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International Journal of Surgical Oncology
Volume 2012, Article ID 127854, 9 pages
Research Article

Survival Implications Associated with Variation in Mastectomy Rates for Early-Staged Breast Cancer

1College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA
2College of Public Health, University of Iowa, Iowa City, IA 52242, USA
3Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA
4Eshelman School of Pharmacy, University of North Carolina, Chapell Hill, NC 27599, USA
5Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA 02115, USA
6Division of General Internal Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA 02120, USA

Received 23 March 2012; Revised 23 May 2012; Accepted 25 June 2012

Academic Editor: Steven Heys

Copyright © 2012 John M. Brooks et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Despite a 20-year-old guideline from the National Institutes of Health (NIH) Consensus Development Conference recommending breast conserving surgery with radiation (BCSR) over mastectomy for woman with early-stage breast cancer (ESBC) because it preserves the breast, recent evidence shows mastectomy rates increasing and higher-staged ESBC patients are more likely to receive mastectomy. These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage. These beliefs may persist because the randomized controlled trials (RCTs) that served as the basis for the NIH guideline were populated mainly with lower-staged patients. Our objective is to assess the survival implications associated with mastectomy choice by patient alignment with the RCT populations. We used instrumental variable methods to estimate the relationship between surgery choice and survival for ESBC patients based on variation in local area surgery styles. We find results consistent with the RCTs for patients closely aligned to the RCT populations. However, for patients unlike those in the RCTs, our results suggest that higher mastectomy rates are associated with reduced survival. We are careful to interpret our estimates in terms of limitations of our estimation approach.