Breast cancer is the most common female cancer all over the world (1). Although the incidence and mortality rates of breast cancer in China are relatively low, they are both on the rise. Due to the large population base, the incidence and death of breast cancer in China rank the first in the world (2, 3).

Compared with other countries, for example, the United States, in which the median diagnosed age of breast cancer is more than 60 years (4), in China, breast cancer occurs at a younger age in women, with the median age at diagnosis of 48–50 years (5–7). Breast cancer in China is with more frequent advanced-stage presentation (6), and there are regional variations in incidence (8). The average total treatment cost for each new case in China is the lowest in the world, but as the largest low-income or middle-income country, breast cancer carries a heavy burden on Chinese patients (9). Another characteristic of Chinese women is their smaller breast size (10). All of these would affect Chinese patients’ and surgeons’ choice of treatment.

Surgery is one of the main methods in the treatment of breast cancer and influences patients’ quality of life. Breast-conserving surgery (BCS) is a standard treatment of early-stage breast carcinoma (11), while findings from a Chinese nationwide survey from 1999 to 2008 showed that mastectomy continues to be the main operation, accounting for 88.8% for primary breast cancer. By contrast, the incidence of mastectomy was 36% in the United States (12). In addition to mastectomy and BCS, oncoplastic surgery could be an option (13, 14), which has developed at a rapid pace and is being performed all over the world (15). However, the oncoplastic rate in China remains low, and most hospitals do not possess this type of surgery.

Most of the aforementioned data were published before 2010 and are therefore relatively old, so it is necessary to review the status quo of surgical treatment of breast cancer in China. Using data from a survey in 2015, we aimed to clarify the current real-world breast surgery in a Chinese population and to provide a reference for the formulation of strategies.

Although our study only included part of Chinese breast cancer patients who underwent surgery from grade 3A hospitals, accounting for about one-tenth of the total incidence in 2015 (16), it is still the largest study to reflect the latest surgery status of breast cancer in China. The age characteristics of the newly diagnosed cases in our study are consistent with previous reports (5–7). Younger age and higher density are a great challenge for the Chinese government in developing screening strategies, as the benefit of mammography remains controversial in women younger than 50 years (17), and half of the Chinese patients are within this range. However, the best recommendations of the age range for mammography screening are based on European and US trials, and China lacks large analogous trials. It is necessary to carry out corresponding research to better guide our clinical practice.

Compared with the United States (less than 40%) (12, 18), in China, mastectomy accounts for 77.2% of surgery for primary breast cancer in our study. South China and North China showed a low rate of mastectomy across the country. It may be due to these two regions containing hospitals from Beijing and Shanghai, which represent higher Chinese medical levels. It is consistent with the rate in first-tier cities. Notably, the rate in South China and North China was high at 70%, but our study only contains large 3A hospitals, so the real results might be worse. There are five possible reasons.

The first reason may be the high percentage of advanced stage at presentation. A previous study (6) revealed that Chinese patients were diagnosed 60.6% at stage I/II and 21.1% at stage III/IV disease, but disease presentations at stage III/IV (visit to oncologist firstly) might be substantially underestimated because most data on the stage at diagnosis are mainly collected from surgical departments. A business survey found that nearly two-thirds of Chinese breast cancer patients were diagnosed with advanced disease (9).

The second influence factor is small breast size. BCS is not suitable when the tumor–breast size ratio exceeds a certain value, which is common in China (6, 19). The third reason is that the development of breast reconstruction in China is less than ideal. Breast reconstruction can help patients achieve disease control and aesthetic appearance. However, the reconstruction rate in China is low, and only several hospitals meet the surgical qualification. A 2019 Chinese study (20) showed that the rate of implant-based breast reconstruction in all the patients who received mastectomy was only 7.06% (4,296/60,877).

The fourth reason is Chinese patients’ misunderstanding of breast surgery. Most of the patients have doubts about “less is more” and tend to regard breast conservation as disease residual. At the same time, they consider reconstruction as major surgery, which means complications, and they fear surgical complications (21). Patient education may help change this situation.

The average total treatment cost of a new case of breast cancer in China ranks low as compared with other countries (9). However, breast cancer is one of the leading causes of catastrophic medical expenditure in China and can rapidly impoverish families (9, 22). The cost of radiotherapy after breast conservation is a heavy burden (23). This may be the fifth reason for the low rate of breast conservation. However, the psychological effects of mastectomy could be higher than the cost of radiotherapy, and this problem could be managed with insurance facilities. Additionally, there is a wide range of variation both across and within geographic regions in the treatment and nursing cost, and it is hard to discern whether higher fees mean better service or survival. With the advancement of the diagnosis-related group (DRG) system in China (24), the gap in breast cancer treatment costs between and within regions would be greatly decreased. Also, based on our data, the median cost of BCS ($2,775.4) is lower than that of mastectomy ($3,454.6). In other words, BCS means more profit for surgeons. Maybe the implementation of the DRG system would encourage surgeons to promote breast-conserving surgery.

About 25% of breast cancer patients in our study have used TCM. The widespread use of traditional medicine is related to beliefs that it can alleviate toxic effects, promote recovery, and improve immune function and quality of life (25). It is different from modern medicine, based on the holistic approach and the Chinese materia medica to diagnose and treat the disease. TCM is an empirical science based on over 2,000 years of accumulated knowledge and practice (26). TCM is usually regarded as a complementary or “alternative” treatment of modern Western medicine in other countries (27). It is regarded the same in most hospitals in China except TCM hospitals. The limitation of TCM applications is mainly due to its lack of evidence-based features (28). The integration of scientific principles and techniques with traditional medicine will serve modern medicine well (29).

Our study has important limitations. Firstly, some patients received both surgery and chemotherapy during the same hospital stay, leading to the cost being not comparable to some extent. On the other hand, the cost in our study is the total cost, including medical insurance reimbursement, rather than patients’ own expense. So the cost in our study cannot reflect the personal medical expenditure. Secondly, our study lacks breast cancer stage; some of our inferences (for example, “this may be due to advanced stage”) are based on other studies rather than our data. More importantly, although we figured out that the data of breast cancer stage at present may be imprecise in China, we are unable to provide relevant data. Thirdly, the hospitals in our study are all at the 3A level, representing a high medical level in China. The data we present could not reflect the reality of breast cancer surgery and the cost. Fourthly, HSR data are still subject to some incomplete or inaccurately recorded information, for example, wrong ICD coding order in the medical records room. However, we checked the logical order, and errors in the data may have been reduced. Finally, the data we provided were a bit outdated (2015); however, they were the most current and large-scale datasets to date.

Our study found that the main breast cancer operation in China in 2015 is mastectomy and that there is a wide cost range of variation both across and within geographic regions and city tiers. There are gaps in breast cancer surgery treatment in comparison to other countries. The Chinese government needs to take measures to improve the quality of treatment for breast cancer patients in China.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Conceptualization: JG, LT, RZ, and LZ. Project administration: LT. Methodology: LT and XB. Data curation: RZ and MJ. Formal analysis: LT. Manuscript preparation: JG and RZ. Final approval of manuscript: all authors.

This work was supported by the National Natural Science Foundation of China [grant number: 82004210] and the National Key R&D Program of China (2018YFC1704400).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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