Breast-conserving surgery is a treatment modality for early-stage breast cancer that causes less physical disfigurement and psychological trauma to the patient. Many prospective randomized trials have demonstrated that overall and disease-free survival rates for early-stage breast cancer are equivalent after mastectomy or BCS with postoperative radiotherapy [2–4], [8, 9]. There appear to be geographical differences in the surgical treatment of early-stage breast cancer. Evidence suggests that physician recommendation exerts the most significant influence on surgical treatment selection for the majority of women [10].
In this study only 19% of surgeons used BCS in their practice while the remaining 81% performed mastectomy. This concurs with two other studies, performed in Tehran and Isfahan University of Medical Sciences, showing that mastectomy was the most prevalent surgical treatment for breast cancer patients [6, 7]. However, it is arguable that BCS rates would rise in Iran if general surgeons, for example, could benefit from continuing medical education, attend scientific meetings, and have access to modern textbooks and current journals. Discussion of these topics lies beyond the scope of this study. Briefly, it should be noted that there is a National Society of Surgeons in Iran. In addition to other scientific meetings that address oncology issues, members of this society have their own annual and occasional scientific meetings, and usually receive printed educational materials including issues on current technology. At present all surgeons and radiation therapists in teaching hospitals and many working in the private sector are Board-certified. Some modern radiation therapy facilities in Iran are very similar to existing facilities in developed countries. Furthermore, we suspect that predicting patient non-compliance with radiation therapy might be subjective impressions on the part of the surgeons, since there is no evidence or published data to indicate that patient compliance with radiation therapy is low.
The findings indicated that gender had no effect on the performance of BCS. This may be due to the small number of female surgeons in this study. Similarly, in a study comparing rates of BCS between male and female surgeons, no statistically significant difference was found between the two groups [11]. However, it is interesting that in our study, 14 out of the 75 male surgeons (19%) indicated that they routinely perform BCS, while 3 out of the 8 female surgeons (38%) stated that they performed BCS.
We found that the surgeons' age and work experience was not significantly associated with performing BCS; other studies have shown that younger surgeons are more likely to perform BCS. In one retrospective study that reviewed the medical records of 952 patients, it was found that surgeons who graduated after 1960 performed BCS more frequently than those who graduated before 1960 [12]. Another study showed that surgeons who graduated after 1980 performed BCS at a significantly higher rate than those who graduated before 1961 [13]. However, the mean age of our study sample was 55.2 (SD = 12.3) years and the mean duration of work experience was 23.2 years (SD = 12.7). In other words, most of our participants were old; only 17% were relatively young. This might explain why most surgeons in this study stated that they performed mastectomy. This is also consistent with the fact that mastectomy is the most prevalent surgical therapy for breast cancer in our teaching hospitals [6, 7]. However, the findings from the present study indicate that there is a trend towards more BCS at teaching hospitals, and it is very likely that a bigger sample would show a significant difference between teaching hospitals and private institutes.
There was a statistically significant association between the experience of the surgeons (measured by the number of beast cancer patients treated per year) and performance of BCS. Surgeons treating more than 20 breast cancer patients per year had a statistically significant higher BCS rate (P = 0.007). Few studies have reported a correlation between the surgeons' experience and their breast conservation surgery rates. A population-based study found that patients treated by surgeons with higher breast cancer case-loads were more likely to receive breast conservation therapy [14]. A survey of surgeons carried out in 1986 showed no evidence of a relationship between the number of breast surgery operations performed and the rate of conservative surgery; but in a repeat survey in 1990, when the overall conservative surgery rate had risen to 42%, a significant association was found for surgeons treating 20 or more patients per year [13].
In this study, the most common reasons given for avoiding BCS were uncertainty about the results of breast conservation therapy (46.3%), uncertainty about the quality of available radiotherapy services (32%), and probability of patient non-compliance (32%). Other reasons noted by the surgeons were the higher cost of breast conserving therapy (17.9%), non-availability of radiotherapy facilities (25.4%), and insufficiency of experience with the BCS technique (14.9%). A few studies have reported surgeons' reasons for avoiding BCS. In one study, the majority of surgeons believed that long-term disease-free survival was equal for mastectomy and BCS, and the preference for mastectomy was mostly due to the inconvenience of radiotherapy [15].
