When a woman is diagnosed with breast cancer, one of the most difficult decisions she may face is how to treat it. Immediately after diagnosis, many women jump to the conclusion that a double (bilateral) mastectomy is the best, life-saving choice. But that’s simply not the case. The choice is not between saving your breast and saving your life. It’s important to point out that women with early-stage breast cancer who have breast-conserving surgery (lumpectomy) live just as long as those who have a mastectomy. There is no difference in survival for women who do not have hereditary breast cancer. If the cancer is diagnosed early and there are no genetic factors that can change the course of the disease, we can reach 95 percent cure rates with appropriate conservative treatment.
This is good news, and yet double mastectomies are on an extraordinary upward swing in the U.S. So, why are so many women choosing to have a mutilating procedure that has moderate to high complication rates? Could it be that advances in plastic surgery promise more attractive artificial breasts than years ago? Or could it be that women are not aware of their options, the positive data and the risks that come with such a drastic approach? Keep in mind – breast cancer is not a localized disease; it is systemic, which is one of the reasons we use some form of systemic hormones or chemotherapy as part of the treatment plan.
For a small number of women, a bilateral mastectomy is necessary because the cancer is an aggressive type or present in both breasts. However, in most cases of double mastectomy, a healthy breast is removed. The decision to proceed with a bilateral mastectomy often is incited by unfounded fear or an inaccurate assessment of the risks and benefits a woman may face. “The Angelina Jolie effect” has played a major factor. In 2013, Jolie publicized her path to a bilateral mastectomy after learning that she carried the BRCA1 gene – a mutation that carries an 87 percent risk for developing breast cancer. It should be noted, however, that the BRCA1 and BRCA2 genes linked to breast cancer are rare (0.25 percent). Only one in 800 women in the U.S. carry these mutations.
Current cancer treatment guidelines discourage bilateral mastectomies for most women. Experts recommend the procedure be considered only on a case-by-case basis for women at high risk of bilateral breast cancer, such as those who carry the BRCA1 or BRCA2 mutation or those who have a higher risk of contralateral breast cancer. To make an educated decision, women should seek a second opinion and discuss the options with specialists, including surgeons, medical oncologists and radiation oncologists. Women shop around when purchasing a new car or clothing, but most do not shop around when dealing with cancer and choosing their physicians. They should. And they also would benefit from talking to other women who have gone through treatment, surgery and recovery.
Thanks to great advances in the field of radiation oncology for breast cancer patients, less aggressive treatments consisting of a lumpectomy followed by radiation have been used with great success for more than 20 years. Brachytherapy is an alternative to conventional irradiation for early breast cancer. Accelerated partial breast irradiation (APBI) delivers radiation only to the part of the breast where the tumor was removed, minimizing the radiation exposure to the adjacent healthy tissue and potential side effects. APBI can be given in a shorter course than some other radiation therapies for breast cancer – usually five to seven days instead of five to six weeks.
It’s important that women with breast cancer weigh the advantages and disadvantages of all treatment options, including a bilateral mastectomy. Women should research their options, think carefully and proceed cautiously in order to make medical choices that will lead to a happy and healthy life post-cancer.
Beatriz E. Amendola, MD, FACR, FASTRO, FACRO
Radiation Oncologist – Innovative Cancer Institute, South Miami