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Conflicts in Decision-Making for Breast Cancer Surgery

¹ Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
² Department of Medicine, University of Michigan, Ann Arbor, MI, USA
³ Department of Family Medicine and Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
⁴ Department of Health Behavior, School of Public Health, University of Michigan, Ann Arbor, MI, USA
⁵ Departments of Medicine and Health Management and Policy, University of Michigan, Ann Arbor, MI, USA

Correspondence: Address correspondence and reprint requests to: Monica Morrow, MD; E-mail: Monica.Morrow{at}fccc.edu

Background: Little is known about the interaction among surgeons, patients, and other physicians in selecting breast cancer surgery.

Methods: We contacted attending surgeons (n = 456) of a population-based sample of 2645 breast cancer patients diagnosed in Detroit and Los Angeles from December 2001 to January 2003. Eighty percent completed a written survey with clinical scenarios.

Results: The mean surgeon age was 50 years, 50% practiced in a community hospital, and breast cancer averaged 31% of practice volume. The mean number of years in practice was 17.2. Female surgeons made up 14.4% of the sample and 35% of the high-volume surgeons. Conflict with patients and other providers was reported by 58% and 32% of surgeons, respectively. When the patient preferred mastectomy and the surgeon favored BCS, conflict was reported by 49.9% of surgeons. Compared with low-volume surgeons, high-volume surgeons were significantly more likely to report conflict in this scenario (44% vs 62%; P = .047). When another provider preferred mastectomy and the respondent surgeon favored BCS, conflict was reported by 34% of surgeons and was more common for high-volume surgeons (P < .001). In a logistic regression model, surgeon volume and practice setting were strongly associated with conflict in this scenario.

Conclusion: High-volume surgeons and those in cancer centers more frequently endorse current clinical guidelines that favor BCS over mastectomy, resulting in greater conflict with patients. These findings support patient reports that patient choice is a key factor in continued mastectomy use.

Key Words: Breast cancer • Decision making • Breast conserving surgery • Conflict