April 1, 2009
WHY SO MANY UNNECESSARY MASTECTOMIES?
 As if the collapse of the world financial system isn't enough to set one’s nerves on edge, a study just published in the Journal of Clinical Oncology reveals yet another alarming trend: during the past several years the percentage of women with non-invasive breast cancer (DCIS) who have their breasts removed entirely (mastectomy) has increased 188%! Since mastectomy is not at all required to treat the vast majority of patients with DCIS, the looming question then becomes "Why are all of these women having their breasts removed?"
Allow me to review some important facts. Non-invasive breast cancer (DCIS, commonly known as ductal carcinoma in-situ) is not life threatening. It is the earliest stage of breast cancer and it does not have the ability to move beyond the breast tissue to invade other organs of the body. Unless DCIS is very large at the time of diagnosis, which is seldom the case these days, it is very adequately treated with lumpectomy and radiation therapy. Most of the time DCIS is diagnosed by mammography and is relatively small in size. Typically, it cannot be felt as a lump and is seen only as microcalcifications on a mammogram. The chance that DCIS will recur after proper treatment is approximately 1 in 100 women diagnosed with the disease per year. Which is to say, at ten years of follow-up, 10 women in 100 with DCIS might have had a recurrence and the other 90 will be completely free of disease. So why are all of these breasts coming off? And, furthermore, why are so many women having their other perfectly normal breast removed at the same time?
The study reported in the Journal of Clinical Oncology was not meant to try to answer these questions but rather it was meant to report the "state of play." Nonetheless, I think it is fair to wonder why all of these breasts are being removed if they don’t have to be. My own suspicion, after spending the past fifteen years rescuing women and their breasts from overly aggressive surgeons, is that women are being unnecessarily frightened and coaxed into aggressive surgery in the false belief that this will provide an improved survival. Of course, most women are naturally afraid of breast cancer. And when they are diagnosed with the disease they are usually surprised and alarmed. They are vulnerable to any suggestion they think might improve their chances of "cure" and they want to do everything they think might help them “beat the disease.” I believe these women are being subtly encouraged to have mastectomies that they do not need and that will not add one day to their life.
A few more facts: women who have been diagnosed with DCIS have an increased risk of developing a similar breast cancer in the opposite breast. However, the risk of "contralateral" breast cancer is also very small – only about 1 in 100 women with DCIS will develop disease in the opposite breast every year following their initial diagnosis. (And medications, like tamoxifen and arimidex, reduce this already small risk even further.) To put it another way: after 10 years of follow-up, 90% of women have not developed disease in the opposite breast. And those that do can be treated with lumpectomy and radiation therapy - as can be done for the original tumor. Mastectomy is not necessary to properly and adequately treat DCIS! Furthermore, it is certainly not necessary to remove a perfectly normal breast that in 90% of women will not develop a breast cancer over the subsequent ten years following diagnosis of the original disease.
If 90% of women with DCIS do not develop disease in the opposite breast during the ten years following their first treatment, why (all of a sudden) is there such a stampede for contralateral prophylactic mastectomy? Does this have something to do with the increasing numbers of plastic surgeons on the market? Perhaps, I can’t be sure. But I do know one thing - these mastectomies are not necessary. The fact that prophylactic mastectomies have increased by 188% is nothing short of alarming.
In the recent report even women with DCIS in one breast who underwent breast-conservation in the breast that had the cancer had a 148% increased incidence of prophylactic mastectomy in the opposite breast – the perfectly normal breast! So, the breast with the cancer is “saved” and the perfectly normal breast is removed! This is just plain crazy. The breast that has the cancer gets to "live" and the opposite breast, without the cancer, has to go. What planet are we living on?
Even though removal of the breast certainly reduces the likelihood that a breast cancer can grow there, it does not add one day to the overall survival of the patient. So, what’s the point? If prophylactic mastectomy is offered in order to reduce the anxiety and worry that the cancer might come back, or that it might occur in the opposite breast, I think women need to know that the risk of this happening is rather small: only 1% per year for every 100 women with the disease. This fact ought to reduce the patient’s anxiety considerably. It certainly has for my patients.
The proof that overall survival is not compromised by breast-conservation and radiation therapy has been documented repeatedly in dozens of studies conducted all over the world. In my own experience, when the Cancer Registry at my hospital, Clara Maass Medical Center in Belleville, New Jersey, reviewed my patients with DCIS they found that I performed 50% fewer mastectomies than other surgeons at my hospital, in my state and (on average) around the country. They also discovered that the recurrence rate for my patients was ten times lower than elsewhere in the state or the nation.
Again, in the vast majority of cases mastectomies for DCIS are not necessary. Recurrence of breast cancer is low if the disease is treated properly; overall survival is well maintained. Women do not have to sacrifice their breasts in order to save their lives. In summary, women with DCIS should not be frightened into having unnecessary surgeries that are risky, mutilating and provide no survival advantage.
I am certainly in favor of preventing breast cancer. I am particularly interested in preventing the recurrence of breast cancer. But the most important thing is to reassure women and give them the correct information about their true risks. DCIS is a non-invasive breast cancer. It does not threaten a woman's life. It can be treated very well with lumpectomy and radiation therapy. A woman with DCIS can keep her breast. She does not need mastectomy. She can keep her opposite breast also. If she should develop breast cancer in the opposite breast she can have breast-conservation with radiation therapy on that breast, too.
If women understood that mastectomies do not increase their survival, if women fully understood that breast-conservation is perfectly acceptable as treatment for DCIS, then I believe there would be far fewer therapeutic or contralateral "prophylactic" mastectomies. Those few women who feel that they cannot tolerate the anxiety that DCIS might recur can surely have mastectomy: but they will be few and far between, I am sure.
I wish more women were given the proper counseling, reassured about the relatively low risk of recurrence of DCIS and offered the least treatment that will provide cure and relative peace of mind - breast conservation and radiation therapy. Hopefully, this message will gain enough currency in cyberspace to help new patients with DCIS save their breasts as they strive to save their lives.
For your additional reference:
Regards,
Kathleen T. Ruddy, MD
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