October is awash in pink, a now famously symbolic colour. Breast cancer awareness month has added significance for survivors across Canada – like Embrun, Ontario’s Tracy Tarnowski, who spent two years battling the disease. We bring her story, and the results of a timely Breast Cancer Surgery Report, which underline the difference in treatment choices for Canadian women who have diverse circumstances and cancers.
The report saw CIHI team with the Canadian Partnership Against Cancer, a chance to merge the expertise of two organizations to help improve cancer care. It examined the rates of mastectomy versus breast conserving surgery (a.k.a. lumpectomy), of re-excisions, and of other surgical procedures and complications. In so doing, it uncovered wide variations in breast cancer surgery across the nation. Rates of mastectomy for unilateral breast cancer, for instance, ranged from 26% in Quebec to 69% in Newfoundland.
In Tracy’s case, all her decisions – chemo, mastectomy, radiation, hysterectomy, reconstructive surgery – spun from her pursuit of fighting the cancer from all available angles.
“I wanted to get rid of the cancer and do whatever I had to do to decrease the chance of it ever coming back,” Tracy told Land. “For example, I had to have a mastectomy, but chose to have a bilateral and remove both breasts – just in case.”
Her all-in pursuit took great willpower and mental strength. “When each surgery date got closer, and I may have felt that I simply could not take another one, I always reminded myself that it was not forever. It was just for now.”
Dr. Elaine Wai, radiation oncologist in Victoria and associate professor at UBC’s Faculty of Medicine, said the report uncovers vital questions that need answers. What is contributing to such a wide range of mastectomy rates? And how about the variation in day surgery versus inpatient surgery – why are some provinces providing services differently? What arrangements of care make day surgery more of an option?
The past two decades have seen major advances in breast cancer care and survival rates. In the 1980s, clinical news broke that patients were equally likely to survive after a lumpectomy and radiation as with a mastectomy – thus they could fight cancer without losing a breast. Yet the report shows widely varying rates of mastectomies in Canada, information that could help local health professionals determine if they are providing the best possible care for their patients.
The report found geography and age to factor into the higher rates of mastectomy. The further the drive, the lower the rates of lumpectomy (which then requires radiation). While distance was no factor for Tracy, who drove 45 minutes to the Ottawa Cancer Centre, she said she can imagine how less accessible care could impact decisions.
On the front line, Dr. Wai finds that people who live further away are far less likely to opt for radiation therapy – which takes up to six weeks, five days a week. The real issue of distance, she said, is money. The costs of staying in the city that holds the cancer centre, transportation costs, costs of lost working days, costs of having people look after your home and possibly older family members, costs of all shapes and sizes. “These are traditionally laid on the patients,” Dr. Wai said. “It becomes a barrier (to treatment).”
The report found that that one segment of women, the 50 to 69 age bracket, had lower mastectomy rates. Age had much to do with Tracy’s aggressive approach to her cancer.
“Since I was only 40, I figured I had a lot of living yet to do,” she said, adding that her body was strong and able to endure the stress of treatment. Every step of her two-year journey, Tracy took with her husband Michael.
“We made decisions together and always had our children in mind to determine how much to tell them and when.” Family and friends proved a major source of strength.
The CIHI-CPAC report reflects a population dispersed across a huge country. Its pan-Canadian lens illuminates the care provided to 22,000 women treated surgically for breast cancer each year.