The JAMA study also found that doctors failed to offer radiation therapy to postmenopausal women and were more likely to recommend mastectomy to the older group than to younger women, even for the same stage of breast cancer. The study also found that the more affluent and well educated the woman, the greater her chances of being offered BCS.

In Britain, one 43 year old journalist diagnosed with breast cancer last February wasn't offered a modified quadrantectomy and chemotherapy until minutes before her scheduled mastectomy.

The lack of information or support by doctors for BCS may account for the suspicion with which many women view breast conserving measures. This point of view is epitomized in a letter written by Dr Michael G Sarr and others to the JAMA (19 August 1992): "Many view mastectomy as dealing with the problem immediately and completely, without postoperative radiotherapy. The acceptance, indeed preference, of mastectomy over breast preserving surgery by the majority of our patients...implies that these patients adjust readily to the loss of the breast."

Indeed, several noted cancer specialists have attempted to demonstrate that women given mastectomies suffer no more psychological trauma than those undergoing BCS. Noted breast cancer specialist Michael Baum and others from London and Manchester studied the psychological outcome of women given mastectomies versus those given BCS (British Medical Journal, 22 September 1990). The study found that about a quarter of those given either operation were depressed or anxious, and so concluded that "there is still no evidence that women with early breast cancer who undergo breast conservation surgery have less psychiatric morbidity [illness] after treatment than those who undergo mastectomy". Significantly, the study found that patients treated by surgeons who allowed them to choose were less likely to be depressed than those whose decision was made for them.

Besides your education or ability to pay (in the case of private patients in the UK), where you live has a lot to do with whether you are offered BCS or mastectomy. Two articles in the New England Journal of Medicine (23 April 1992) showed a marked difference in the use of BCS in the US, depending on geographical area. Women were more likely to be offered BCS in the Northeast (17 per cent) or Middle Atlantic States (20 per cent) than they were in the South (5.9-7.3 per cent). BCS was more on offer in urban than rural areas, in teaching hospitals, large hospitals and those with on site radiation therapy. Interestingly, an editorial in the same issue pointed out that higher rates of conservation surgery were found in those 17 states with informed consent laws requiring doctors to offer patients with breast cancer information about their treatment options.

Besides the problem of overtreatment, too much surgery might delay your doctor's ability to discover whether the cancer has spread. Dr Bernard Fisher and colleagues from the National Surgical Adjuvant Breast and Bowel Project in Pennsylvania, writing in The Lancet (10 August 1991) about the nine year study of 2000 women mentioned above, showed that mastectomy or radiation therapy actually prevented the diagnosis of distant disease since the recurrence of another tumour tended to be a "powerful" marker that the cancer could spread, thus aiding its early treatment. "These findings further justify the use of lumpectomy," concluded Dr Fisher.