Breast Cancer: Woman Is Partner in Choosing Treatment

by Food and Drug Administration (FDA)

This is the second of two FDA Consumer articles on breast cancer. The first article, in last month's issue, discussed breast cancer risk factors, the anatomy of the disease, biopsy of a suspicious lump or area in the breast, and mammography. This article covers treatment and breast reconstruction.

In a recent talk on breast cancer, Susan Bates, M.D., remarked, "It has been said that a woman must know more about her disease in breast cancer than a physician. With the array of choices currently facing a woman diagnosed with breast cancer this is more true now than ever before."

The choices that Bates, a researcher at the National Cancer Institute (NCI), refers to were not available to Joyce Fine of Bethesda, Md., 19 years ago when, at 43, she underwent a Halsted radical mastectomy — removal of her entire breast, the underlying chest muscles, all the axillary (underarm) lymph nodes, and some additional fat and muscle. Fine's surgeon did not discuss with her possible treatment alternatives. The Halsted radical was the standard treatment for breast cancer in 1972.

"There was no discussion," Fine recalls. "He convinced me I had to have the tumor out as soon as possible and that I should sign a release that if they find at biopsy that it's cancerous, they should remove it right away."

The surgeon acknowledged that Fine could have a two-step procedure, in which only a biopsy would be done at first, and surgery, if the tumor proved malignant, would be scheduled later. (See "Breast Cancer: Complacency the Enemy of Cure" in the July-August 1991 FDA Consumer for more on breast biopsy and the two-step procedure.) "But he said that if I go that way, it would metastasize [spread] and I couldn't be put under anesthesia again soon," she says. "It would be a waiting period of a couple weeks, and I was so frightened I said I'd do it in one procedure. He made me feel as though if I didn't, I might be dead in two weeks."

And so, like so many women with breast cancer then, Fine went into surgery not knowing if she would leave the hospital physically the same as she entered, or minus one breast as the result of extensive, disfiguring surgery.

"Beginning in the 1940s, studies were suggesting that so much surgery was not necessary," says Bates. "In Europe, by 1971, smaller operations were accepted, but in the United States, change was slow in coming. Surgeons were reluctant to abandon the Halsted radical mastectomy for fear of giving inadequate treatment."

Treating Early-Stage Disease

Both the surgery and the process Fine experienced now belong to medical history. Surgical treatment now emphasizes breast conservation — preserving the breast when possible. Lumpectomy (also called segmental mastectomy or tylectomy), in which only the tumor and a margin of surrounding tissue is removed, is light years away from the Halsted radical, both in its physical and psychological effects.

Radical mastectomy was based on the rationale that breast cancer started with a tumor in the breast and, over time, spread in an orderly fashion to the lymph glands under the arms and then, through the lymph and blood, to other parts of the body — usually the lungs, liver, bone, or brain. Halsted's procedure was designed to remove the avenues of possible spread.

By the late 1970s, experts had determined that the Halsted radical mastectomy was not necessary. As Bates says, "It was a consensus that less is more."

This conclusion was based on research that changed the concept of how breast cancer progresses. It is now understood that very early in the disease (although exactly how early is not known), breast cancer cells travel through the blood and lymph to other parts of the body. In this process, called micrometastasis, the cancer is so small it can't even be detected with a microscope. Treatment now emphasizes removing the tumor while sparing the breast and controlling metastasis with the use of additional therapy that may include radiation, chemotherapy (drugs that kill cancer cells), hormone therapy, or a combination.

As new approaches to surgical and medical treatment have been tried, each method has had its supporters and dissenters. In 1957, NCI organized the National Surgical Adjuvant Breast Project to create a pool of data gathered from research on breast cancer treatments. In the late 1970s, scientists reviewed study results and determined that simple, or total, mastectomy, in which only the breast was removed, was as effective as the Halsted radical.

Then, in 1990, at a National Institutes of Health consensus development conference on treatment of early-stage breast cancer, a panel of experts agreed that still less extensive surgery, lumpectomy, gave the same results if radiation followed surgery to kill any remaining cancer cells. The lymph nodes are also removed for examination during this procedure.

The panel concluded that breast conservation treatment is not only appropriate for most women with early-stage disease, but also "is preferable because it provides survival equivalent to total mastectomy and also preserves the breast. Total mastectomy remains an appropriate primary therapy when breast conservation is not indicated or selected."

"Despite nearly 20 years of studies showing that survival with lumpectomy and radiation is equivalent to that of mastectomy, only one-fifth of women eligible for lumpectomy have the procedure. This may be due in part to the slowness of some surgeons to accept and offer, without subtle or explicit bias, the newer procedure," says Bates.

Wendy Schain, Ed.D., a participant at the NIH conference and psychosocial director of adult oncology at the Memorial Cancer Institute in Long Beach, Calif., says that of the 14 most recent studies examining the psychosocial consequences of breast surgery, all showed that patients with breast conservation therapy had significantly improved body images compared with patients who underwent mastectomy.

"For most of the kinds of psychological symptoms we measure, there are not vast differences in magnitude between the two treatment groups," she says. "But the issues underlying the different symptoms are very dissimilar. The depression in mastectomy patients is due primarily to feelings of disfigurement and concern about the impact on intimate relationships, whereas the underlying reasons for depression in breast conservation are fatigue and loss of vitality.

"Chemotherapy, whether following mastectomy or lumpectomy, is the single most psychologically undermining course of treatment," says Schain. "It pervades all areas of well-being, both physical and psychological, ranging from feelings of lowered self-esteem to energy drain and other physical distresses."

Schain says that some patients with lumpectomy seem to have some increased anxiety about recurrence, but that the studies on this are "pretty much split and should not be interpreted to mean that the cosmetic benefits gained from breast conservation would be offset by increased fear of recurrence."

About the Author

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