Mastectomies on increase

The Baltimore Sun

In a stark reversal of a long-term trend, more early-stage breast cancer patients are choosing mastectomy, despite evidence that the aggressive, disfiguring surgery has the same survival rate as removing the malignant lump, new research shows.

The study by doctors at the Mayo Clinic in Rochester, Minn., suggests that a more detailed screening technique may have led additional women to have their breasts removed.

But researchers also found a rise in mastectomies among women who weren't examined with the new magnetic resonance imaging technology. Some doctors say more women are opting to have their breasts removed because of an overwhelming fear the cancer will return.

"For some women, their quality of life is better with their breasts removed because you get rid of the concern, the anxiety" about recurrence, said Dr. Lisa Jacobs, a surgical oncologist with the Johns Hopkins Breast Center who was not affiliated with the study. "A lot of women come in and say, 'I don't ever want to do this again.'"

Still, doctors worry that some patients are being treated too aggressively because many of the cancers spotted by ultra-sensitive MRI would never develop into dangerous tumors. There is also no research on whether the use of MRI improves overall survival.

The study found that 43 percent of breast cancer patients chose mastectomy at the Mayo Clinic in 2006 - up from 30 percent three years earlier. The 2006 rate was almost the same as the 45 percent of breast cancer patients who had mastectomies in 1997.

Fifty-two percent of women who had an MRI in 2006 had mastectomies, but so did 41 percent of women who didn't have an MRI.

Anecdotal evidence - and a recent study showing more breast cancer patients choosing prophylactic mastectomy in the cancer-free breast - suggests that the trend extends beyond the Mayo Clinic.

"Are we doing the right thing for women? Is converting a woman to mastectomy ... will that lead to a better clinical outcome?" said Matthew P. Goetz, assistant professor of oncology at the Mayo Clinic and one author of the study.

Goetz, who spoke to reporters yesterday, will present the paper May 31 at the American Society of Clinical Oncology's annual meeting in Chicago. The work was released yesterday along with nearly 5,000 other abstracts in advance of the conference.

The unusual data release occurred because some drug company stock prices fluctuated suddenly in past years between the time ASCO members got copies of the abstracts and the time they were publicly released. Some of the research papers involve trials of cancer drugs. To prevent a repeat, ASCO decided to release nearly all of the material at once this year.

Mastectomy rates began to decline nationwide soon after a 1990 National Institutes of Health Consensus Panel reported that breast conservation surgery - lumpectomy plus radiation therapy - was as effective as mastectomy for overall survival of most women with early-stage breast cancer. There was some increased risk of cancer recurrence when a breast was left behind, the group said.

The medical community began to view high mastectomy rates as a negative, counting against hospital rating scores, with the implication that a center with high rates wasn't up on new techniques and treatments.

There was a sense that paternalistic doctors were encouraging women to undergo major surgery when it wasn't necessary. But Jacobs said she thinks today's return to mastectomies is about something else.

"Before, it was felt the physicians were pushing it," she said. "It's the patients pushing it now."

Jacobs and other physicians also cited a new feeling of empowerment on the part of patients - mixed with more available treatment information, genetic testing and better breast reconstruction surgery.

"People want to have their breast cancer treated and reduce the chances that they'll have to face it again," said Dr. Stephen Grobmyer, a surgical oncologist at the University of Florida's Shands Cancer Center in Gainesville. "We see patients every week that are very educated and in many cases know what they want: It's mastectomy."

Jacobs said she always explains all of the options to her patients. Whenever appropriate, she starts the conversation with, "You are a perfect candidate for lumpectomy."

But a patient's concerns may go beyond that. Many women who get mastectomies don't need chemotherapy or radiation, eliminating the side effects and hardships of five-day-a-week radiation for six weeks after a lumpectomy.

An MRI does help find more cancers - about 3 percent in one study. But it is also associated with a high number of false-positive results - 75 percent in another study.

Doctors recommend an MRI for women who have a genetic trait associated with breast cancer or a family history of the disease. An MRI, which uses powerful magnetic fields, radio waves and a computer to produce detailed pictures, tends to work better than mammograms in detecting abnormalities in women with dense breast tissue.

The Mayo Clinic study examined 5,414 women with early-stage breast cancer who had surgery at the hospital between 1997 and 2006. The study noted which women had received a pre-operative MRI, which Mayo began using in 2003.

The women who had an MRI before surgery had already been diagnosed with breast cancer, and doctors were typically trying to see if there was additional cancer - either elsewhere in the cancerous breast or in the other breast.

Florida's Grobmyer said the use of an MRI in this manner "helps us better select patients for breast conservation."

Still, the technology has its detractors. They say that the MRI is so new that it finds many lumps that are unlikely to develop into cancer. But once identified, those lumps may lead to unnecessary treatment and anxiety.

At the same time, some cancers found only by MRI may be in a different quadrant of the breast than the original cancer, making mastectomy the correct treatment.

Dr. Julie Gralow, a medical oncologist at the Fred Hutchinson Cancer Research Center in Seattle who specializes in breast cancer, said yesterday that much of the surgery is probably appropriate.

But, she added, "What would be a real shame is if women are choosing mastectomy based on MRI findings that are benign ... and they end up having more aggressive surgery than they need."

The discussion is similar to a debate over high-powered CT scans for lung screening. CT scans find smaller cancers, but many are relatively harmless, and the jury is still out on whether a CT scan actually improves survival rates.

In other breast cancer research released yesterday, Canadian researchers found that breast cancer patients with a vitamin D deficiency were 94 percent more likely to have their cancer spread and 73 percent more likely to die, compared with women with adequate vitamin D levels.

More than one-third of the 512 breast cancer patients studied had a vitamin D deficiency, and another third had "insufficient" levels of vitamin D.

Dr. Pamela Goodwin, a medical oncologist at Mount Sinai Hospital in Toronto, said there is growing evidence that women should get more vitamin D. The body normally produces vitamin D when it's exposed to sunshine, but the vitamin is also available in supplements.

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