Can You Have Breast Cancer and Avoid Surgery
Ann Surg. 2005 Aug; 242(2): 276–280.
Patients' Refusal of Surgery Strongly Impairs Breast Cancer Survival
Helena Grand. Verkooijen
From the *Geneva Cancer Registry, Institute for Social and Preventive Medicine, Geneva University; †Department of Gynecology and Obstetrics, Geneva Academy Hospitals; ‡Division of Radio-Oncology, Geneva University Hospitals; and §Division of Oncology, Geneva Academy Hospitals, Switzerland.
Gérald K. Fioretta
From the *Geneva Cancer Registry, Institute for Social and Preventive Medicine, Geneva Academy; †Department of Gynecology and Obstetrics, Geneva Academy Hospitals; ‡Division of Radio-Oncology, Geneva Academy Hospitals; and §Division of Oncology, Geneva Academy Hospitals, Switzerland.
Elisabetta Rapiti
From the *Geneva Cancer Registry, Found for Social and Preventive Medicine, Geneva University; †Department of Gynecology and Obstetrics, Geneva University Hospitals; ‡Segmentation of Radio-Oncology, Geneva Academy Hospitals; and §Partitioning of Oncology, Geneva University Hospitals, Switzerland.
Hervé Bonnefoi
From the *Geneva Cancer Registry, Found for Social and Preventive Medicine, Geneva Academy; †Section of Gynecology and Obstetrics, Geneva University Hospitals; ‡Sectionalisation of Radio-Oncology, Geneva Academy Hospitals; and §Segmentation of Oncology, Geneva University Hospitals, Switzerland.
Georges Vlastos
From the *Geneva Cancer Registry, Institute for Social and Preventive Medicine, Geneva University; †Department of Gynecology and Obstetrics, Geneva University Hospitals; ‡Sectionalization of Radio-Oncology, Geneva University Hospitals; and §Partition of Oncology, Geneva Academy Hospitals, Switzerland.
John Kurtz
From the *Geneva Cancer Registry, Found for Social and Preventive Medicine, Geneva University; †Department of Gynecology and Obstetrics, Geneva Academy Hospitals; ‡Sectionalization of Radio-Oncology, Geneva Academy Hospitals; and §Sectionalisation of Oncology, Geneva University Hospitals, Switzerland.
Peter Schaefer
From the *Geneva Cancer Registry, Institute for Social and Preventive Medicine, Geneva Academy; †Section of Gynecology and Obstetrics, Geneva University Hospitals; ‡Division of Radio-Oncology, Geneva Academy Hospitals; and §Division of Oncology, Geneva University Hospitals, Switzerland.
André-Pascal Sappino
From the *Geneva Cancer Registry, Plant for Social and Preventive Medicine, Geneva University; †Department of Gynecology and Obstetrics, Geneva University Hospitals; ‡Segmentation of Radio-Oncology, Geneva University Hospitals; and §Sectionalisation of Oncology, Geneva Academy Hospitals, Switzerland.
Hyma Schubert
From the *Geneva Cancer Registry, Establish for Social and Preventive Medicine, Geneva University; †Department of Gynecology and Obstetrics, Geneva University Hospitals; ‡Division of Radio-Oncology, Geneva University Hospitals; and §Sectionalization of Oncology, Geneva University Hospitals, Switzerland.
Christine Bouchardy
From the *Geneva Cancer Registry, Constitute for Social and Preventive Medicine, Geneva Academy; †Department of Gynecology and Obstetrics, Geneva Academy Hospitals; ‡Division of Radio-Oncology, Geneva University Hospitals; and §Division of Oncology, Geneva University Hospitals, Switzerland.
Abstract
Objective:
To compare patient and tumor characteristics and survival between women who refused and women who accepted surgery for breast cancer.
Summary Background Data:
Surgery represents the central component of curative chest cancer treatment, only some women decide not to undergo surgery. Recent studies on the prognosis of non operated breast cancer are nonexistent.
Patients and Methods:
This report included all 5339 patients aged < 80 years with nonmetastatic chest cancer recorded at the Geneva Cancer Registry between 1975 and 2000. Nosotros consulted the clinical files of all nonoperated women to identify those who refused surgery. Patients who refused surgery were compared with those accepting surgery using logistic regression. The effect of refusal of surgery on breast cancer mortality was evaluated past Cox proportional hazards analysis.
