Breast-sparing surgery may offer small survival advantage, but women still opt for mastectomies
Mastectomies are back in vogue: Blame it on celebrities such as E! talk show host Giuliana Rancic and comedian Wanda Sykes, who appeared to bounce back easily after their recent double mastectomies and reconstruction for early-stage breast cancer. Or blame it on the overwhelming need to have some peace of mind after receiving a frightening breast cancer diagnosis: practically every woman knows someone who has died from the disease -- often in the prime of her life.
Regardless of the reason, breast surgeons have seen a surge in requests from breast cancer patients who opt to have both their breasts removed (including the one that’s cancer-free) rather than removing just the malignant lump in one.
That’s despite findings from seven large clinical trials, which showed that, for women with small tumors that hadn’t spread beyond the breast, mastectomies didn’t provide additional lifesaving benefits over more conservative surgery -- called a lumpectomy -- followed by radiation.
In fact, a study published Monday in the journal Cancer suggests that breast cancer patients who opt for lumpectomies with radiation might have a 14 percent smaller risk of dying of breast cancer compared with those who have mastectomies.
The researchers followed more than 100,000 breast cancer patients, who chose which treatment to have, for nearly 30 years. Because it wasn’t a randomized clinical trial, the study couldn’t determine whether lumpectomies or the radiation administered afterward provided an actual survival benefit or whether the women who chose lumpectomies lived longer because they were in better health overall than those who chose mastectomies.
“It’s a nice study,” said Dr. Mehra Golshan, director of breast surgical services at Dana-Farber/Brigham and Women’s Cancer Center, “but it’s hard to imagine that less surgery with radiation gives a better outcome.” At the minimum, the two types of surgery offer the same shot at survival, he added.
So why are women still choosing mastectomies?
“They’re worried about the cancer coming back in the breast or occurring in the opposite one,” Golshan said. “I spend a lot of time counseling women about this, telling them that we’ll monitor them closely through frequent screenings.” But many don’t want to live with the uncertainty.
He pointed out that women who carry one of the breast cancer gene mutations -- which account for 7 to 9 percent of all breast cancers -- should be counseled to consider a double mastectomy since they have a significant likelihood of developing life-threatening aggressive breast tumors after their initial diagnosis.
But most of the rise in mastectomies has stemmed from a sharp increase in the diagnosis of the tiniest cancers in women who don’t have breast cancer gene mutations. These stage 0 or “in situ” cancers are self-contained and are considered by some oncologists to be pre-cancers because they may not ever grow and spread into breast tissue.
With higher quality breast imaging, some 60,000 women now now get diagnosed with these in situ cancers every year compared with fewer than 7,000 to 8,000 a year in the early 1980s. While oncologists initially recommended mastectomies for these cancers to ensure a nearly 100 percent cure, they’ve been recommending lumpectomies with radiation for the past several years after studies showed that the breast-sparing treatment provides the same survival odds.
But women with in situ cancers still usually choose mastectomies, and Golshan explained one reason why. With a mastectomy, the odds are less than 1 percent that a woman will have a recurrence of cancer in the region where the breast was removed such as, say, by her collarbone. With a lumpectomy, a local recurrence happens 5 to 6 percent of the time.
These recurrences are highly treatable, Golshan said, and rarely life-threatening, but many women simply don’t want to face the possibility of more breast cancer or more treatment.
That certainly makes sense except that no surgery -- no matter how extreme -- will ensure a cancer-free life. Cancer is an insidious disease that can crop up at any time, in any organ, and in any person no matter how much they exercise, eat right, and follow a healthful lifestyle.
Most of us will die with cancer in our bodies, though we may not die of the cancer itself -- and we may not even know we have it.
Perhaps if we can wrap our brains around this notion, we might be a little less scared of a “stage 0” cancer diagnosis. Older men with early stage prostate cancer are often told they can opt for no immediate treatment and just close monitoring, but women don’t have this option yet for breast cancer.
That’s probably coming in the future, Golshan said, when research identifies which stage 0 breast cancers are more likely to never spread.
In the meantime, oncologists could do a better job calming women’s fears and educating them on the long and painful recuperation period involved with breast reconstruction following a mastectomy. (Rancic, to her credit, discussed the harsh realities of her recuperation with Glamour magazine in this interview.)
“It’s a good three to six months before a woman feels like herself again,” Golshan said. While surgeons can frequently preserve the nipple and provide more natural-looking results these days, the breast and nipple usually feel numb to the touch, which often reduces sexual pleasure.
Most women who decide to have mastectomies (with or without reconstruction) believe that the choice they made was lifesaving and the best option for them. Some, though, have regrets.
“Not an insignificant minority of patients have told me when all is said and done that they wouldn’t have gone through it had they known what it would be like,” Golshan said.Deborah Kotz can be reached at firstname.lastname@example.org. Follow her on Twitter @debkotz2.d