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Why Do We Treat Early Breast Cancer Like It’s the Dark Ages?

Breast conserving surgery, sometimes with radiation seeds, for lower stage breast cancer existed as early as the 1920s. A series of studies demonstrated its efficacy, but not until Fisher et al published the results of NSABP B-06 in 1985 did a majority of eligible patients pursue breast conservation. Interestingly, rates of women deciding against avoidable mastectomies have not continued to increase toward the 100% mark since that time, and, in fact, went down in subgroups of women during the interval following the study’s publication.

A great number of societal concerns may be at fault for this, not the least of which was the Angelina Jolie effect, which, while it involves a different breast cancer situation, did a lot to normalize the loss of this particular body part.

Lumpectomy vs mastectomy is a decision that asks women to understand statistics, greatly impacts their self-image, and often must be made at a time when they have many good years of life ahead of them if the cancer can be managed successfully. It is such a complex choice that someone who spends their every clinic day guiding women in making it can still be completely caught off guard by a patient’s thinking on the topic. In the US more than in other countries with comparable health resources we have not been successful in further reducing rates of unnecessary mastectomies.

Enter the recent massive prospective study from Sweden published this month in Jama Surgery showing that breast conservation may lead to greater survival. In almost 49,000 women with breast cancer both overall mortality and breast cancer specific mortality were reduced in patients after lumpectomy and RT compared to those treated with mastectomy even after correction for an array of potentially confounding factors. The effect held for early-stage node positive patients as well as N0.

“In short,” say the authors, “more extensive breast surgery does not appear to save any lives.”

It will be very interesting to see the impact of this information on surgical practice, particularly in the US where a well-oiled machine of breast reconstruction may explain part of our patients’ apparent lack of concern over losing a natural breast. I suspect an additional component in the decision as it exists now stems from the extreme radiation phobia of my compatriots, which, as demonstrated by this study, has little foundation in potential for real harm. But that’s a subject for another post.

How do you think your practice will be affected by the knowledge that overall survival may be better in patients treated with breast conservation than after mastectomy?

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About Dr Kate Hitchcock
Kate Hitchcock, MD, PhD, is a radiation oncologist, biomedical engineer, and retired aircraft carrier driver who grew up as a Wyoming cowgirl. When she is not at the hospital, you can find her with Carolyn, Mary, Tyler, Nick, Marlee, and Colby the barking dog, enjoying the natural splendor of the great state of Florida. She thinks you should visit sometime and try to solve the puzzle of why the natives have so carefully shunted all of the tourists toward the House of Mouse. Connect with her on Twitter:

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