Results:
Lxx patients (1.3%) refused surgery. These women were older, more oftentimes unmarried, and had larger tumors. Overall, 37 (53%) women had no treatment, 25 (36%) hormone-therapy alone, and 8 (xi%) other adjuvant treatments alone or in combination. Five-yr specific breast cancer survival of women who refused surgery was lower than that of those who accepted (72%, 95% confidence interval, 60%–84% versus 87%, 95% confidence interval, 86%–88%, respectively). Later on accounting for other prognostic factors including tumor characteristics and stage, women who refused surgery had a two.ane-fold (95% confidence interval, ane.5–iii.1) increased risk to die of breast cancer compared with operated women.
Conclusions:
Women who refuse surgery for breast cancer have a strongly dumb survival. This information might help patients who are hesitant toward surgery make a amend informed conclusion.
Breast cancer treatment involves multidisciplinary collaboration. For each individual patient, the handling proposal is non merely adapted to the characteristics of the patient and tumor (ie, age, stage, grade, and receptor status), simply also to the patients' preference. To make a well-informed conclusion, every patient should be enlightened of both the beneficial and adverse effects of the different treatment options.
Despite the increasing efficacy of radiotherapy, chemotherapy, and hormone therapy, these modalities are still adjuvant treatments and until now, surgery remains the central component of curative treatment of breast cancer.
For professionals, chest surgery is intuitively the all-time way to treat local affliction. Yet, hard evidence in the grade of contempo studies on the prognosis of nonoperated breast cancer is nonexistent. For women, withal, surgery remains a mutilating intervention, even in case of breast-conserving surgery. Some women choose non to be operated and physicians have only subjective arguments to convince their patients to take surgery.
The aim of this population-based study was to appraise the characteristics of women who decide not to undergo surgery for chest cancer and to judge the impact of this decision on breast cancer-specific survival.
PATIENTS AND METHODS
We used data from the Geneva cancer registry, which records all incident cancers occurring in the population of the canton (approximately 420,000 inhabitants). The registry collects data from various sources, and is considered accurate, as attested by its very low pct (<2%) of cases recorded from decease certificates but.1 Every infirmary, pathology laboratory, and physician are requested to report all cancer cases. Trained registrars systematically abstract data from medical and laboratory files. Physicians regularly receive questionnaires to secure missing clinical and therapeutic data. Decease certificates are consulted systematically.
Recorded information include socio-demographic information, method of discovery, tumor characteristics (coded according to the International Nomenclature of Diseases for Oncologyii), stage of disease at diagnosis, treatment during the first 6 months after diagnosis, survival status, and cause of death.
The registry regularly assesses survival, taking every bit reference date the date of confirmation of diagnosis or the appointment of hospitalization (if it preceded the diagnosis and was related to the affliction). In improver to passive follow-upwardly (standard examination of death certificates and hospital records), active follow-up is performed yearly using the files of the Cantonal Population Office (part in charge of the registration of the resident population). Crusade of expiry is taken from clinical records and coded according to the World Health Organization's classification.3
We included all patients younger than 80 years with nonmetastatic breast cancer recorded at the Geneva Cancer Registry between 1975 and 2000. We nerveless additional data from the clinical files of all women who did not undergo surgery to differentiate between those who refused surgery and those who did not accept surgery for other reasons. In addition, nosotros recorded the reasons for refusing surgery.
We excluded patients who did not have surgery because of other reasons than refusal (northward = 133), for example, comorbidity or complete response after neoadjuvant chemotherapy.
Clinical tumor size was classified as T0 (tumor non palpable), T1 (<ii cm), T2 (2–5 cm), T3 (>5cm), T4 (invasion of chest wall/peel and inflammatory carcinoma), and unknown. Lymph node invasion was classified equally N0 (no clinical testify of lymph node metastases), N+ (clinical evidence of lymph node metastases), and unknown. Social class was based on the patient'due south last occupation or, for unemployed women, that of the spouse. Other variables ofinterest were age, civil status, period, and method of discovery.
