Questions grow about rise in aggressive surgery for early breast cancer

breastIt’s described as an “aggressive, costly, morbid, and burdensome” surgery that often lacks “compelling evidence” that it contributes to patients’ “survival advantage.” So why are increasing numbers of women  deciding to have both their breasts removed when doctors detect early stage cancer in one breast?

New research, based on a questionnaire and follow-up with more than 2,400 women, recommends that surgeons be clearer and more direct about treatment options and outcomes with breast cancer patients. That’s because 17% of respondents said, incorrectly, that they think that removing the other healthy breast in a woman with cancer in one breast helps prevent the disease’s recurrence, while almost 40 percent said they didn’t know this procedure’s effects.

Researchers found that many women—including more than 40 percent of their respondents—with breast cancer contemplate the surgery known as contralateral prophylactic mastectomy (CPM), and that sufficient numbers of surgeons may not explain why it may be inappropriate for them. Their study has been published in the peer-reviewed Journal of the American Medical Association Surgery. As the Los Angeles Times reported:

[CPM may seem like] a logical way to reduce the risk of breast cancer, but in most cases, it isn’t. Unless a woman has a genetic mutation that increases her risk for the disease, the chance that a patient with early-stage cancer in one breast will later develop it in the other breast is very low — too low, doctors say, to justify the risks that come with surgery. That’s why the American Society of Breast Surgeons advises doctors to steer most women away from CPM. This wasn’t always the case, but treatments like chemotherapy, immunotherapy and hormone therapy have become so effective that in addition to reducing the risk that the known breast cancer will return, they also make it unlikely that a second breast cancer will develop, the study authors explained.

The American Society of Breast Surgeons has made it clear that CPM counseling should be robust and respectful of women’s choices, though the surgery isn’t a prime option for most. The newspaper said that researchers suggested that, ironically, women who were more involved in their breast cancer care tended to consider CPM more than those who left decisions more up to their surgeons. The paper said that “women were more likely to opt for CPM if they were younger, white, had attended at least some college, had a mother, sister or daughter with breast cancer, had private insurance (instead of Medicaid) or had larger breasts.”

Among survey respondents, 37 percent had doctors who recommended against the aggressive approach, and just 2 percent of these women underwent CPM. In contrast, 46 percent of respondents said their surgeons neither recommended nor discouraged the procedure—and, in this group, 21 percent of the patients underwent the surgery. Among women with higher risks, such as those with genetic mutations that might predispose them to recurrent female cancers, 26 percent of respondents fitting this profile said they had CPM. But 14 percent of respondents with average risk also had the surgery.

I’ve written about the risks and costs of overtreatment, for example with aggressive prostate cancer therapies and the mistaken notion that every individual over a certain age should undergo frequent and repeated mammograms or the prostate-specific antigen (PSA) testing or colonoscopies. Cancer can be terrifying, and I’ve also written that celebrity cancer commentaries may not be providing the soundest guidance to the public. Still, the disturbing rise in CPM, as the researchers have pointed out, underscores the need for surgeons to speak up. It’s great that women are informing and involving themselves deeply in their care, and many women say they value the sense of security that CPM seems to offer them. But I’ve written, too, about informed consent—patients’ fundamental right to be fully told about all aspects of their medical care. Doctors bear a burden because of their experience and medical knowledge to give their patients all the facts they need to make intelligent decisions about what treatments to get and where. If women aren’t getting the best available medical expertise about early stage breast cancer and what CPM will or won’t do, that’s a huge problem, and surgeons need to step up to deal with this situation.

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