title: Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011.
abstract: OBJECTIVE
  Bilateral mastectomy is increasingly used to treat unilateral breast cancer. Because it may have medical and psychosocial complications, a better understanding of its use and outcomes is essential to optimizing cancer care.
  
  
  OBJECTIVE
  To compare use of and mortality after bilateral mastectomy, breast-conserving therapy with radiation, and unilateral mastectomy.
  
  
  METHODS
  Observational cohort study within the population-based California Cancer Registry; participants were women diagnosed with stages 0-III unilateral breast cancer in California from 1998 through 2011, with median follow-up of 89.1 months.
  
  
  METHODS
  Factors associated with surgery use (from polytomous logistic regression); overall and breast cancer-specific mortality (from propensity score weighting and Cox proportional hazards analysis).
  
  
  RESULTS
  Among 189,734 patients, the rate of bilateral mastectomy increased from 2.0% (95% CI, 1.7%-2.2%) in 1998 to 12.3% (95% CI, 11.8%-12.9%) in 2011, an annual increase of 14.3% (95% CI, 13.1%-15.5%); among women younger than 40 years, the rate increased from 3.6% (95% CI, 2.3%-5.0%) in 1998 to 33% (95% CI, 29.8%-36.5%) in 2011. Bilateral mastectomy was more often used by non-Hispanic white women, those with private insurance, and those who received care at a National Cancer Institute (NCI)-designated cancer center (8.6% [95% CI, 8.1%-9.2%] among NCI cancer center patients vs 6.0% [95% CI, 5.9%-6.1%] among non-NCI cancer center patients; odds ratio [OR], 1.13 [95% CI, 1.04-1.22]); in contrast, unilateral mastectomy was more often used by racial/ethnic minorities (Filipina, 52.8% [95% CI, 51.6%-54.0%]; OR, 2.00 [95% CI, 1.90-2.11] and Hispanic, 45.6% [95% CI, 45.0%-46.2%]; OR, 1.16 [95% CI, 1.13-1.20] vs non-Hispanic white, 35.2% [95% CI, 34.9%-35.5%]) and those with public/Medicaid insurance (48.4% [95% CI, 47.8%-48.9%]; OR, 1.08 [95% CI, 1.05-1.11] vs private insurance, 36.6% [95% CI, 36.3%-36.8%]). Compared with breast-conserving surgery with radiation (10-year mortality, 16.8% [95% CI, 16.6%-17.1%]), unilateral mastectomy was associated with higher all-cause mortality (hazard ratio [HR], 1.35 [95% CI, 1.32-1.39]; 10-year mortality, 20.1% [95% CI, 19.9%-20.4%]). There was no significant mortality difference compared with bilateral mastectomy (HR, 1.02 [95% CI, 0.94-1.11]; 10-year mortality, 18.8% [95% CI, 18.6%-19.0%]). Propensity analysis showed similar results.
  
  
  CONCLUSIONS
  Use of bilateral mastectomy increased significantly throughout California from 1998 through 2011 and was not associated with lower mortality than that achieved with breast-conserving surgery plus radiation. Unilateral mastectomy was associated with higher mortality than were the other 2 surgical options.
authors.affiliation: Department of Medicine, Stanford University School of Medicine, Stanford, California2Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California.
authors.forename: Allison W
authors.initials: AW
authors.lastname: Kurian
authors.affiliation: Cancer Prevention Institute of California, Fremont.
authors.forename: Daphne Y
authors.initials: DY
authors.lastname: Lichtensztajn
authors.affiliation: Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California3Cancer Prevention Institute of California, Fremont.
authors.forename: Theresa H M
authors.initials: TH
authors.lastname: Keegan
authors.affiliation: Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California3Cancer Prevention Institute of California, Fremont.
authors.forename: David O
authors.initials: DO
authors.lastname: Nelson
authors.affiliation: Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California3Cancer Prevention Institute of California, Fremont.
authors.forename: Christina A
authors.initials: CA
authors.lastname: Clarke
authors.affiliation: Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California3Cancer Prevention Institute of California, Fremont.
authors.forename: Scarlett L
authors.initials: SL
authors.lastname: Gomez
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000401:mortality* / Q000601:surgery*; D002140:California / Q000453:epidemiology; D015331:Cohort Studies; D017558:Elective Surgical Procedures / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D015412:Mastectomy, Segmental / Q000706:statistics & numerical data*; D008875:Middle Aged; D018714:Radiotherapy, Adjuvant; D012042:Registries / Q000706:statistics & numerical data; D012306:Risk; D018426:SEER Program