Health

Unnecessary Mastectomies
Diana Zuckerman, Ph.D.

It is shocking but true: approximately one out of every two American women who have a breast removed as treatment for cancer do not need such radical surgery.

Whether a woman undergoes a mastectomy or a lumpectomy (which removes the cancer but not the breast) depends less on her specific diagnosis than on other factors, such as where she lives, her income and health insurance, where she receives medical care, her age, and when her doctor was trained.

Although it's been known for years that lumpectomy and other breast-saving surgeries are just as effective as mastectomy for patients in the early stages of breast cancer, in most parts of the country most of the women who receive an early-stage diagnosis will undergo the more radical and disfiguring surgery. Limited information and biased recommendations are undermining breast cancer patients' choices.

Articles published in some of America's most prestigious journals show that many of the more than 182,000 women who are newly diagnosed with breast cancer every year do not have access to all the information they need to make the treatment choices that are best for them. This raises questions about what doctors know and what they are telling their patients.

In addition, mastectomy is often followed by "reconstructive" breast surgery that involves the use of synthetic breast implants or tissue transfers from other parts of the body. These reconstructive surgeries have risks, but the lack of published epidemiological studies means that many of the women making these decisions have limited information about their safety.

After all the research that has been done on the safety of lumpectomies, why are so many women undergoing mastectomies they don't need and then having reconstruction that can cause serious problems? One reason may be economic. In many facilities, it's actually cheaper to remove a breast than it is to perform a lumpectomy and provide the necessary follow-up radiation therapy.

Some striking research findings include:

In some hospitals, all breast cancer patients had mastectomies, regardless of their diagnosis. In one large urban hospital serving mostly poor women in Texas, 84% of the women with early stage breast cancer had mastectomies and only 16% had lumpectomies.

In a study of 157 hospitals, patients treated by doctors trained before 1981 were less likely to have lumpectomies or other breast-saving surgery than women who had younger doctors.

One study indicated that women getting mastectomies were more likely to have followed their doctors' recommendations, but women getting lumpectomies were more likely to have obtained a second opinion, and felt more actively involved in making the decision.

A study of 175 surgeons found that even doctors who know that lumpectomy is as safe as mastectomy may persuade their patients to get mastectomies by making subtly biased recommendations. Other studies showed that some women were not even told that lumpectomies were an option.

Women deserve better.

Breast cancer patients should make the choices that are best for them, wherever they live and no matter how affluent they are. We need to do a better job of making sure that all doctors and their patients have accurate, unbiased information so that women can make those choices, no matter who they are, or who provides their medical care.

Research clearly shows that lumpectomy and other breast-conserving surgeries are just as safe as mastectomy for most women with early stage disease, and yet approximately half will undergo the more disfiguring procedures.

Choices about breast implants and autologous tissue reconstruction are based, at best, on a few published studies that provide limited information about the long-term safety of these procedures. Many healthy women who have strong family histories of breast cancer consider prophylactic mastectomies, and their decisions are also based on very limited information, because there are few studies showing the effectiveness of that procedure.

Breast cancer is the most common malignancy in women in the United States; more than 182,000 women will be newly diagnosed this year.

Unlike previous generations, most of these women will have several choices to make, including the type of surgery, whether to have radiation, the type of adjuvant therapy (chemotherapy or hormonal therapy), and the type of reconstruction, if any. However, many of these women will not have access to all the information they need to make the choices that are most appropriate for them.

There is considerable research evidence that where a woman lives, her income level and health insurance, the type of medical facility, when her doctor was trained, and the doctor's enthusiasm for breast-conserving-surgery may have more impact on her surgical treatment than her specific diagnosis.

For example, research has clearly shown that most women who are diagnosed with noninvasive or early-stage breast cancer can be very safely and effectively treated with breast-conserving surgery. And yet, so few women have this surgery that it raises questions about whether they are objectively informed about the advantages and disadvantages of their surgical options.

In addition, the lack of research on some prevention and treatment options makes it impossible for many women to obtain the information they need to make fully informed choices.

The historical context is essential to understanding why information may be inadequate. Many of today's breast surgeons were trained at a time when there were few choices in breast cancer treatment, and tradition may still influence some doctors against breast-conserving surgery.

Halsted developed the radical mastectomy in the 1890s; this procedure removed the breast, skin, nipple, areola, pectoral muscles, and all the axillary lymph nodes on the same side. Even more radical procedures were sometimes used, removing part of the breastbone and ribs to get the internal mammary nodes.

In the 1940s, doctors in England developed the modified radical mastectomy, which removed the breast and axillary lymph nodes, but left the chest muscles intact. Although the reoccurrence rates seemed comparable to those for the Halsted, the modified radical mastectomy did not become more common than the Halsted procedure in most US hospitals until the mid-1970s.

When researchers determined that many breast cancers grow slowly, treatment decisions became less urgent, and clinical trials were conducted to evaluate less radical procedures. In a study started in 1971, Fisher compared the survival of women who were randomized into three treatment groups: radical mastectomy, simple mastectomy (which removes only the breast and areola), and simple mastectomy with radiation.

After 15 years, the survival rate was the same for all three groups. This study, published in 1985, was a turning point, resulting in surgical choices for more women diagnosed with breast cancer. Choices about radiation, chemotherapy, hormonal therapy, and reconstruction also influence surgical decisions. Now that women have so many choices to make, informed consent has become an important issue for breast cancer patients.

