Editor’s Note
	Gender Differences in Interpretation of Research Data

“Every woman wants to be beautiful and desirable, no matter what her age. And unfortunately, breasts are the ‘deal’; they make you a woman. That’s what you think. Women want to be pretty and whole, regardless of their age. Women in their 70s are still working. They’re active. They’re dating. They’re getting married. They need to be beautiful all the time.”

— 77-year-old breast cancer survivor treated with breast-conservation

“ My doctor explained all the options. He said, ‘You don’t necessarily have to lose your breast. We can just take the tumor out, but you will need radiation.’ That was one of the deciding factors. The thought of having to go to the hospital five days a week to have radiation didn’t appeal to me. So, that’s when I said, ‘Just take the breast. I’ve got another one. I want to live. And I’ll deal with it from there.’”

— 37-year-old breast cancer survivor treated with mastectomy

Our medical education group recently held an editorial meeting with 35 community-based surgeons and four faculty members (Drs Patrick Borgen, Kevin Fox, Generosa Grana and Terry Mamounas). While our audio series focuses on the clinical perspectives of breast cancer research leaders, we are also very interested in the viewpoints of surgeons at the front line of patient care. To enhance the discussion, we showed video clips from interviews with breast cancer survivors. One of the most discussed was a series of comments on breast-conserving surgery (see above).

Many studies — including a new data set from the ATAC adjuvant trial that is discussed in this program by Dr Gershon Locker — have demonstrated considerable variation in the use of breast conservation. The most significant factor is the physician’s attitude when presenting the options.

Our Breast Cancer Update working group meeting quickly demonstrated a dichotomy about this issue. Most of the attendees and faculty members indicated that they present lumpectomy to their patients as the preferred alternative. This is based on research data demonstrating equivalent survival with presumed decreased morbidity and psychosocial distress. However, a vocal minority of physicians in attendance staunchly supported mastectomy as a reasonable and equivalent option. In fact, one surgeon had chosen mastectomy when she, herself, was diagnosed with breast cancer some years ago.

As the discussion proceeded, I noticed that most of the physicians defending mastectomy were female surgeons, and the sole faculty member agreeing with this perspective was medical oncologist, Dr Genny Grana. These practitioners were in no way claiming that mastectomy resulted in greater survival, but they highlighted what they believed to be a lower rate local recurrence — an event they believed to be emotionally traumatic.

Female physicians had the perception that male physicians might generalize too much about the deeper feelings women have about their breasts. They also felt that some women, such as the physician who was a breast cancer survivor, find less difficulty than imagined when facing mastectomy.

This conversation is particularly relevant to comments in the enclosed program by Drs Mel Silverstein and Blake Cady, both of whom believe that women with early breast cancer often receive too much local therapy. Dr Cady notes that local recurrence may be a predictor of poor prognosis, but it is not an independent determinant of breast cancer mortality. He does acknowledge that patients may wish to minimize their risk of local recurrence by choosing, for example, postsurgical radiation therapy.

These discussions are a reminder that clinical research often provides new therapeutic options that may be perceived differently by individual patients and physicians. Additionally, these perceptions may vary with age, culture and, perhaps, gender. In this program, Dr Hy Muss, a leading investigator in the field of breast cancer in the elderly, notes that many physicians believe that older women are less interested in breast-conservation than younger women. However, surveys about this issue contradict that perception.

In patients with breast cancer, the choice of primary surgery is only one example of a plethora of controversial decisions for which multiple options are supported by research evidence. Another major issue involves the choice of adjuvant systemic therapy. The interviews with Drs Muss and Locker highlight several recent research studies that have made decision-making about the use of adjuvant chemotherapy and endocrine treatment much more complex. New results from a CALGB trial in women with node-positive tumors suggest a survival advantage to “ dose-dense” chemotherapy, which is given every two weeks. However, there are only three years of follow-up and no other confirmatory trials have been reported. The ATAC trial is another important recently reported study that has complicated adjuvant treatment decisions. This historic study demonstrates a disease-free survival advantage for anastrozole compared to tamoxifen in postmenopausal women, but not enough deaths have been observed to comment on mortality.

Our editorial board agreed that when clinical research data supports multiple acceptable options, patients should be allowed to actively participate in treatment decisions. In that regard, it is interesting to consider a new initiative our education group has launched to learn more about how women with breast cancer perceive treatment trade-offs. Over the next four months, we will conduct a series of three “ Breast Cancer Town Meetings,” in which breast cancer survivors who were diagnosed at least one year ago will utilize electronic keypads to “vote” on a variety of treatment-related issues. Our first meeting was held in New York City on May 17, 2003. Select results are presented below and have also been submitted as an abstract to the 2003 San Antonio Breast Cancer Symposium.

The most striking observation from this initial endeavor was the strong reinforcement of prior patient surveys indicating that women are very motivated to accept therapies that offer the likelihood of even modestly reducing the chance of cancer recurrence and mortality. Even relatively toxic treatments seem to be acceptable to patients for relatively minimal improvements in cancer-related outcome.

The overriding concern of cancer control must be considered in the debate about local breast cancer therapy. No matter how much we reassure patients that local recurrence is not an independent predictor of mortality, the thought of “treatment failure” is frightening to every patient. Perhaps, for some women, the emotional downside of concern about local recurrence may outweigh the cosmetic benefit of less extensive surgery.

— Neil Love, MD

Mandelblatt JS et al. Measuring and predicting surgeons' practice styles for breast cancer treatment in older women. Med Care 2001;39:228-42. Abstract

Weinberg E et al. The influence of gender of the surgeon on surgical procedure preference for breast cancer. Am Surg 2002;68(4):398-400. Abstract

Breast Cancer Town Meeting: Keypad Polling Results During a day-long meeting, a multidisciplinary panel* verbally presented the potential risks and benefits of commonly utilized adjuvant therapies for a series of hypothetical scenarios of women with primary breast cancer as they would counsel similar patients in their practice. Breast cancer survivors responded via electronic keypads to a series of related questions.

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