Statistical Analysis
We used a example-command approach to compare the characteristics of women who refused surgery with those of women who accepted surgery: cases were patients who refused surgery and controls all other patients. Nosotros generated odds ratios of refusing surgery using unconditional multivariate logistic regression assay. Outset, we estimated the outcome of each variable of interest in a univariate way to place factors significantly linked refusal of surgery. To guess which variables were independently linked to refusal, we adapted the model on all variables with a significant event in univariate analysis.
Disease-specific survival was studied past the actuarial method. The run a risk to die of breast cancer among women who refused surgery compared with women who accepted surgery was evaluated by Cox proportional hazards assay accounting only for age (age-adjusted effect), and for all factors linked to breast cancer survival (multiadjusted effect). Statistical analyses were performed with SPSS software (SPSS 10 version, Chicago, IL).
RESULTS
Amidst the 5339 women younger than fourscore years and diagnosed with nonmetastatic breast cancer during the study period, seventy (i.3%) decided not to undergo surgery. 16 patients (23%) refused considering of psychologic problems (mainly depression), x (14%) chose to undergo alternative therapy, half-dozen women (8.five%) chose not to undergo surgery because of other medical problems, 1 (one.four%) adult female was too afraid to undergo surgery, 1 (ane.iv%) considered herself too old (77 years) and 1 (1.4%) woman refused because she did non accept medical insurance. The remaining 35 (l%) women unambiguously refused surgery, merely their reasons were unclear.
20-five women (36%) were treated with hormone therapy only, 2 (2.8%) were treated with radiotherapy, ii (2.8%) with chemotherapy, and four (five.7%) received combinations of chemotherapy, radiotherapy, and tamoxifen. The bulk of the patients (n = 37, 53%) did not receive any type of treatment. 14 women (20%) who refused surgery had a surgical intervention more than than 6 months afterdiagnosis (median follow-upwardly, 48 months; range, 6–93 months), mostly because of progression of local affliction.
Table ane presents the characteristics of the women who refused surgery and of women who accustomed surgery. Women who refused surgery were on average 10 years older (68 years) compared with women who accepted surgery (58 years). They were more ofttimes single and they were more frequently treated in the public hospitals. The tendency to refuse surgery was relatively constant during the written report period, merely during the period 1991 to 1995, patients were somewhat more than likely to pass up surgery. The tumors of women who refused surgery were approximately 5 times (multiadjusted odds ratio, v.3; 95% confidence interval [CI], two.9–9.8) more likely to be detected fortuitously, for example, during the investigation of another physical condition. They too had more often large T4 tumors, and their clinical lymph node status was more than frequently unknown.
Tabular array 1. Comparison of Breast Cancer Patients Who Chose Non to Undergo Surgery and Those Who Accepted Surgery and Factors Linked to Refusal of Surgery
Effigy one shows the disease-specific survival curves of women refusing and women accepting surgery. Afterwards 5 years, the illness-specific survival was 72% (95% CI, lx%–84%) for women who refused surgery and 87% (95% CI, 86%–88%) for women who accepted surgery (P < 0.01). Afterward 10 years, the disease-specific survival rates were 36% (95% CI, twenty%–52%) and 75% (95% CI, 74%–76%), respectively (P < 0.001). In the subgroup of women who received radiotherapy, chemotherapy, or hormone therapy (solitary or in combination) (n = 33), the disease-specific survival rates were 81% (95% CI, 65%–97%) at 5 years and 28% (95% CI, 2%–54%) at x years. In the group of patients who did non receive any treatment at all, these percentages were not significantly different: 64% (95% CI, 58%–80%) and 39% (95% CI, xx%–58%), respectively. Amongst the 14 women who had a surgical intervention more than vi months later diagnosis, the 5- and 10-year disease-specific survival rates were 92% (95% CI, 78%–100%) and 43% (95% CI, 16%–seventy%), respectively.
FIGURE 1. Observed chest cancer-specific survival of breast cancer patients who chose not to undergo surgery and those who accepted surgery.
