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Introduction

According to International Agency for Research on Cancer (IARC) statistics, 1 in 8 women in the European Union (27 member states) and the former member United Kingdom will develop breast cancer before the age of 85 years old. In Europe, an average of 20% of breast cancer cases occur in women younger than 50 years old; 36% appear between the ages of 50 and 64, while the remaining cases are reported above this age⁽¹⁾.

Breast cancer is considered to be the most frequent cancer among women across European Union countries, with more than 400,000 cases diagnosed each year. The most important risk factors for breast cancer are considered to be age, genetic predisposition, estrogen replacement therapy, and lifestyle factors, including obesity, physical inactivity, nutrition habits and alcohol consumption⁽²⁾.

Breast cancer is a major public health problem in Romania, representing the first cause of mortality (8.68%) for women between 15 and 49 years old. According to Globocan 2018 statistics, Romania has an annual mortality comparable to the European average, although the reported incidence of breast cancer in Romania is 30% lower.

The long-term results of international, randomized clinical trials have described equivalent survival between the majority of patients with stage I or II breast cancer who had breast-conserving surgery (BCS) followed by radiation therapy (RT) and the group that underwent mastectomy^(3,4). Although more data are required, some observational studies suggest possible improved survival and reduced recurrence rates with BCS^(5-8).

An important aspect to be taken into consideration is that the risk of complications is almost twice as high for women who undergo mastectomy with reconstructive surgery compared to BCS plus radiation therapy⁽⁹⁾. The reasons for BCS-eligible patients to choose mastectomy include reluctance to undergo radiation therapy after BCS and fear of disease recurrence^(10-12). According to the data published so far, there are three categories of women who are more likely to undergo mastectomy: younger women (those under 40 years of age), patients with larger and/or more aggressive tumors, and those who live further from their treatment facility^(13,14).

Due to the reduced risk of cancer recurrence (about 50% at 10 years) and the risk of breast cancer death (almost 20% at 15 years) for patients treated with radiation, BCS is typically followed by radiotherapy⁽⁴⁾.  

Given the particular importance of breast cancer in Romania, we studied a small lot of patients from our region to assess whether the surgical choice of patients with breast cancer could be correlated with global statistics.

Method

Patients treated for breast cancer at the Filantropia Clinical Hospital of Craiova, Romania, over a period of almost 10 years (between August 2007 and March 2017) were included in our retrospective study.

We have gathered data from 85 patients with breast cancer stages ranging from IA to IIIA. The participants were only female patients, there were no male patients whose data corresponded to our eligibility criteria. 

The inclusion criteria were: patients age >18 years old, early-stages (I-IIIA) breast cancer diagnosed, which have underwent radical or breast conservatory surgery. IIIB and IV stages were excluded.

The following data were recorded for each patient: baseline information (age and sex), as well as diagnosis date, disease stage and TNM classification. The information about neoadjuvant chemo- and radiotherapy, adjuvant chemo- and radiotherapy were also recorded. We entered data regarding each patient surgery type: radical or conservatory. The informed consent was obtained from each patient. The analysis was performed with descriptive statistics – mean, relative frequency, standard deviation.

Results

From a total of 95 patients, 85 were included in the study after signing the informed consent. The remaining 10 patients (10.53%) were diagnosed with stages IIIB (8.42%) and IV (2.11%) breast cancer, and did not fulfill the inclusion criteria.

The mean age of the study population was 53 years old (range: 27-87 years old). The patients diagnosed with early stages (IA-IIIA) breast cancer underwent either BCS or mastectomy, as follows: 28 patients (32.94%) underwent breast-conserving surgery, while the remaining 57 patients (67.05%) had mastectomy (Figure 1). The median age of the subgroup of patients who underwent BCS and of the subgroup that had mastectomy is relatively close: 52.1 years old for BCS versus 53.4 years old – the average age of the mastectomy surgery.

The distribution of cases by stage at diagnosis for breast cancer is presented in Figure 2, while the correlation between stages and the surgery type is depicted in Figure 3. More advanced stages were associated with higher rates of mastectomy.

