Why do so many women may not need double mastectomy?admin 2017-11-24
More and more women with breast cancer are opting for double mastectomy - even a less radical treatment may be as life-saving as it is. Health has investigated the reasons behind this controversial choice.
Last December, the Casey Bressler Health Survey got the news, and many of us were worried that a biopsy revealed that the suspected lump in her right breast was actually cancer. Her surgeon told her she was a good candidate for mastectomy because the tumor was less than 2 centimeters long - they could remove it and keep her breasts. But Bressler's mother and grandmother died of breast cancer, so instead, she told her surgeon she wanted a double mastectomy.
"My mother had a single mastectomy when she was first diagnosed, a mastectomy in her 30s, and a second mastectomy 20 years later when she found cancer in another breast. Between her, she had numerous mammograms and constant worries, "says Bressler," a 56-year-old hospital administrator in Tacoma, Washington. "I don't want to do that. I want to take them away and finish them. "
Even a decade ago, treating cancer in a breast by removing both of them - known contralateral preventive mastectomy ("contralateral" means contralateral, "preventive" means preventive) - sounded like a radical option. But now, CPM is becoming more common - a trend that worries some doctors, because in most cases, there is no convincing medical reason to get rid of healthy breasts. "More newly diagnosed women come to clinics instead of asking," what is my choice of treatment? 'they said,' I want to get rid of the breast, '"says Dr. Michael Sabel, MD. University of Michigan. "It's not necessarily the wrong choice, but we want to make sure patients do it for the right reasons - and know what they're doing."
What drove the surge?
These numbers are eye-opening: In a study published earlier this year, researchers at Brigham Women's Hospital found that between 2002 and 2012, the proportion of women who identified CPM doubled, ranging from less than 4% to nearly 13% of women diagnosed with stage 1 to 3 cancer in a single breast. . "I'm not surprised because I see it every day in practice - but it's a bit worrying," said Dr. Mehra Golshan, senior research author and chairman of surgical oncology for Brigham and Women's. "Double mastectomy is not without risks, especially when you have reconstruction - most women choose to do so. And it will not increase your chances of cancer, because breast cancer is not likely to spread to another breast. "In other words, if your goal is to beat your cancer, removing healthy breasts is likely to give you very little survival advantage. So why are so many women?
Worry about being number one in the list. When Christine Hunt, 48, of Brooklyn, Connecticut, was diagnosed with stage 1 chemotherapy-resistant breast cancer in 2014, the same year her mother was diagnosed for the second time and knew she wanted a double mastectomy. Like Kathy Bressler's mother, Hunt's mother had undergone a mastectomy and then developed cancer in another breast decades later. Hunter said, "I don't want to worry too much when other shoes will fall off."
Dr. Todd Tuttle, director of surgical oncology at the University of Minnesota School of Medicine, said it was natural for women diagnosed with breast cancer to feel anxious about cancer cells in other breasts. "But fear can cause you to seriously overestimate the risk," he said. In a survey conducted a few years ago by Dr. Tuttle and his colleagues, they found that women with cancer in one breast were more than 30 percent more likely to develop potentially fatal tumors in the other breast - well above the actual risk of four. To 5%, "he said.
Dr. Saber adds that doctors may inadvertently promote anxiety in women by ordering more MRI mammograms for newly diagnosed patients. Because MRI provides more sensitive mammograms than mammograms, they are more likely to detect suspicious but ultimately harmless abnormalities in cancer-free breasts. "This may scare some women into thinking they should remove healthy breasts just in case," Dr. Saber said.
But even if you know that the risk of cancer in another breast is small, it's still hard to calm your fears - every time you have a mammogram, you feel fear or breast abnormalities, says Shoshana Rosenberg, ScD, an epidemiologist at the Dana-Farber Cancer Institute in Boston. In the past decade, Nicole Witt, 47, of Brandon, Florida, underwent seven suspicious mammographic biopsies before eventually having a double mastectomy in 2013. "My sister was diagnosed with breast cancer in her 30s, so it's really early for me to start receiving treatment mammography," she said. "I did a lot of biopsies, and I felt like I was having a mastectomy. This incredible pressure. When my last biopsy showed that the cells were not cancer but not 100% normal, my doctor and I agreed that I should have a double mastectomy. I feel very relieved to leave this problem behind. "
The younger you are, the more likely you are to develop a second type of cancer, which may make anxiety a powerful consideration for women in their 20s and 30s, Rosenberg says. "You can tell a young woman that the risk of contralateral breast cancer is low, but her risk of cancer is low - so it's only guaranteed so far. If women have children, the first thing they want to think about is that they want to watch their children grow up, "she said. "Preventive mastectomy may be the right choice if you think you can't handle the stress and worry of having a mammography every six months. In other words, surgery may not be the best way to get anxious. "
Change the times
But it's not just anxiety that drives this trend; there's also a subtle shift in attitudes in favor of double mastectomy, which may encourage more women to pursue more extreme treatments. "Fifty years ago, as medical historians pointed out, doctors were more likely to recommend radical mastectomy for women, so women believed that mastering their health meant saving their breasts through mastectomy," Dr. Karen Hurley said. A clinical psychologist specializing in the risk of hereditary cancer in New York. Today, partly because of news reports of genetic mutations, women tend to view double mastectomy as an empowerment option, Hurley said: "There's not much talk about the courage of women who choose to retain their breasts and maintain screening programs."