The age-adjusted take a chance to dice of breast cancer for women who refused surgery compared with women who accepted surgery was 3-fold increased (hazard ratio, iii.0; 95% CI, 2.1–4.ii). Later adjusting for catamenia of diagnosis, social grade, method of discovery, sector of care, clinical tumor size, clinical lymph node status, and use of nonsurgical therapy (tamoxifen, radiotherapy, chemotherapy alone or in combination), the risk to dice of breast cancer was still ii-fold increased (gamble ratio, 2.1; 95% CI, 1.5–3.1) among women who refused surgery.
Word
This study is the kickoff to quantify the bear upon of patient refusal of surgery on the survival of breast cancer. It clearly demonstrates that women who refuse surgery accept a doubled risk to dice of breast cancer, regardless of personal factors, tumor characteristics, stage, and nonsurgical treatment.
This study is not randomized and we realize that, fifty-fifty later on adjusting for all available variables linked to patient refusal or prognosis, we cannot rule out a choice bias related to unrecorded factors. Even so, because clinical trials are ethically unfeasible, only observational studies tin can evaluate the effect of patient refusal of surgery on the outcome of breast cancer.
The importance of surgery for curative treatment of breast cancer was already recognized by the Greek physician Galen of Pergamum (130–200 A.D.).four He stated that cancer can only be cured by surgical removal of the tumor where it borders on the healing tissue. Over the past centuries, surgical techniques accept evolved enormously and have gone from mutilating amputations of breast, peel, pectoral muscle, and axillary lymph nodes to breast-conserving tumorectomy followed by spotter lymph node biopsy.4 Still, surgery for breast cancer is always, to a larger or lesser extent, disfiguring and often affects the woman'southward torso image, cocky-esteem, and sexuality.5,6 Nevertheless, 99% of all Geneva women accepted a surgical intervention.
The women who chose not to undergo surgery were quite different from their accepting counterparts. They were older, more than ofttimes single, and more often treated in the public hospitals. In improver, we observed that women who had their tumors detected fortuitously were at increased risk to refuse a surgical intervention. We cannot conclude whether this is due to the sudden and unprepared confrontation with breast cancer or to the fact that women who do not accept surgery accept a trend to neglect their disease and exercise not consult a doc when they have symptoms. Anyhow, physicians should exist aware that this patient category is at increased take a chance to refuse surgery and that, for these patients, they may need to emphasize the importance of surgery.
We also observed that women who refused surgery had larger tumors. Once again, the design of this written report does not allow us to conclude whether this reflects a tendency of women who refuse surgery to neglect their affliction or whether large tumor size predisposes to refusing surgery.
There are definitively other factors that affect the decision to undergo surgery or not, which we did not have into account. Siminoff and Fetting investigated factors affecting the decision to undergo adjuvant treatment of breast cancer.7 They found that the more information regarding the treatment and its side furnishings was given to the patient, the less likely she was to take adjuvant treatment. They besides saw that the stronger the doctor recommended the treatment, the more likely the patient was to accept the proposed therapy. Women who refused adjuvant therapy were more than willing to take risks and were generally better educated. In our study, nosotros had no information on educational level, but nosotros observed no pregnant difference in social course (usually related to level of education) between women refusing or accepting surgery. In that location was indeed a nonsignificant tendency for the opposite: an increased risk of refusing surgery among women of lower social class.
Well-nigh women who refused surgery did not receive any therapy at all. At that place are simply very few studies bachelor on the natural history of chest cancer, ie, the outcome of breast cancer without therapy. Bloom et al studied a series of 250 women with untreated breast cancer (diagnosed between 1805 and 1933) and constitute particularly poor survival rates: 18% at 5 years and iii.6% at 10 years.8 Several groups studied the effect of omitting surgery, only using radiotherapy, chemotherapy, and tamoxifen, alone or in combination, on survival of patients with operable breast cancer. Some reported that radiotherapy lonely or in combination with chemotherapy is equivalent to breast cancer treatment that includes surgery.nine–13 However, none of these studies included an appropriate control group (ie, women treated with surgery), and information technology is therefore impossible to depict whatsoever conclusions on the upshot of omitting surgery on breast cancer prognosis. One more contempo study looked at the outcome of surgery among patients who had a complete response after neoadjuvant chemotherapy.xiv In this selected population, surgery appeared to reduce the local recurrence rate but did not ameliorate survival. However, this study was not randomized, and although some important prognostic characteristics seemed to exist well balanced betwixt operated and nonoperated patients, it can not be excluded that "healthier" patients were selected for handling without surgery.
