despite the demonstrated benefits to the patient as well as to the health care system, many radiation oncologists continue to administer conventional courses of radiation therapy for patients who qualify for accelerated treatment.
New Guideline Issued to Help Save Breast Tissue
According to a new guideline issued by the Society of Surgical Oncology (SSO) and the American Society of Radiation Oncology (ASTRO), women no longer need to remove small amounts of breast tissue surrounding cancerous cells as a preventive measure to keep cancer from spreading. “It was important for us to create this guideline because we want women to have the confidence to select a lumpectomy rather than a mastectomy when medically possible and breast cancer physicians to be confident about knowing when a margin is adequate,” states Monica Morrow, Memorial Sloan Kettering’s chief of breast cancer surgery and co-chair of the guideline. Morrow says a fear that cancer will return ultimately drives some women to choose to undergo a mastectomy. "If cancer cells are at the edge or margin, then more surgery is needed. If cancer cells are only close to the edge, then removing more normal breast tissue is not needed," Morrow says. “The definition of the appropriate surgical margin for breast cancer has been a major controversy for decades, but we see excellent outcomes in women who undergo lumpectomy followed by radiation therapy,” she adds.
A Closer Look at the Conventional Treatment Plan
Patients and physicians have a complex and personal decision to make when considering breast cancer treatment options. To highlight this complexity, Oliver Wyman’s Practicing Wisely™ program took a closer look at a key aspect of treatment plans to highlight the potential for making lumpectomy a less onerous option. By analyzing the practice patterns of radiation oncologists, the Practicing Wisely™ team measured variation in the use of accelerated radiation treatment versus the conventional regimen for qualifying patients. The research found that 75% of radiation oncologists administered a conventional course of treatment (≥ 5 weeks) in a majority of their cases, to patients who were eligible to complete treatment in just 3-4 weeks.
Greater Visibility Can Promote More Meaningful Decision Making
At the forefront of treatment decisions should be visibility among physicians on how their practice pattern compares with that of their peers and latest medical studies and guidelines. Research shows that such visibility can lead to meaningful change in providers’ practice patterns, creating a reduction in unnecessary care. For example, a program informing radiation oncologists of their use of a prolonged course of radiation relative to their peers resulted in a 20% average decrease in prolonged course use.
As patients and their oncologists weigh the pros and cons of mastectomy versus lumpectomy with radiation therapy, the option of accelerated radiation therapy may remove one worry for women who are looking for alternatives to breast removal.