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Post lays out limitations of study showing longer survival with breast cancer surgery

Women with Stage 4 breast cancer survive longer if they have surgery, study shows

Our Review Summary

surgeryThis story is about a large retrospective study that was published this week in the journal JAMA Surgery. The research suggests women who opted for surgery to treat their breast cancer had better survival rates than those who didn’t, even though the number of surgeries has plunged from 1988 to 2011.

This Washington Post report does many things well: It quantifies the benefits of breast surgery in absolute terms, points out the study’s limitations and doesn’t make sweeping recommendations based on this research. Furthermore, the story uses cautionary language, making readers really question whether surgery is the better option for stage 4 breast cancer patients. It also incorporates two independent sources who provide some critical perspectives, such as the two other small studies that showed no correlation between surgery and survival in this group of women.

We would have liked to have seen more discussion on the harms of breast surgeries, as well as the existing therapies for breast cancer patients. And we would have liked for the report to have pointed out that usually younger women underwent surgery in the study, which may have affected the results.

Overall, however, the Washington Post puts forth a thorough, nuanced story based on the latest findings.

 

Why This Matters

Though current screening recommendations for breast cancer are intended to identify cancers at an earlier, more curable stage of disease, women still present with metastatic disease (cancer that has spread to other parts of the body). This can occur because of not having screening or not having it regularly enough, or it may relate to aggressive disease that develops and metastasizes prior to it being detected on standard imaging tests. For those women with metastatic disease, particularly younger ones, cure and thus long-term survival is uncommon. The question addressed in this story is whether the addition of surgery to standard aggressive therapy – generally chemotherapy and radiation treatment – leads to longer survival. The story does a good job of describing the benefit seen in this retrospective study as well as highlighting its limitations. Specifically, there is no evidence from higher quality, prospective studies that surgery provides additional survival benefit. Clearly such studies are needed and the article suggests that such studies are currently underway. The challenge is what to recommend for women who currently face this treatment decision. The simple answer is that we don’t really know and the article does a good job of not overselling surgery based upon the results of this study.

Criteria

Does the story adequately discuss the costs of the intervention?

Not Satisfactory

The cost of breast surgery in the US varies widely depending on the type, hospital and region, and so we acknowledge that it would have been difficult to provide solid numbers here. Nevertheless, we feel that cost remains relevant for this piece. This study basically argues that surgery plus other aggressive non-surgical treatment vs. non-surgical treatment alone may lead to longer survival. Since this isn’t proven, one could reasonably ask about the costs of these two approaches. This may be analogous to the prior use of autologous bone marrow transplantation (BMT) in women with metastatic breast cancer. The high cost of this treatment led to fights with insurers over coverage and finally to a randomized trial that showed no benefit. We don’t do autologous BMT anymore. Could a similar scenario play out here? The question seems worth asking and addressing.

Does the story adequately quantify the benefits of the treatment/test/product/procedure?

Satisfactory

The Washington Post story quantifies the potential benefits of surgery, detailing that women who underwent breast surgery had better survival rates than those that didn’t (median of 28 months versus 19 months). Despite the better outcomes, the article adds the number of surgeries dropped from 67.8 percent in 1998 to 25.1 percent in 2011, which it describes as an “intriguing question” about that approach.

Furthermore, the story is quick to point out early in the story that surgery may not be the right option for all women and “may be better for some women than it was in 1995.”

We applaud the fact that the benefits are reported in absolute terms and in a more cautionary manner, which is why we give it a Satisfactory rating here.

Does the story adequately explain/quantify the harms of the intervention?

Not Satisfactory

Breast surgery can lead to complications, such as bleeding and infection, like any major surgery. Patients usually choose between breast-sparing surgery (surgery that takes out the cancer and leaves most of the breast) and a mastectomy (surgery that removes the whole breast).

According to cancer.gov, mastectomies can affect a woman’s psychological well-being due to a change in body image and the loss of normal breast functions. Furthermore, women undergoing total mastectomies lose nipple sensation, which may impede sexual arousal.

Other breast surgeries could lead to sudden drops in estrogen production, which could induce early menopause in premenopausal women.

Since harms are not addressed, we give it a Not Satisfactory rating here.

Does the story seem to grasp the quality of the evidence?