Dr. Sabel said the change in attitudes was partly due to media coverage of breast cancer celebrities. He and his colleagues recently analyzed news reports from 2000 to 2012, when CPM rates were increasing - and found that when a star underwent bilateral (bilateral) mastectomy, her treatment became the focus of the story, coverage tended to be significantly positive, and the risks and benefits of choice were not clarified. "In articles about celebrities who underwent unilateral mastectomy or tumor removal, their treatment was often not even mentioned," Dr. Saber said. "Even if it involves major health decisions, celebrities will also affect the trend."
But an important fact is often unclear in media reports: some celebrities who have undergone double mastectomy actually carry a genetic mutation that puts them at high risk of breast cancer. An estimated 250,000 to 415,000 women in the United States with BRCA1 or BRCA2 mutations - including Angelina Jolie, she
The headlines for preventive double mastectomy in 2013 - surgery can reduce their risk of developing the disease by more than 90%. The National Comprehensive Cancer Network (NCCN), an organization that creates evidence-based clinical practice guidelines, has identified preventive double mastectomy as a viable option for women with genetic mutations.
However, the NCCN recommends CPM for women diagnosed with breast cancer in one breast who do not carry high-risk mutations. Most breast surgeons agree with this suggestion. A recent survey of 601 breast surgeons showed that although 95% of patients felt comfortable with CPM in women with BRCA mutations, only 34% of women were comfortable with surgery in women at average risk. In July, the American Association of Breast Surgeons issued a statement saying that CPM should not be encouraged in a woman at risk of breast cancer.
"I always mention contralateral mastectomy as an option - but if the patient is unlikely to benefit, I'll explain why I don't advocate it," Dr. Saber said. "But most patients who choose it have decided that this is the route they want to take before they talk to a surgeon, even though most of them do not have any known mutations that increase their risk of breast cancer."
Two other factors may play a role in women's decision to implant CPM: first, surgery is covered by insurance. "I think it should be covered, but women definitely feel different," said Shelley Hwang, MD, director of breast surgery at Duke University. Second, mastectomy and reconstruction techniques have improved - if you do both, it's easier to create symmetrical breasts, says Deanna Attai, M.D., a breast surgeon and assistant clinical assistant professor at David Geffen Medical School. University of California at Los Angeles. "Many women are interested in more natural breast appearance, minimal scarring and symmetry," Dr Attai said.
Risk and return
When Jennifer Bolstad, a 40-year-old landscape architect in Brooklyn, New York, first learned about her right breast cancer eight years ago, she thought she had only had a mastectomy on that side. "My husband and I will start trying to have children, and I really want to breastfeed," she said. But when her doctor told her that she had invasive lobular cancer of a type that slightly increased the risk of cancer in unaffected breasts, she decided to have a double mastectomy and sacrifice her breast-feeding ability.
"I didn't have any known genetic mutations, but I saw two aunts diagnosed with the disease, and one died in her 30s. I don't want to live in the rest of my life, "she said. "But a few years later, when I was pregnant with my son, I really mourned the loss of my breasts, and there were some unintended consequences, such as my breasts didn't feel any way" - a common side effect of mastectomy and reconstruction.
Dr. Hwang says most women who get CPM don't regret making their own decisions, but studies show that many women want to know more about these tradeoffs before they start surgery. For example, it is important to understand that, on average, women receiving CPM have a worse quality of life than those who choose less invasive treatment options - they may even have lower levels of physical fitness. Dr Huang's research is because surgery itself has the side effects of long-term problems. For example, Dr. Hwang says up to a third of women suffer from chronic pain after reconstructive mastectomy. "You can also get infected, and there will be no wound healing," she added. "These factors may not change your mind, but you should know them before the operation."
Knowing the risks and benefits is particularly important for BRCA-negative women diagnosed with ductal carcinoma in situ (also known as stage 0 cancer). Precancerous abnormal cells in the breast duct - 31% of them choose CPM, and each recent study shows that although low-risk DCIS can usually be safely treated by doing nothing, it only needs to be regularly administered. Take a mammogram to make sure that there is no progress, "Dr. Hwang said. "Mastectomy is a big price for a disease that is unlikely to kill you," she points out.
Kathy Bressler said the fact that double mastectomy was more invasive than mastectomy did not worry her, but it ended up being a bigger operation than she had expected. Then the skin on one of her breasts began to die; to save it, she had to lie in a hyperbaric chamber filled with 100% oxygen every day for hours for five weeks. "Because surgeons cut your muscles to make room for tissue expanders, and they put tissue expanders in before implantation, you initially have T. Rex arms," she added. "My pain was the first two weeks. "Reconstructive mastectomy may take months, hours of surgery (each requiring weeks of recovery), and months.
In contrast, breast tumor resection is a relatively simple operation. "We made a small incision and the risk was very low, and most women had good cosmetic results," Dr. Saber said. However, most patients still need radiation.
But there is no regret for him. Her postoperative pathological report showed three tumors in her right breast. Her cancer has also become a three negative, a particularly aggressive subtype. "My breast X ray examination is very clean, and ultrasound shows only the first tumor," she said. "So I do not observe breast cancer according to my intention. I think the fear of another round will always exist - now I just don't have. "
However, even double mastectomy can not eliminate all risks. When Jennifer Bolstad became pregnant, she developed stage 0 lobular carcinoma in situ in a small amount of breast tissue and left it on the "healthy" side. "I'm not sure if I still have a natural breast, we'll find it as soon as possible, so I think it's a sign that I made the right choice for a double mastectomy," she said. "But no treatment is guaranteed. You must consider the most acceptable choices and deal with the consequences when they occur. "