Buried in last week's news that double mastectomies don’t improve survival outcomes for women with breast cancer (among the general population— not those with a genetic predisposition to the disease) was another interesting tidbit: Women with early stage disease treated with lumpectomy and radiation had higher survival rates than those who’d had a single mastectomy alone. This is not the first time I’ve read that finding. In 2013, the largest-ever observational study of women with early breast cancer also found lumpectomy with radiation was associated with not just equivalent, but better survival odds than mastectomy. Women over 50 with hormone-receptor positive disease had the greatest advantage—a 13 percent lower risk of death from breast cancer. These results are significant because, after declining throughout the 1990s and early 2000s, the rates of mastectomy among women with stage I or II cancer began rising again in 2005.
Why has there been an uptick in women choosing mastectomy? And what would make those women less likely to survive? The studies don’t answer those questions, but one clue may be that women who choose mastectomy are more likely to be lower income and uninsured (making the word “choose” deceptive). These women may be financially or logistically unable to go through six weeks of radiation, especially if they also need chemotherapy, which is, in itself, time-consuming and expensive. Such patients may have reduced access to care or other, complicating health issues that would affect survival. The women who choose mastectomy are also more likely to be women of color. Minority women contract breast cancer less often than white women, but when they do, they tend be younger and have a more virulent form of the disease, so their outcomes are, inevitably, worse.
What about women who feel they do have a choice (and some do not, depending on the placement and size of their tumor)? Why would they opt against breast-conserving surgery when outcomes are the same or possibly better than mastectomy? Anyone facing medical crisis tends, according to Steven J. Katz, a professor of medicine and health management and policy at the University of Michigan, to act from the gut rather than the head. Mastectomy intuitively feels like the more aggressive choice, even though, because radiation can treat a larger area than surgery, it’s not. (That difference may also explain some of the disparity in survival.) When I was first diagnosed with breast cancer in 1997, I chose lumpectomy, but looking back, that, too, was ultimately a gut decision. I remember thinking that, five, ten, 15 years after treatment, I didn’t want the body I saw in the mirror to be a perpetual reflection of cancer.
Apparently that perspective is falling out of fashion. Particularly in the last few years, women have been tacitly encouraged to do “everything you can” by an increasing number of high-profile women (Amy Robach, Samantha Harris, Wanda Sykes, Christina Applegate) who are hailed as heroic by the media for removing both breasts after diagnosis. “I made my decision because I love life,” Sykes has said. And who doesn’t? (These women’s treatment choices are, of course, their own affair; I’m only commenting on how they publically frame those decisions for everyone else.)
Removing the organ that betrayed you, according to Susan Love, founder of the Dr. Susan Love Research Foundation and author of Dr. Susan Love’s Breast Book, offers the illusion of control. “Most women don't realize that cancer in your breast is not what kills you. Rather it’s the cancer cells that make it to more important organs—the lungs, the liver, the bones. So the living or dying part is not about what you do to the breast; it is the systemic treatments such as chemotherapy, hormone therapy and/or targeted therapy like Herceptin that make the big difference. But having a mastectomy or bilateral mastectomies gives you the illusion of control at a very scary time and for many women that itself is worth it.”
It’s actually great news that the least invasive surgery produces the best results. Newly diagnosed women can now confidently keep their healthy breast; they can confidently choose breast conserving surgery over mastectomy; they can endure less pain and risk of complication both from surgery itself and reconstruction. And in doing all that they may actually increase their chances of survival!
I don’t want to dictate or second-guess anyone’s choice. We make the decisions we make at the time that we make them with the information we have, knowing it will change, and we don’t look back. But, moving forward, I hope that women facing new diagnoses have the most accurate data when making their choices: that mastectomy—whether removing one or both breasts—does not appear to increase survival. And I hope that the understandable quest for personal control at the time of diagnosis doesn’t distract us from the real issues in breast cancer today: reducing harm, assuring access to quality care, understanding metastasis, seeking the causes of cancer, and finding a way to keep those whose disease progresses alive.