The patients were further divided into three categories depending on age: the young subgroup (<50 years old), middle-age subgroup (50-64 years old) and older subgroup (>64 years old). Patients younger than 50 years of age predominantly underwent mastectomy – 65.63% (21 patients), while 34.38% (11 patients) had BCS. Regarding the 50 to 64 years age group, mastectomy was performed on 25 patients (67.57%) versus 12 patients (32.43%) who had BCS. Patients older than 64 years old also generally underwent mastectomy: 11 patients (68.75%), whilst 5 patients (31.25%) had BCS (Figures 4 and 5). There was no significant difference between the age groups in terms of surgical choice.

Discussion

Surgery continues to represent a crucial component in breast cancer treatment, despite the latest developments in medication. Studies analyzing mastectomy versus BCS followed by radiation therapy show comparable overall survival rate and disease-free survival rate for the two operations^(15,16). Additionally, BCS is followed by less surgical complications and increases cosmetic outcome for patients^(17,18). As a result, this procedure is recommended by the US National Institutes for Health for early breast cancer stage and is chosen by 60% of patients in the USA⁽¹⁹⁾. Globally, the percentage of women electing BCS varies. While Europe has similar high rate to USA (73% of patients receive BCS), China has a nationwide rate of 11%^(20,21). Our regional study reveals a decreased rate of breast-conserving surgery (32.94%) compared to European countries and USA.

Studies assessing the sociodemographic factors affecting the choice of surgery reported age as the most frequent, offering multiple explanations as to how age influenced the patients’ decision⁽²²⁾. The most common results show a likelihood for the extremes of diagnostic age to undergo mastectomy. Specifically, increasing age is correlated with a decreasing probability of choosing BCS. Compared with a group of 65 to 69 years old, all older age groups including 70 to 74 years, 75 to 79 years, and 80+ years were less inclined to elect BCS⁽²³⁾. Moreover, the results from two other large studies suggest that younger women also tend to choose BCS. Patients aged less than 40 years and older than 64 years were more likely to undergo mastectomy than 40 to 46 years old age group⁽²⁴⁾. After analyzing a large cohort of over 100,000 patients, it was reported that women younger than 50 years old and those older than 65 years old elected mastectomy far often than those aged 50 to 64 years old⁽²⁵⁾. However, our study shows similar rates for mastectomy across all age groups.

The possible explanations for the reluctance of patients older than 60 to undergo BCS could be the decreased interest in cosmetic results and a greater concern over the effects of radiation therapy on their bodies⁽²⁶⁾. Overall, the main individual belief factors for women to undergo radical breast surgery were fear of cancer recurrence (mastectomy was considered the most reassuring option), a more expedient procedure (it provides a rapid treatment for employment, as well as domestic concerns), and avoiding the potential side effects of radiation therapy^(24,27-30). Conversely, women choosing BCS mentioned body image concerns, equivalent long-term survival, and the lesser extent of the surgery⁽²²⁾.

Furthermore, the clinicopathological factors also play a significant role in the choice of treatment. Among them, a larger tumor size is frequently associated with a higher rate of radical breast surgery. Correspondingly, our study shows an association between more advanced stages and higher rates of mastectomy. The reasons behind this correlation are diverse and can potentially influence the surgeon recommendation. First, a large tumor requires a more challenging surgical procedure and can be associated with a higher rate of re-excision^(31,32). Secondly, the risk of local recurrence increases with the size of the tumor^(33-35). Also, the cosmetic outcome can be less satisfying. Regarding individual belief factors, a large tumor can alter the patients’ understanding of the severity of the neoplasm and their faith in the outcome of a breast-conserving surgery⁽²²⁾. In terms of physician-related factors, increased BCS rates are correlated with surgeons which possess the following characteristics: higher case number, training, as well as female gender⁽²³⁾.

The lack of data on whether the BCS-eligible patients were explicitly given the opportunity to choose between the procedures could have influenced the results of our study and could potentially explain the high rates of mastectomies. It is unclear to what extent the surgeon interfered in the decision-making process. Also, without a long postoperative follow-up interval on the patients, this study is unable to compare the overall survival rate and disease-free survival rate.

Conclusions

There was no significant difference between the age groups in term of surgical choice in the study population. Approximately two thirds of women underwent mastectomy compared to BCS followed by radiotherapy, with similar rates across all age groups. These results could suggest that Romania has lower rates of BCS for breast cancer compared with the European and American averages, while maintaining higher percentages in comparison to Asian countries.

Conflicts of interests: The authors declare no conflict of interests.