Nancy Reagan’s Choice of Mastectomy Seems to Have Influenced Many Breast Cancer Patients

A new study from the Medical College of Wisconsin Cancer Center has shown that celebrity role models can influence decisions about medical care. The national study of breast cancer treatment patterns following Mrs. Ronald Reagan’s decision to have a mastectomy in 1987 showed that 25% fewer women than expected underwent lumpectomy or breast-conserving surgery.

The study results were published in the March 11, 1998 issue of the Journal of the American Medical Association, by Ann B. Nattinger, MD, MPH, associate professor of medicine at the Medical College and principal author of the study. The study was funded by the National Cancer Institute and the Department of the Army.

The rate of lumpectomy use had been stable for 2 years before Mrs. Reagan’s mastectomy in October 1987. During the 6 months following her surgery, about 3,400 more women than expected, based on previous rates of utilization, chose mastectomy over lump- ectomy. This sharp drop in the use of breast-conserving surgery was not associated with any publications in the medical literature or lay press that called into question the effectiveness of this procedure.

Celebrity Influence Greatest Among White Women
The celebrity influence was most significant among white women. It was also most prominent among women age 50 to 79 years in the central and southern region of the country. However, it was most sustained among women living in areas with lower levels of income and education—those with incomes, at the time, of less than $25,000.

According to Dr. Nattinger, the long-standing belief that public figures influence popular behavior has never been objectively studied beyond anecdotal documentation. “Our national population-based study shows that the influence of celebrity role models appears to be strongest among persons who demographically resemble the celebrity and among those of lower income and education status.”

During a routine screening mammography in 1987, Mrs. Reagan was found to have a suspicious lesion. On October 17, 1987, she underwent an open biopsy of the lesion followed by a modified radical mastectomy in the same operation. Her choice of treatment was criticized in the lay press, with one breast cancer specialist saying that by choosing mastectomy she has “set us back 10 years.” This controversy, in turn, resulted in articles defending the right of Mrs. Reagan and other women to choose the therapy best suited to them.

“Because more mastectomies were chosen by women demographically similar to Mrs. Reagan, we believe that her treatment choice had a direct influence on the women and did not impact on the surgeons’ selection of treatment for their patients,” Dr. Nattinger theorizes.

“Also, we believe that lower income women may have chosen mastectomy over lumpectomy in the belief that the since the First Lady had the best medical advice, that should also be their treatment of choice,” Dr. Nattinger added.

The researchers examined patient records included in two well-known databases. The first is the Surveillance, Epidemiology and End Results (SEER) tumor registry of the National Cancer Institute (NCI), which provides population-based data on diagnosis and treatment of cancer for approximately 10% of the US population. The second is the Medicare part A charge data, which provides national information on hospital treatment for more than 90% of women age 65 years and over. The researchers also used the National Newspaper Index and the Magazine Database to analyze the content of lay press stories relating to choice of mastectomy or lumpectomy for breast cancer treatment.

The SEER Data
From the SEER records, the investigators selected a cohort of 83,250 women, aged 30 years and older who underwent lumpectomy or mastectomy treatment for local or regional breast cancer between 1983 and 1990. A cohort of over 80,000 women from the Medicare data during 1987 and 1988 was selected using the same criteria.

The decrease in use of breast-conserving surgery was apparent in white but not African-American women and was seen among women treated in both urban and rural areas. The effect was observed during the fourth quarter of 1987 and the first quarter of 1988 among women of all income and educational strata.

Mrs. Reagan’s choice of treatment appeared to have the greatest influence in the south Atlantic and east south central region of the country, while it was less in the middle Atlantic region. The reduction in the use of breast-conserving surgery in each state did not correlate with the popular vote for President Reagan in the 1984 election or with a rating of the state’s members of Congress on a conservative-liberal scale.