When I started out as a breast surgeon in the early 1980’s, most women diagnosed with breast cancer were told they needed to have a modified radical mastectomy—removal of the breast and all of the lymph nodes in the armpit. Many others were still being treated with a radical mastectomy—removal of the breast and lymph nodes and the pectoral (chest) muscle. Why? Surgeons strongly believed that the more they removed the lower the chance of having the breast cancer come back.
Then, in 1981, researchers reported the results of a groundbreaking study conducted in Italy that had randomly assigned women with stage I or II breast cancer to have either a radical mastectomy or a “quadranectomy” (removal of the quarter of the breast containing the tumor, all of the lymph nodes in the armpit, and part of the chest muscle). Much to the surprise of the surgical world, the survival results were the same! This study, published in the New England Journal of Medicine, made it clear that our surgical goal—“get it out” quickly and aggressively—was open to question.
Even so, American surgeons were slow to accept this new data. In fact, many often said to me, “That only applies to Italian women with Italian breast cancer… in America we need a more aggressive approach!” To my mind, there was no reason that Italian women would be any different, but no one really cared what a young female surgeon thought she knew about women’s breasts.
Then, in 1985, an American study published in the NEJM that compared the two procedures, both with and without radiation, showed the same results. Because this study was conducted on American women, American surgeons began to believe that it wasn’t necessary to remove the whole breast. This idea was reinforced over time as new studies showed that even less of the breast could be removed, leading to today’s lumpectomy. This approach also was supported by other studies that were showing that giving chemotherapy and hormone therapy after surgery (adjuvant therapy) to kill any cancer cells that might have already left the breast could extend survival.
Having performed surgery during this evolution and having fought for a woman’s right to have a lumpectomy and keep her breast, I have been struck by the statistics showing an increase in the number of women choosing to have a mastectomy instead of a lumpectomy. There are multiple reasons this is occurring, from the decrease in the stigma of mastectomy to the improvements in reconstruction, as well as the ongoing and all too understandable anxiety associated with future mammograms and fear of a recurrence.
But while it’s easy to understand why women would perceive more as possibly better, and, if not better, at least the same in terms of the cancer and their peace of mind, we also need to continue to look at what the research shows. And a study published this week online in Cancer gives us a lot to think about.
The study, led by Shelley Hwang, a surgical oncologist at Duke University in North Carolina, looked at what happens in the real world to women who were diagnosed with stage I or II breast cancer and had to decide to have a lumpectomy and radiation or a mastectomy. Their goal was to answer these questions: Does mastectomy affect long-term outcome? Would the women who had a mastectomy have better overall survival or be less likely to die of breast cancer? (Overall survival is how likely you are to die of anything. Breast cancer-specific survival is how likely you are to die of breast cancer.) Is there a difference based on the age you are diagnosed? Does it matter if the tumor is hormone-sensitive (ER+ and/or PR+)?
Using the California Cancer Registry, Hwang and her colleagues identified 112,514 women aged 18-80 who had been diagnosed with breast cancer between 1990 and 2004 and who met the criteria for their study. Within this group, 61,771 (55%) had had a lumpectomy and radiation and 40,383 (45%) had had a mastectomy.
During the 10 years after these surgeries, there were a total of 31,416 deaths; 39 percent (12,252) were due to breast cancer. Much to everyone’s surprise, the women who chose lumpectomy followed by radiation had the same or better overall survival or breast cancer-specific survival—regardless of age, or hormone status! Breast cancer specific survival favored the lumpectomy group too—and that stayed the same after taking into account tumor grade, proportion of positive nodes, race, socioeconomic status, tumor size, age at diagnosis, and year of diagnosis.
Overall, the best survival advantage was seen in women over 50 with hormone positive tumors. Among this group, those who had a lumpectomy followed by radiation had a 13 percent lower chance of dying of breast cancer and a 19 percent lower chance of dying overall than those who had a mastectomy.
Why? We don’t actually know. There were some things the study couldn’t account for, such as health care access or other health issues that may have led women to choose a mastectomy over a lumpectomy. But it certainly gives us something to think about as we ponder why, when it comes to breast cancer, so many women continue to believe “more is always better.” It should also help women newly diagnosed with a stage I or stage II breast cancer who are trying to decide what is best for them.