Reviewers: John Han-Chih Chang, MD and Kenneth Blank, MD
Source: Journal of the American Medical Association 1998; Volume 279: pages 762 - 766.
Cancer treatment can take on various forms. It can include surgery, radiation therapy or chemotherapy. Recommendations on what is required to treat the certain cancer is influenced by extent of disease, medical condition of the patient, and other factors, not the least of which is patient preference. There are specific cancers in which one type oftreatment is as equally efficacious as the others. Early stage prostate and breast cancer are among those that have more than one equally curativemodalities.
Public figures are influential in their lifestyles and their life'schoices, especially when medical decisions are involved. Afflicted with early stage prostate cancer, General H. Norman Schwartzkopf had successfulradical prostatectomy (surgery), while Fortune writer Andy Grove went theroute of radiation therapy, also successfully. Does this affect what men will choose when faced with the same decision?
Nancy Reagan was found to have an early stage breast cancer in late 1987. She eventually underwent a modified radical mastectomy according to this latest JAMA article. What effect, if any, does her choice have on the decisions made by the general population when such a public figure selects one type of cancer treatment over another? This question is evaluated in this article based on data from early breast cancer patients in the 1980's to 1990's.
The author gathered information from databases of the Surveillance, Epidemiology, and End Results (SEER) tumor registry and the Medicare Part Acharge data. The SEER tumor registry draws its cohort from the cancer patients in Connecticut, Hawaii, Iowa, New Mexico, Utah, Atlanta (GA),Detroit (MI), San Francisco-Oakland (CA) and Seattle-Puget Sound (WA). Over 80,000 women with breast cancer over the age of 30 spanning 1983 to 1990 were selected to be evaluated retrospectively from the SEER tumor registry. The Medicare Part A cohort spanned between 1987 to 1988. Again 80,000women age 65 or older with the diagnosis of breast cancer were studied fromthis population.
The data was evaluated by quarter years. The numbers of patients choosingone treatment over the other was documented for each quarter year period. Many variables were studied in correlation with the choice of treatmentmodality.
Based on the SEER tumor registry database, there has been a steady increase in the percentage of patients that choose breast conservation surgery and definitive radiation therapy. In figure 1 of the article, the rate of breast conservation therapy in 1983 was 14% with a rise to approximately 35% by 1990. There was a small drop in the rate of breast conservation therapy from approximately 28% to 22% in the two quarter-year periods following Mrs. Reagan's modified radical mastectomy. This was calculated to be a decrease of 25% from the 1987 second and third quarter-year rate. Various demographic groups were analyzed, and it was discovered that the decrease was most apparent among women aged 50 to 79 years. The decrease was more apparent among white women and nearly non-existent in African-American women. The return of the steady increased incidence of breast conservation therapy was more readily seen in the more affluent and better-educated women.
Also, based on the SEER tumor registry data, the largest drop in breast conservation therapy utilization was seen in the 65 to 79 year oldrange. Thus, Medicare data seemed to be very applicable. Based on quarterly year assessments, there was a drop of 24.5% in the usage of breast conservation. The decrease was greatest in the South Atlantic and East South Central regions.
There have been two well published trials that have established the equivalent efficacy of modified radical mastectomy and breast conservationsurgery followed by definitive radiation therapy. Both the NCI-Milan trial(Veronesi et al. World Journal of Surgery 1994) and the NSABP B-06 (Fisheret al. New England Journal of Medicine 1995) demonstrated similar overallsurvival rates between the two treatment modalities.
Because of the equivalence of the treatments for early stage breast cancer, the choice is usually a personal one made by the patient to suit her lifestyle and peace of mind. Sometimes what others do or say, especially public figures, influences our daily life decisions. It appears from this article that it have some effect on breast cancer patients that were of lower income and educational status and similar demographically to Mrs. Reagan - aged 50 to 79 years and white. The women with the higher educational background in the quarter-year periods following trended away from Mrs. Reagan's influence more quickly than others.
In life, public figures can be misconstrued as role models. Their lifestyles and decisions are adopted by general population, because they are the standard that one is comparing him or herself. It appears in the case of Mrs. Reagan's choice to pursue mastectomy lead to a trend (significant or not) away from breast conservation therapy. Whether this is counterproductive or not is a very subjective question. What is important to remember for both patient and physician alike - when making a decision on medical care, be informed about the treatment's technical aspects, efficacy and side effects, NOT the celebrity who might have had itdone.