Pre-emptive removal of healthy breast may accomplish nothing

MIAMI >> Many women who undergo contralateral prophylactic mastectomy to remove a healthy breast along with a diseased breast do not need to, but might do so for peace of mind.

When Sandra Perez, a Pembroke Pines mother of two, was diagnosed with cancer in her left breast, she was adamant about following the least invasive form of treatment.

“I told the doctor, ‘I don’t care what you do, but I don’t want my breast removed,’” said the 49-yearold insurance agent.

When Sari Sosa, a pharmaceutical rep from Kendall, got the life-changing news about cancer in her right breast, she was “completely and utterly in shock.” Unlike Perez, however, she decided the best way to attack the tumor was by getting both breasts removed.

“I didn’t want to be in the same place dealing with the same worries a few years down the road,” said Sosa, 46.

These two divergent reactions are typical of early breast cancer patients. More and more, however, women are choosing contralateral prophylactic mastectomy, or CPM — removing the healthy breast along with the diseased breast — instead of just removing the tumor and surrounding tissue, known as a lumpectomy. (Lumpectomies involve radiation after the surgery.)

Studies show the CPM rate has increased more than fivefold since 1998, fueled more by overestimation of potential risk than actual survival rates. The jump has caused concern in the medical community.

“It’s a very personal choice, but I think some of these decisions are being made out of fear rather than current research findings,’’ said Dr. Mecker G. Moller, a surgical oncologist and professor of surgery at the University of Miami Miller School of Medicine. “There is only a small percentage of high-risk patients who would benefit from undergoing prophylactic mastectomies, based on genetic predisposition. But some patients don’t want to continue living with the threat. They want peace of mind.”

Peace of mind is not without a price. A double mastectomy is a potentially riskier procedure than a simple lumpectomy, in which surgeons remove the tumor and surrounding tissue but leave the breast intact. What’s more, choosing to remove both

“It’s a very personal choice, but I think some of these decisions are beingmade out of fear rather than current research findings.” — Dr. Mecker G. Moller, Miller School of Medicine, University of Miami

breasts to treat cancer affecting only one side does not improve survival rates for most women.

A Stanford University study of almost 200,000 California women who were diagnosed with unilateral breast cancer found that the 10-year survival rates were almost identical — about 82 percent — for those women with double mastectomies, compared with those who had chosen the breast-saving surgery to remove the tumor. It was the first-ever study, published last month in the Journal of the American Medical Association, to compare breast cancer surgeries.

In the study, based on data from 1998 to 2011, a little over half the women had a lumpectomy. The number with double mastectomies, however, increased notably over time, with the most significant rise occurring in women younger than 40, a group where the more invasive surgery jumped from 4 percent to 33 percent during this period.

Younger women might choose the more aggressive treatment because they have longer to live and want to hedge their bets, explained Dr. Carmen Calfa, a breast oncologist at Memorial Breast Cancer Center in Broward. “They want to make sure they’re doing everything. Peace of mind is a hard thing to quantify.”

Overall, white women with private insurance and those who received care at a National Cancer Institute-designated center were most likely to seek a double mastectomy, the study found. By contrast, women of racial and ethnic minorities, as well as those with public insurance or Medicaid, were more often to favor unilateral mastectomies. The removal of one breast was associated with a higher risk of death in the study, but researchers believe that could be due to the size of the tumor, the stage of the disease and other unrelated socioeconomic risk factors that might have delayed diagnosis and treatment.

There are a few cases in which bilateral mastectomies are recommended, of course— when there is cancer in both breasts, when there are large tumors, a genetic mutation or inflammatory cancer. Some women, like actress Angelina Jolie, undergo a prophylactic double mastectomy as a preventive measure. Jolie was a carrier of BRCA1, a gene that increases the chances of contracting breast and ovarian cancer. Her doctor said she had an 87 percent chance of developing breast cancer and her mother died of the disease at 56, according to news reports.

But very few women fall into that high-risk category. In cases where cancer is found only in one breast, the National Comprehensive Cancer Network discourages removing the healthy breast, recommending that it be considered on a case by case basis only for high risk women.

The results of the Stanford study weren’t a surprise to doctors, who have noted the same results with their patients. Research has shown that only between 3 to 9 percent of most women who undergo a lumpectomy or a unilateral mastectomy go on to develop cancer in the other breast.

“It’s a game of odds,” said Dr. Claudia Giron, associate director of Baptist Health Breast Center. “It’s about choices, and those choices are really very dependent on the individual. As a physician you have to look at many factors, the patient’s overall health, tumor characteristics, even the social support they will have for follow-up treatment and imaging.”

Even with the low odds of developing cancer in the other breast, the risk might be too chancy for some women. The fear of developing cancer in a healthy breast can be highly stressful, affecting a patient’s family and lifestyle. Sosa, for example, has no regrets.

After speaking to her specialist, she stuck to her original decision to remove both breasts. Though she has no family history of breast cancer nor any genetic mutation, her estrogen-positive breast cancer “was growing at a very, very fast rate and in my doctor’s opinion the aggressive therapy was best.”

Perez, on the other hand, is “absolutely secure” about her lumpectomy.

“My thought is why go through all that when you don’t have to,” she said.