A few years back, an old friend of mine called to tell me that she had breast cancer. She then went on a rant about the breast surgeon she saw who recommended a lumpectomy followed by radiation therapy. She told him in no uncertain terms that she wanted a mastectomy, she viewed that breast as a traitor and she wanted rid of it. When he began to discuss immediate reconstruction of her breast, she was even angrier. “It’s so typical of a man to think of a woman as two breasts. What do I need it for?”
I was stunned. Women had been fighting to get the medical “establishment” to study breast-conserving surgery, and when the studies were finally done, showing that long-term survival rates were the same with both forms of treatment, they fought to get doctors to offer this surgery to their patients. And here was my friend, railing at her surgeon for doing the very thing we women had told him and his colleagues we wanted them to do.
I thought of my friend when I read a Journal of Oncology study looking at the treatment decisions women with early stage breast cancer make. Researchers in Los Angeles and Detroit, responding to the still high mastectomy rate in these women, along with the regional disparities in treatment, interviewed a group of women with early breast cancer. The researchers thought, as many before them have thought, that cancer surgeons must be steering their patients toward the mastectomy option. This concern has become so widespread, in fact, that 20 states have passed laws requiring surgeons to present all treatment options to their patients. Maybe if we had more patient involvement in the treatment discussion, mastectomy would be less common.
Researchers in this study, still certain that doctors were the culprits, were taken aback by their results. It turned out that the more involvement a woman had in her treatment decision, the more likely she was to choose mastectomy, with 41 percent of women who said they made the treatment decision themselves, without involving their doctor, opting for mastectomy 27 percent of the time. Since only 15 percent of surgeons recommended mastectomy, the theory that doctors drove the decision just didn’t hold up.
Why would women choose to lop off a breast rather than hanging on to it? The researchers found that the major concern for the women who chose mastectomy was recurrence of their cancer. Local recurrence (in the breast in the case of breast-conserving surgery or on the chest wall in mastectomy patients) is a little more common in breast-conserving surgery patients than in mastectomy patients. And while mastectomy is a pretty involved surgery, with major down time and considerable possibility for ill effects, five to six weeks of radiation therapy, five days a week, is no picnic either.
I had another friend whose breast cancer did come back locally – in her case it was after a mastectomy – and I remember the absolute betrayal she felt. She had fought and licked this cancer, and she was not at all prepared to face that battle again.
What this study tells us, I think, is that it really is imperative for physicians to discuss all treatment options with their patients. We just cannot assume that all women want to hang on to both their breasts. Those states that passed the disclosure laws thought they were making sure women knew about the breast-conserving option, the option NIH recommends for most women with early-stage breast cancer. But women want to consider all the options, to decide what is best for them.
If women are opting for mastectomy because they think they will live longer, then we physicians need to educate them that studies don’t support a longer life for mastectomy patients. But if they are weighing all the risks and benefits, and considering the impact this cancer has on their own body and their own life, then we need to support them and their choice.
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