June 10, 1997

6. Options

It usually requires a considerable time to determine with certainty the virtues of a new method of treatment and usually still longer to ascertain the harmful effects.

Alfred Blalock (1899-1964)

Twenty years from now, if I were writing this article, it might be possible to say that there is one best treatment for breast cancer. That is not possible today, because the jury is still out on several important issues. A study of cancer of the colon might be done in 5 or 10 years; one on breast cancer takes at least 10 to 20. The definitive studies on breast cancer treatment started in the '70s with studies to compare radical with simple mastectomy. Many of the studies, particularly on lumpectomy (removal of just the tumor rather than the whole breast), are still in progress.

Today, a person with a breast lump has several options. The old method of doing a frozen section and proceeding as they used to, with a modified radical mastectomy or a simple mastectomy, is still available. Older surgeons might do it, but it is not done very often these days. Radical mastectomy might be done only in exceptional circumstances. The most frequently used option these days is to have the lump, if it is relatively small, removed with local anesthesia. If it is large, then a biopsy is performed. A biopsy involves taking a small piece of the tumor. After the tumor has been examined by a pathologist, further options can be explored without rushing. The advantage of doing it all in one operation is that it takes less time and costs less. The disadvantage is that the likelihood of an error in diagnosis is greater. Doing it in two stages allows time to get a second opinion and the time to carefully consider all possible options.

A modified radical mastectomy is a simple mastectomy, but the surgeon takes much of the tissue in the armpit and with it, many of the lymph nodes draining the breast, which are checked for the presence of cancer. Its advantage to the patient is that she will have a better idea whether the tumor has spread, on which further treatment or lack of treatment may be based. One advantage is that if nothing is found, often nothing more will be done because you are probably cured by the surgery alone (odds are better than 4 out of 5).

There was a large flap in the news, a few months ago, about one surgeon in Canada who submitted falsified data to a large breast cancer study. Fortunately, this was not the only group doing this work. There are a number of well-controlled studies on the effect of lumpectomy, that go to 10 years after the operation. I heard one authority and several newspeople say that "lumpectomy is as effective a cure as mastectomy". That is only partly true. Lumpectomy alone is not very effective. On the other hand, lumpectomy combined with a total of 5,000 rads of X-ray, delivered over a large number of treatments, will produce survival that is the equivalent of mastectomy. In other words, as far as we can determine to date, lumpectomy combined with radiation seems to be as effective as mastectomy in curing breast cancer. There are complications of X-ray which are likely to show up later. One complication that is showing up now is that a woman who has had X-ray treatments to the chest area is at increased risk of developing lung cancer, if she smokes. I think that it is reasonable to expect other complications to show up. To many women, these long term risks are acceptable in order to preserve their breasts.

The procedure in vogue today for women with breast cancer who refuse to lose their breasts, is to do a lumpectomy, the removal of just the cancer. A second incision is made in the arm pit and a number of lymph nodes are taken and sent to the pathologist for study. The breast area is irradiated and, if the nodes are positive, adjuvant chemotherapy is recommended.

Women with positive lymph nodes are frequently given adjuvant chemotherapy, which is chemotherapy give shortly after either mastectomy or lumpectomy with radiation. Some physicians use it with women who have negative nodes as well. People I know who have had chemotherapy claim that it is rough, but many therapists think that it isn't. There are good data that show that the percentage of women (with positive nodes) who survive breast cancer for more than 5 years, is appreciably greater with adjuvant chemotherapy. Whether this represents increased cures or not remains to be seen. The next 5 or 10 years should tell the story. In any case, a person who has not been cured by the surgery who is given adjuvant chemotherapy is likely to go for a longer time before a relapse.

For women who want the best chance of a cure, mastectomy is the preferred, time tested, treatment. Twenty years from now, this may not be so, but I doubt it. There are many surgical options as far as taking lymph nodes are concerned. Taking nodes does not improve a persons chances of a cure, but it does tell the physician whether the cancer is one that tends to spread and whether adjuvant chemotherapy is indicated.

Having experienced both a modified radical and simple mastectomy, there is no question in my mind the the simple operation is less painful and has fewer complications. There are a number of surgical techniques that are used, depending on the surgeon.

I have heard from several sources that female surgeons tend to be more considerate with regard to the special problems of women. If I were a woman with a breast tumor, given a male and female surgeon of equal competence, I suspect that I would go to the female. However, competence should be the primary consideration.

I would like to conclude with some advice: Examine your breasts monthly and, should you find a lump, get to your physician. A person with a very small cancer has a much greater chance of being cured than does a person with a larger cancer; the smaller the cancer, the better the prognosis. A woman with breast cancer does not necessarily have to lose her breast. With breast cancer, delay can be fatal.

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