Decision involvement and receipt of mastectomy among racially and ethnically diverse breast cancer patients

Abstract

Background: Few studies have evaluated the association between patient decision involvement and surgery received among racially and ethnically diverse patients or patients' attitudes about surgery and the role of family and friends in surgical treatment choices.

Methods: Women diagnosed with nonmetastatic breast cancer from June 2005 through February 2007 and reported to the Los Angeles or Detroit Surveillance, Epidemiology, and End Results registries were mailed a survey after diagnosis (N = 3133). Latina and African American women were oversampled. The response rate was 72.4%. The analytic sample (N = 1651) excluded those with stage IIIA or higher disease, self-reported clinical contraindications to breast-conserving surgery with radiation, and unclear race or ethnicity. The dependent variable was receipt of mastectomy initially. The primary independent variables were patient involvement in decision making, race or ethnicity, attitudes about recurrence, the effects of radiation, the impact of surgery on body image, and the role of others in decision making. Latinas were categorized as low or high acculturated. The association between patient involvement in decision making and the receipt of mastectomy was evaluated using logistic regression while controlling for other independent variables. All statistical tests were two-sided.

Results: The analytic sample was 23.9% Latina (12.0% low acculturated, 11.9% high acculturated), 27.1% African American, and 48.9% white, and 17.2% received a mastectomy initially. For each racial or ethnic group, more women who reported a patient-based decision received mastectomy than those who reported a shared or surgeon-based decision (P = .022 for low-acculturated Latinas, P < .001 for other groups). Women who reported that concerns about recurrence or radiation effects were very important in their surgery decision were more likely to receive mastectomy than those less concerned (for recurrence concerns, estimated relative risk [RR] = 1.66, 95% confidence interval [CI] = 1.28 to 2.10; for radiation concerns, estimated RR = 2.35, 95% CI = 1.88 to 2.85). Women who reported that body image concerns and their spouse's opinion were very important in their surgery decision less often received mastectomy than those less concerned about body image or who placed less weight on their spouse's opinion (for body image concerns, estimated RR = 0.47, 95% CI = 0.30 to 0.74; for spouse's opinion, estimated RR = 0.53, 95% CI = 0.36 to 0.78).

Conclusion: Greater patient involvement in decision making was associated with receipt of mastectomy for all racial and ethnic groups. Patient attitudes about surgery and the opinions of family and friends contribute to surgical choices made by women with breast cancer.

Figure 1

Study flow diagram. SEER = Surveillance, Epidemiology, and End Results.

Figure 2

Association between patient involvement in decision making and receipt of mastectomy, by race and ethnicity. Includes women with stage 0–II breast cancer and no clinical contraindications to breast-conserving surgery with radiation (N = 1651). P values are based on χ² tests (two-sided) for differences in decision involvement and receipt of mastectomy for each racial or ethnic group.

Figure 3

Association between patient attitudes about surgery and receipt of mastectomy. Includes women with stage 0–II breast cancer and no clinical contraindications to breast-conserving surgery with radiation (N = 1651). P values are based on χ² tests (two-sided) for differences in degree of importance of each attitude (not/a little vs quite/very important) in surgical decision making and receipt of mastectomy.