Welcome back to The Breast Blog Ever, where Dr. Silva and I present relevant topics about breast cancer diagnosis, treatment and anything breast cancer related. My name is Kris Beauchamp. I’m a two-time breast cancer survivor. During my cancer journey, I found Dr. Silva, who is one of the most intelligent, informed, skilled yet humble and kind doctors I’ve ever met (and I’ve met a lot, believe me!) It’s been six and a half years since the second diagnosis, and I’m happy to say that with all the factors thrown in, I’ve got less than a 3% chance of recurrence and I’m regularly under his watchful care.
Dr. Silva and I have a genuine desire to help people who are facing breast cancer. We want you to be informed so that you can make the best decisions possible and achieve the best outcome. We had discussed the possibility of collaborating on a blog for women, and we are delighted to be up and running! This is his first article. He has written it in ‘lay terminology’ but it may still be a bit mind-boggling, so I’ve provided a list of terms as well as a brief summary and closing comments.
Please remember, we are not giving you medical advice, just providing information for you to become more informed. We want you to be equipped to find and receive the best medical care possible and to ask good questions to your doctors so that you may make the most informed decisions for your own health and well-being.
We welcome your questions or comments. Now here is Dr. Silva:
Why are women with a single early breast cancer having their opposite normal breast removed also?
In 1991, a National Cancer Institute Consensus Conference endorsed breast conserving surgery (BCS), defined as lumpectomy with post-operative whole breast irradiation, over mastectomy as the preferred treatment of early stage breast cancer (ESBC). In 2002, with more than 25 years of follow-up, renewed examination of all the studies which made this recommendation possible revealed the same results. Over the years this led to a decrease in mastectomy rates. By 2003 BCS rates in the USA approached 69%. Recent reports have demonstrated that in the US this trend is decreasing despite the fact that breast cancers in the US are increasingly smaller at diagnosis. More alarmingly, many women who have no established genetic predisposition or increased risk for developing a cancer of the opposite normal breast are opting to have it removed also.
Among the reasons documented for this tendency is the introduction of MRI in breast diagnostics. Its use coupled with incomplete assessment by clinicians of any real genetic risk has led fearful and uninformed patients with ESBC to unnecessary preventive removal of the opposite normal breast (CPM). Many patients, young and old, opt for CPM based on a questionable MRI finding without a biopsy to prove it is cancer. The standard of care requires that no decision be made about such a finding without a biopsy proven diagnosis of cancer. Multiple distressing reports have shown an increase in CPM from 4.2% in 1998 to 11% in 2003. In one report 8.3% of these women were age 60 or older at the time of CPM. In these women’s normal expected lifetime, the odds of developing a cancer in the other breast are near zero. Among women age 18-49, where a larger proportion could be at increased genetic risk, 25% opted to have their other breast removed. These reports also show that the CPM rate increased with MRI use. Often, the reason for CPM was physician’s advice regarding the risk of cancer in the normal breast. This negligible risk has been documented since the days of the radical mastectomy and demonstrates how inadequate informed consent can be very damaging. This risk is well established as 3% at 5 years. Furthermore, it is decreased by 50% in patients using tomoxifen and 20% in those treated with chemotherapy. These are frequently used to treat their initial breast cancer. Clearly, preventive removal of the normal breast can have no impact on the survival of a patient in whom the stage of her known cancer is the primary determinant of survival. At present, there is no question that increasing utilization of MRI by physicians not familiar with all of its limitations coupled with patient’s inordinate fear and inadequate risk assessment lead to very difficult and hurried conversations. Many specialized cancer surgeons find that all this information is hard to convey at a single visit as it may require discussion about reliable alternative surveillance strategies, prevention strategies, accurate genetic risk assessment and its limitations without resorting to removal of a normal breast. The explosion in our knowledge about breast cancer, the selective testing of individuals at genetic risk and the prudent use of MRI requires the use of evidence based algorithms within specialized multidisciplinary breast centers to care for what is the complicated problem of breast cancer.
Edibaldo Silva, MD, PhD, FACS
- LUMPECTOMY = surgery to remove the lump and surrounding tissue
- WHOLE BREAST IRRADIATION = radiating the entire breast area
- MASTECTOMY = surgically removing the entire breast, surrounding tissue, and some lymph nodes
- RADICAL MASTECTOMY = a mastectomy where underlying muscle is removed as well (rarely done any more because the cancer is dealt with before it gets to the muscle)
- ESBC = early stage breast cancer
- BCS = breast conserving surgery
- CPM = unnecessary preventive removal of opposite breast
Summary: After 25 years and a follow-up of initial studies, a National Cancer Institute Consensus Conference drew the same conclusions: lumpectomy followed by whole breast irradiation is the preferred treatment for ESBC. Yet, in only 5 years, the women opting for unnecessary breast removal jumped from 4.2% to 11%! It nearly tripled!
Why has the number of women choosing breast conservation decreased? Why are they choosing to have both breasts removed even though it isn’t necessary?
Some possible reasons:
- having tests, specifically breast MRI, done but not having the results evaluated by someone specially skilled to do so
- only receiving partial information
- patients rush to make a decision without even having a biopsy first to see if it is cancer
Kris’s closing comments:
When facing cancer, there are so many variables to consider. Just one visit to the doctor doesn’t provide enough time to unpack them all. Too often though, a decision to remove both breasts is made without all the facts. (I remember the knee-jerk reaction I felt of “just get it out of me!” Thankfully, my doctors responded that I didn’t need to rush, but had time to make an informed decision. They were right! Even though it’s difficult to wait, an informed decision is always better than a hasty one.)
A person facing breast cancer needs to have a qualified (experienced, knowledgeable and skilled) team of doctors helping them make the best decisions for their particular situation. Their doctors will want to discuss surveillance strategies, prevention tactics, genetic risk assessment, as well as treatment options and timetables. The team will need to discuss the best course of action for you before bringing to you their recommendations. It’s excruciatingly difficult to wait, but it’s worth it.
Fear is never a good teacher. It is an even worse doctor. If you or a friend or family member are facing breast cancer, Dr. Silva and I urge you to go to a specialized multidisciplinary breast center. (And for what it’s worth, from my perspective, a teaching hospital is going to be the most ‘cutting edge’ – pardon the pun – they’ll have the most up-to-date information as well as doctors who are leading the way.) Remember, you can win a battle that you are well-equipped to fight!