It is of swell importance that women are entirely involved in the conclusion-making process concerning their handling, and we acknowledge that they have the full right to choose not to undergo surgery. With the results of this study, physicians volition be able to improve explicate the importance of surgery to patients who are hesitant toward chest surgery. This might assist these women make a better informed determination.
Footnotes
Supported by a PROSPER Grant (3233-069350) from the Swiss National Science Foundation (to Dr. H.Grand.V.).
Reprints: Christine Bouchardy, Physician, PhD, 55 Bld de la Cluse, 1205 Geneva, Switzerland. East-mail: hc.eginu.psmi@ningamydrahcuob.enitsirhc.
REFERENCES
one. Bouchardy C. Switzerland, Geneva, In: Parkin DM, Whelan SL, Ferlay J, et al, eds. Cancer Incidence in Five Continents, vol. 7. Lyon, France: International Agency for Research on Cancer, 1997:666–669. [Google Scholar]
2. ICD-O. International Nomenclature of Diseases for Oncology, 1st ed. Geneva: World Health Organization, 1976. [Google Scholar]
3. ICD-O. International Classification of Diseases for Oncology, 1st ed. Geneva: World Health Arrangement, 1967. [Google Scholar]
4. Ariel IM, The function of surgery in handling of breast cancer: historical review and electric current status. In: Ragaz J, Ariel IM, eds. High-Chance Chest Cancer Therapy. Berlin: Springer-Verlag, 1991:87–107. [Google Scholar]
v. Arora NK, Gustafson DH, Hawkins RP, et al. Impact of surgery and chemotherapy on the quality of life of younger women with chest carcinoma: a prospective study. Cancer. 2001;92:1288–1298. [PubMed] [Google Scholar]
6. Ganz PA, Kwan L, Stanton AL, et al. Quality of life at the end of main handling of breast cancer: first results from the moving beyond cancer randomized trial. J Natl Cancer Inst. 2004;96:376–387. [PubMed] [Google Scholar]
7. Siminoff LA, Fetting JH. Factors affecting treatment decisions for a life-threatening affliction: the case of medical treatment of breast cancer. Soc Sci Med. 1991;32:813–818. [PubMed] [Google Scholar]
eight. Bloom HJ, Richardson WW, Harries EJ. Natural history of untreated chest cancer (1805–1933): comparison of untreated and treated cases co-ordinate to histological course of malignancy. BMJ. 1962;5299:213–221. [PMC free article] [PubMed] [Google Scholar]
9. Van Limbergen E, Van der SE, Van den BW, et al. Local control of operable chest cancer after radiotherapy alone. Eur J Cancer 1990;26:674–679. [PubMed] [Google Scholar]
ten. Jacquillat C, Weil M, Baillet F, et al. Results of neoadjuvant chemotherapy and radiations therapy in the chest-conserving treatment of 250 patients with all stages of infiltrative breast cancer. Cancer. 1990;66:119–129. [PubMed] [Google Scholar]
11. Dubois JB, Salomon A, Gary-Bobo J, et al. Sectional radical radiations therapy in breast carcinoma. Radiother Oncol. 1991;twenty:24–29. [PubMed] [Google Scholar]
12. Jacquillat C, Weil M, Auclerc M, et al. Neoadjuvant chemotherapy in the conservative direction of breast cancer: a study of 252 patients. Recent Results Cancer Res. 1989;115:36–42. [PubMed] [Google Scholar]
thirteen. Amalric R, Santamaria F, Robert F, et al. Radiation therapy with or without primary express surgery for operable chest cancer: a 20-year experience at the Marseilles Cancer Institute. Cancer. 1982;49:30–34. [PubMed] [Google Scholar]
14. Band A, Webb A, Ashley S, et al. Is surgery necessary after consummate clinical remission following neoadjuvant chemotherapy for early breast cancer? J Clin Oncol. 2003;21:4540–4545. [PubMed] [Google Scholar]
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357734/
0 Response to "Can You Have Breast Cancer and Avoid Surgery"
Post a Comment