Satisfactory

The evaluation of evidence was excellent in this Washington Post story, as it pointed out the limitations to the study and described other studies that had not reported the same results. For example, the story explains the limitations of retrospective data, which look back on patients’ treatments. Since the motivations behind therapy decisions are unknown, the conclusions could be rendered unreliable for clinical decision-making, the article says. Another limitation was the over-representation of Africa-American women in the study. It also details two prospective studies that found no survival difference among women with stage 4 breast cancer.

One limitation that was overlooked, however, was that usually younger women underwent surgery, which may have also confounded the results. And according to the original research report, age (younger than 45 years) was an independent predictor of prolonged survival.

The story also describes and quantifies the research, mentioning the study looked at 21,372 women with stage 4 breast cancer from 1988 to 2011.

Lastly, we applaud the story’s use of cautionary language. The report doesn’t jump to premature conclusions or make recommendations based on this one JAMA Surgery study, One of the sources says, “It’s premature to suggest… that removing the breast will help them live longer in the face of stage 4 disease.”

For all these reasons, we rate it Satisfactory here.

Does the story commit disease-mongering?

Satisfactory

The article does not engage in disease mongering, although it could have been helpful to learn more about the prevalence of breast cancer in the US.

Does the story use independent sources and identify conflicts of interest?

Satisfactory

The Washington Post report interviews two independent sources – the chief surgical oncologist at the University of Michigan and the medical director of a breast cancer center – and their comments bring a much needed critical perspective to the piece.

No conflicts of interests are reported, both in the original research article and in the Washington Post story.

Does the story compare the new approach with existing alternatives?

Satisfactory

The article hints at “more sophisticated treatments and better imaging techniques” that have developed over time, but it doesn’t explicit state what those are. We would have liked to have seen a sentence or two describing some existing breast cancer treatments, in the case the patient chooses not to opt for surgery.

However, since the story mentions radiation as a possible therapy, we give it a Satisfactory rating here.

Does the story establish the availability of the treatment/test/product/procedure?

Not Applicable

The availability of risk-reducing  breast surgery is not in question, since it is not a new intervention.

Does the story establish the true novelty of the approach?

Satisfactory

The article makes it clear that surgery is not a new intervention to treat breast cancer, stating that women and their clinicians have opted for surgery since at least 1988.

Does the story appear to rely solely or largely on a news release?

Satisfactory

The story doesn’t seem to be based on news releases we found online. The Washington Post article shows evidence of original reporting – shown by the comments from the two independent sources and two study authors – and also cites the JAMA Surgery paper.

Total Score: 7 of 9 Satisfactory

Comments (4)

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Lenny Bernstein

December 4, 2015 at 10:10 am

Thank you again for another well-reasoned critique. By way of explanation–not argument–we have to decide in all these stories how far afield we can go given the space we have (even online, there are limits to how much people will read). Cost and complications were a bit beyond the scope of this piece, even though it was consumer-oriented.
Best,
Lenny Bernstein
Washington Post

Reply

    Kevin Lomangino

    December 4, 2015 at 12:02 pm

    Lenny,

    Thanks very much for the constructive feedback. We know we set a high bar and that stories will not always live up to the standard on every criterion, and that there are legitimate reasons for this. Cost most definitely would have been difficult to address as we noted in the review. I would suggest that harms, arguably, are more critical since the value of the extra survival time must be balanced against the risk of reduced quality of life from potential surgical complications during that extra time. These quibbles certainly don’t detract from our overall high estimation of the piece. Again, nice work!

    Kevin Lomangino
    Managing Editor

    Reply

      Laurence Alter

      December 21, 2015 at 5:33 am

      To Misters Bernstein & Lomangino:
      It’s quite *heartening* to see respectful dialogue back-and-forth between writer and reviewer. Parenthetically, I have quibbles about calling the absence of harms addressed as “quibbles” by Reviewer Lomangino!
      Respectfully,
      Laurence

Gauthier Bouche

February 8, 2016 at 7:21 am

Thanks for the interesting review. I however disagree with your assessment of the criteria “Does the story seem to grasp the quality of the evidence?”. The Washington Post article failed to mention the largest randomized controlled trial published to date on this very important clinical question. This trial was reported in September 2015 in the Lancet Oncology (http://www.ncbi.nlm.nih.gov/pubmed/26363985) and unfortunately did not receive any media attention (despite our attempt http://tinyurl.com/jda8k4b). With these results in mind, the Washington Post news item may be considered misleading, questioning its 4-star rating.
Best.

Reply