Women's Health

Breast Cancer and Elective Double Mastectomies: A Thing of the Past?

Breast Cancer and Elective Double Mastectomies: A Thing of the Past?

Oncology physicians and surgeons are baffled as more women with cancer in just one breast are choosing to have a double mastectomy instead of opting for traditional forms of treatment. (The double mastectomy procedure in these cases is the removal of a healthy breast and is medically referred to as Contralateral Prophylactic Mastectomy or CPM).

Today, there are several treatment options for women with breast cancer. So why, a study asks, would a woman choose to have both breasts removed when one option would be to just remove part of the affected breast, then follow up with radiation?

The latter intervention, referred to as “breast-conserving surgery” would be less disfiguring and would also allow the woman to keep all her healthy breast.

Why the increase in CPM?

“The increase in CPM is largely among young women with early-stage unilateral breast cancer and without genetic risk factors like BRCA.” (Alexandra Sifferlin, referencing the related 2015 study at the University of Texas MD Anderson Cancer Center)

(BRCA is a genetic abnormality found to play a large role in the development of “familial” breast and ovarian cancers.)

The University of Texas study also found that mastectomies and breast reconstruction not only cost more but have brought about more complications that lumpectomies.

Additionally, a 2016 Duke University study indicates a double mastectomy is recommended for women with the BRCA genetic mutation placing her at high risk for breast cancer in the currently healthy breast. But, for non-BRCA patients, the CPM doesn’t necessarily prolong life. (Senior author Dr. Shelley Hwang, chief of breast surgery at the Duke Cancer Institute.)

Some reasons given for women’s choice for elective removal of the healthy breast are for “peace of mind” regarding fears the cancer will show up in the other breast, avoidance of radiation treatments, for “cosmetic reasons”, and because she’s heard from friends and relatives about their choice to have CPM.

Research results

With the surge of women choosing CPM in mind, a 2015 research team at the University of Texas MD Anderson Cancer Center determined in their study that the risk for complications was doubled for mastectomy and reconstruction in comparison to a lumpectomy then followed by radiation (referred to as breast-conserving surgery).

That research team also found that women with early stage breast cancer who had lumpectomies were 21% more likely to be living ten years later compared to women who had mastectomies.

In the midst of this surgical crisis of sorts, most physicians are seeking ways to help their cancer patients live longer while limiting unnecessary treatments.

Although it’s been said that Doctors tend to discourage the CPM procedure unless the woman is at high risk due to presence of the BRCA gene, a current research study, published in Jama Surgery, offers a somewhat different slant on this issue.
The study researched what influence the attending surgeon might play in a patient’s choice for a CRM. It also considered the surgeon’s underlying opinion about that procedure.

The survey was population-based in that its focus was to answer research questions related to a specific group of people: In this case, the subjects were all women with breast cancer who received treatment services from an attending surgeon.
A total of 7,810 women were enrolled in the study. The women were seen for early stage breast cancer between 2013 to 2015.
16% of the patients had the CPM procedure.

Follow-up after procedures

Surveys were mailed to the women about two months after their surgeries. Surveys were then mailed to the 488 attending surgeons identified by the study participants.

A majority of those attending surgeons had extensive experience with breast cancer treatment. As identified in the research report, 52% had practiced for more than 20 years and 30% treated over 50 new breast cancer patients each year. There was a 70% response rate from the women polled, and 77% from the surgeons. (Steven J. Katz, MD, MPH; Sarah T. Hawley, PhD, MPH; Ann S. Hamilton, PhD; et al).

Findings showed that, in this particular case, surgeons favoring the CPM approach performed 34% of these surgeries while those preferring the breast-conserving surgery performed only 4%. Thus, it was determined that those particular attending surgeons exerted strong influence on the likelihood of the CPM procedure for women diagnosed with breast cancer. (Katz, Hawley, Hamilton, et. al). 

Another type of cancer where some women have requested CPM surgery is ductal carcinoma in situ (DCIS). We learn that DCIS is the most common breast cancer diagnosis, with more than 60,000 new cases per year. This condition is considered to be a precancerous stage of the disease. The abnormal cells are isolated in the milk-producing sacs and ducts in the breast. Women with this condition have been traditionally treated by surgery, radiation, and hormonal treatment, with some receiving CPM surgery per request. (“DCIS: What You Need to Know”)

In considering treatments for DCIS, “Adding radiation after a lumpectomy for DCIS does not improve a patient’s long-term survival… Our job as doctors is to educate patients about their options to help them make the right choice for them. (Jean L. Wright, M.D., associate professor of radiation oncology and molecular medicine at Johns Hopkins University School of Medicine in Baltimore, Md.)

"Watchful waiting," in which patients are monitored for signs of trouble, may be a better track for them,” says Dr. Laura Esserman, (researcher and breast cancer surgeon at the University of California San Francisco's Carol Franc Buck Breast Care Center.)

From JAMA Oncology, we learn the following:

  • The essence of watchful waiting” is the foundation for a new plan of care for DCIS. As a growing number of women with this type of Stage 0 breast cancer are choosing not to have surgery or radiation, they are electing for “active surveillance.” This translates to “no further care” after doctors remove all the abnormal cells during a biopsy used to diagnose DCIS.
  • In active surveillance, the status of the DCIS is monitored every 6 months and may be treated with hormone therapy with an oral medication such as tamoxifen. As long as the cancer cells are “contained” the condition is not a cause of death. Should the cancer become invasive, then a different treatment approach will be necessary.

Final thoughts

The thinking of doctors and patients about continuing established aggressive steps to respond to DCIS is evolving as new information emerges about who's most at risk.

It has been found that high risk groups for women with DCIS are black women and those diagnosed with DCIS under age 35. “Researchers advised continuing with current aggressive treatment for women in these two high risk groups” (JAMA Oncology).
When women are diagnosed with breast cancer, it causes a flood of emotions, a barrage of questions to be asked, and the weight of decisions to be made.

It could be helpful for a supportive family member to be involved with the discussion on treatment options.

They should find out all they can about the diagnosis and treatment options: Ask the surgeon for handouts and do research online or at the library.

And, above all, they should feel free to exercise their right for a second opinion.