By Gregg Goldin
WMS Medical Society
Breast cancer affects 1 in 8 American women. The majority of those afflicted will have an important decision to suddenly confront: should I keep my breast, or should I have it removed? This has been a hot topic recently as mastectomy rates have been on the rise, particularly double mastectomies. But is the trend based in any scientific proof, or is it from a shifting public perception? I feel it is my responsibility as an oncologist to set the record straight and assist women and their families in making an informed decision.
Early in the 1900’s, as modern surgery was in its infancy, sterile technique, blood transfusions, and anesthesia helped to overcome significant barriers to surviving a trip to the operating room. A pioneer in his day, Johns Hopkins surgeon William Halsted became famous for developing a curative operation for breast cancer: he advocated for removal of the entire breast. However, he didn’t stop there… Based on his belief that cancer spreads in a radial pattern, he pushed his resections to the limits, including underlying muscles (and sometimes rib bones!), a procedure that left some women with gaping holes in their chest walls. Halsted’s “radical mastectomy” prevailed from 1895 to the mid-1970s, during which about 90% of patients in the U.S. underwent the disfiguring surgery.
In the 1950’s and 60’s, a radiation oncologist named Bernard Fisher disputed Halsted’s radical treatment philosophy through a series of elegantly performed, high quality trials (some of the first of their kind), which definitively showed that less surgery could be just as effective. For over a decade, there was much resistance from the status quo, and many in the medical community accused Fisher and his supporters of placing women’s lives at risk by not recommending the radical surgery. Fisher’s arguments would become bolstered by women’s rights activists, who cited mastectomy as one of the examples of sexism in medical care.
The socially charged movement prevailed. It became acceptable to remove the tumor and obtain negative margins with a rim of surrounding normal breast tissue (i.e. perform a lumpectomy), but you had to follow that up with 4-6 weeks of x-ray treatments to the breast (and the combination is termed breast conservation therapy, or BCT). The smaller lumpectomy operation can be performed with gentler forms of anesthesia, carries significantly less risk, and does not require an overnight stay in the hospital. Radiation (or x-rays) will cause temporary tiredness and skin redness, and modern computer-planned techniques pose very little risk of serious side effects.
We now have more than 40 years of follow-up data with BCT showing that, if followed closely with mammograms and examinations, any return of the cancer can be detected sufficiently early to still achieve cure. So, while a patient pursuing BCT accepts about a 5-10% chance for recurrence in the breast, there is no difference in survival vs. mastectomy.
Not every patient is eligible for BCT. Care is taken to select those who will have an acceptable cosmetic outcome and are candidates for radiotherapy. Contrary to what many think, having lymph nodes involved does not affect the ability to pursue BCT.
Usually it is a large tumor that precludes BCT, whereby it becomes difficult to make the breast look and feel natural after having the mass removed (though some may be rendered candidates if chemotherapy is first used to shrink the tumor). Another example is that of a genetic predisposition. The famed actress Angelina Jolie underwent double mastectomies, owing to a mutation in her BRCA1 gene. This is an inherited familial disease which carries an alarmingly high risk of breast and ovarian cancer, such that the routine recommendation is to have both breasts and ovaries removed.
While only 0.25% of American women harbor a BRCA mutation, the startling fact is that mastectomy rates are on the rise in the general population, with no compelling scientific basis. The double mastectomy rates have risen from 2% in 1998 to 12% in 2012, and over 30% of women younger than 45 years seek out the two-sided procedure.
The preponderance of data shows that BCT survivors report superior ratings of self-image and daily functioning. Though plastic surgeons have made incredible progress in their ability to reconstruct the breast after mastectomy, I’d argue that the outcome cannot compete with a woman’s natural body. Moreover, reconstruction has risks of its own, secondary to increased time spent in the operating room and hospital. Patients with a history of smoking or diabetes may have significant trouble with the healing process.
We cannot exclude the possibility that BCT patients may actually fare better, as a recent Dutch study of 37,000 women showed an improved 10-year rate of overall survival with BCT over mastectomy. This provocative report is by no means a definitive answer due to methodological flaws, but it does raise an interesting possibility. How can this be true? I don’t claim to know the answer, but I do know that radiation is a very potent cancer cell killer that is unique in its mechanism of action. It doesn’t need to rely on the blood to reach cancer cells, or timing of the cell cycle to exert its effects (as chemotherapies and similar drugs do require), and it’s used in a controlled fashion to “mop up” any stray cells that the surgeon cannot see, such that even a mastectomy procedure does not remove all of the tissue that is exposed to x-rays in a typical radiation treatment.
The decision is very personal. Some women will do anything to keep their breasts, but for others a mastectomy offers peace of mind. While I can certainly empathize with this desire to “take them off” and be rid of the worry, it still doesn’t change the simple, well-proven fact that there is no improvement in survival (or ultimate cure) by undergoing the amputation. The breast does not have to be the enemy. A less morbid treatment with equivalent survival is available for those who are eligible, and it has been routine now for nearly half a century.
Dr. Gregg Goldin is a member of the Western Carolina Medical Society.