Surgery for breast cancer in St. John's : the statistics, the surgeons' view, the patients' view

Walsh Dicks, Elizabeth L. (1999) Surgery for breast cancer in St. John's : the statistics, the surgeons' view, the patients' view. Masters thesis, Memorial University of Newfoundland.

[English] PDF (Migrated (PDF/A Conversion) from original format: (application/pdf)) - Accepted Version Available under License - The author retains copyright ownership and moral rights in this thesis. Neither the thesis nor substantial extracts from it may be printed or otherwise reproduced without the author's permission. Download (15MB) [English] PDF - Accepted Version Available under License - The author retains copyright ownership and moral rights in this thesis. Neither the thesis nor substantial extracts from it may be printed or otherwise reproduced without the author's permission. (Original Version)

Abstract

Background: Surgical management of localized breast cancer has changed dramatically in the past two decades. Randomized clinical trials of women with stage I or II lesions have shown there is no significant difference in survival rates between women receiving modified radical mastectomy (MRM) or breast conserving surgery (BCS). However, there are substantial regional variations in types of surgery for breast cancer. It would then seem that surgeons and patients' views could help explain such variations. This study aimed to clarity the numbers of MRM and of BCS performed within the Health Care Corporation of St. John's, Newfoundland during the years 1994-1997. In addition, the aim was to contrast the surgeons' view of the different types of surgical interventions for breast cancer with the views of women who had undergone different types of surgery. -- Method: The records of all surgeries for breast cancer, irrespective of staging of the disease, were extracted from the Health Care Corporation of St. John's (HCCSJ) for the period of 1994-1997 and coded according to the Canadian classification of diagnostic, therapeutic and surgical procedures (Statistics Canada, 1986). Chart audits were completed to ensure accuracy of the extracted data. All surgeons within the general surgery program of the HCCSJ who did breast cancer surgery regularly and consented to participate in the study completed a short questionnaire and were interviewed about their own surgical practices, their views of the decision making processes of women and which factors they felt impacted these particular patients' choices for surgical intervention for their breast cancer. Four focus groups and one private interview were organized with 21 women who had either MRM or BCS to provide them with the opportunity to discuss their surgery. The interviews and focus groups were taped, transcribed and common themes extracted. -- Results: A total of 363 surgeries were performed for breast cancer within the HCCSJ during 1994-1997. Of these 71.9% were MRM. There was little variation between years at each site but significant differences in rates between sites. MRM was a more common procedure for women from outside the city and for older women. According to the surgeons, most diagnostic visits took place in a hospital clinic and lasted approximately 20 to 30 minutes. They emphasized the importance of the woman's choice and they claimed they always gave women an opportunity for choice. However, a substantial majority of the women were unsure they had been given such an opportunity. The majority of women who underwent MRM stated they did in fact have their minds clearly made up to have a mastectomy regardless of what information the surgeon gave them. They also stated that they chose MRM because they thought of the breast as diseased, were more familiar with this form of surgery and felt it would be better protection from recurrence. Those patients who had received BCS described reaching the decision jointly with their surgeon once all of the options had been described and discussed. -- Conclusions: Modified radical mastectomy is the dominant procedure being performed within the Health Care Corporation of St. John's, Newfoundland. While surgeons may advise women of their options during the diagnostic visit, many of the women may not hear the options because of their heightened anxiety. Alternate ways of informing women of their options are discussed.

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