Cancer treatments, especially for breast cancer, have become remarkably sophisticated and are responsible for saving millions of lives. But in some cases, the inclination toward surgery in one or both breasts may be unnecessary—or at least not without major complications. That has a growing number of experts saying that the standard ways in which breast cancer is treated verges on overkill—and needs to be rethought. A new study published Friday in the Annals of Surgery adds nuance to the picture.
The rate at which such surgeries are performed has skyrocketed. An oft repeated fact is that number of women with breast cancer in one breast who choose to have both breasts removed—called contralateral prophylactic mastectomy (CPM)—has doubled in a decade. Now, in the new study, scientists report that, in fact, rates of women who choose CPM tripled between 2002 to 2012. Nearly 50% of women who get CPM also undergo reconstructive surgery, compared with 16% in the women who have only one breast removed.
“What we saw is that the rates of prophylactic mastectomy is not only increasing, but increasing more quickly,” says the study’s senior author Dr. Mehra Golshan, distinguished chair of surgical oncology at Brigham and Women’s Hospital. That trend remained similar regardless of the woman's age, how advanced her breast cancer was at diagnosis and despite its hormone status—meaning whether the breast tumors contained estrogen receptors or not.
At the same time, the overall survival among women opting for CPM is no different from that of women choosing lumpectomy, in which only a portion of the affected breast is removed. And a paper published in early March found CPM does not markedly improve a woman’s quality of life. That concerns some scientists and doctors. “If I can say that the prophylactic mastectomy is going to keep you alive longer, then absolutely, that’s something we should definitely strive for,” says Golshan. “But it really made no difference in terms of overall outcome and survival.”
So why are women continuing to undergo invasive surgery on a healthy breast? For one, there is a lingering—though inaccurate—belief that cancer in one breast will spread to the other. “Cancer spreading from the left breast to the right breast or from the right breast to the left breast almost never happens,” says Golshan. And while it’s true that women diagnosed with cancer in one breast may develop an entirely new cancer in the opposite breast, even that rate is relatively low and not enough to prompt additional screening or any other action.
Another factor contributing to the rise of CPM may be advances in reconstructive surgery that could make women more comfortable with the idea of removing her breasts if she can restore them later. But Golshan says that such surgery comes with a price; there is often a loss of sensation in the chest area, and the tissue never returns to its original state.
Then there are the economics. In the U.S., the high rates of prophylactic mastectomy may be driven in part by the fact that insurance companies cover all surgical options that women might choose, from lumpectomy with radiation to a single mastectomy of the affected breast to double mastectomy including the unaffected breast.
Medically speaking, experts think that removing the opposite breast when one breast has cancer should be limited to women with known genetic mutations for breast cancer, for women with a family history, or those who were exposed to radiation as children. Only about 10% of women newly diagnosed with breast cancer fall into this category, and they make up only a third of the women opting for removal of their healthy breasts.
The vast majority are women, says Golshan, who likely don’t need to remove their healthy breasts and, more importantly, won’t benefit from doing so. “Whether it’s patient perception, what the doctors tells the patients, how we discuss the options — we’ve got to figure out what is driving prophylactic mastectomy rates so high,” says Golshan. “Removing the opposite, happy, healthy breast in general for most women diagnosed with breast cancer doesn’t make sense.”