Informed consent relies on a patient receiving accurate information and freely making a decision based on that information. If objective information is not available on some aspects of breast cancer treatment because of lack of research, then the patient should be told that there is no research, or that existing research is inconclusive.

If physicians describe their own experiences to patients, they should also explain the limitations of that information compared to data from long-term, objective empirical research.

Breast-Conserving Surgery

In a landmark study comparing women with early-stage breast cancer who received breast-conserving surgery followed by radiation with those who had mastectomy, eight years after surgery, approximately 91% of the women in both groups remained free of cancer.

A consensus conference convened by the National Institutes of Health (NIH) in 1991 concluded that breast-conserving surgery with radiation was as effective as mastectomy for the treatment of early-stage breast cancer.

The participants understood that breast-conserving surgery would not be the choice of every woman who was eligible, and that the expense, inconvenience, and fear of radiation would deter some women; nevertheless, the consensus was that lumpectomy and other breast-conserving surgery would be preferable for most patients.

The NIH consensus conference on breast cancer surgery was intended to help breast-conserving surgery gain wider acceptance by informing physicians and the public that these procedures are as safe as more radical surgery. In the decade since then, however, most of the women who have been eligible for lumpectomies have undergone mastectomies instead.

Women who are poor and who live in certain parts of the country are especially unlikely to have breast-conserving surgery. For example, in a 1995-1996 study of patients at a large, urban, university-affiliated Texas hospital serving primarily medically indigent patients, only 16% of those eligible received breast-conserving surgery.

Although fear of breast cancer or radiation may make some women reluctant to choose breast-conserving surgery, one would expect that information clearly explaining that they would live just as long with lumpectomies as with mastectomies would reassure more than 16% of any group of women.

Since breast-conserving surgery was believed to be safest for women with early-stage breast cancer, one would expect well-informed women with stage I breast cancer to be significantly more likely to undergo breast-conserving surgery than those with stage II breast cancer.

Instead, the vast majority of women in this study underwent mastectomies regardless of stage, and the authors expressed concern that the surgeons' opinions and recommendations were the likely reason for the high rate of mastectomy.

Attitudes may be more important than knowledge; a substantial proportion of surgeons who knew that lumpectomy was as safe as mastectomy unknowingly influenced patients in favor of mastectomy with subtly biased presentations.

Similarly, the surgeon's "interest and enthusiasm" for breast-conserving surgery increased the likelihood of patients choosing that treatment. Physician attitudes were also found to be influential in earlier studies of breast-conserving surgery.

Lumpectomy with radiation is often more expensive than mastectomy, so financial incentives may also contribute to unnecessary mastectomies.

Studies of low-income women indirectly support concerns that breast cancer patients are making surgical decisions that may not be based on informed choice.

Researchers believe that physician knowledge and attitudes are a likely explanation for the dramatic regional differences they have documented in breast-conserving surgery. Differences in physician knowledge and attitudes could also contribute to widely varying breast-conserving surgery rates within states.

Prophylactic Mastectomy

As women have become more aware of the risk factors for breast cancer, including family history and gene mutations, healthy women who are concerned about their risk of cancer are deciding whether to undergo prophylactic mastectomies.

This raises informed consent issues in two ways:

Are women receiving accurate and understandable information about their risk of breast cancer?

And are they appropriately informed about the risks and benefits of prophylactic mastectomy? The fact that women were willing to undergo prophylactic mastectomies even before research indicated that the surgery significantly reduces the risk of cancer indicates the level of fear associated with the disease.

Statistics warning that one of every eight women will get breast cancer are often quoted in the media, but it is less widely understood that the lifetime risk is much higher than the risk for women under age 50 and exponentially higher than the risk that a woman of any age will get cancer in the next five years.

The first step in informed consent for women considering prophylactic mastectomies should be to clarify the differences between lifetime risk and short-term risk, and to emphasize that estimates about the risks associated with genetic factors are very preliminary.

Improving Informed Consent for Breast Cancer Patients

Informed consent for breast-conserving surgery, prophylactic mastectomy, and reconstructive surgery is limited partly because physicians themselves lack the information they need to appropriately inform their patients. In all these situations, informed consent should focus on what is not known about long-term risks in addition to what is known about failure rates and local complications.

Physicians should provide as much objective information as possible, including long-term follow-up data from their own patients. We do not know if most doctors inform women of the lack of research, but there is clear evidence that at least one medical association is providing women with overly optimistic statements about the safety of implants. Related Articles http://www.mercola.com/2001/nov/21/mastectomies.htm National Center for Policy Research for Women & Families Journal of the American Medical Women's Association, Fall 2000, 55: 285-289

National Center for Policy Research (CPR) for Women & Families 1444 Eye St NW, Suite 900 Washington, DC 20005. (202) 216-9507 http://www.cpr4womenandfamilies.org

DR. MERCOLA'S COMMENT:

The most important thing when it comes to cancer is prevention. There are so many options to breast cancer prevention, but of course most all involve changing the eating plan and making some lifestyle changes and clearing up some emotional wounding.

Related Articles http://www.mercola.com/2001/nov/21/mastectomies.htm

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