“New Breast Surgery Comes with Choices”

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The Story

“New Breast Surgery Comes with Choices”
by Jeanne Erdmann
Cure, June 26, 2010

The Pitch

[Erdmann notes: I came up with this idea after attending the Society of Surgical Oncology meeting in 2010. I learned quite by accident that it was going to be held in St. Louis and I talked my way in. I’d found several story ideas that I pre-pitched to the web editor for Cure, and this is the one she chose. I subsequently wrote a full pitch.]

The Choice

Breast cancer surgery has come a long way from radical mastectomies. Nipple-sparing surgery can restore breasts that look identical but reconstructed breasts don’t weigh or feel the same. On the flip side, women opting for mastectomy often choose to have both breasts removed, even with cancer confined to one breast. Women face a difficult choice either way.

“Jane Smith” decided to have both breasts removed even though her doctor told her that the extreme surgery wouldn’t improve her chance of survival… [TK real patient who chose bilateral therapeutic mastectomy.]

Some studies show that mastectomy rates are rising in the United States. Studies done at single institutions show that women opt for two extremes: having both breasts removed or minimal breast reconstructive surgery. Populational studies, such as the SEER database (Surveillance Epidemiology and End Results), show that mastectomy and breast reconstruction rates are holding steady among U. S. women.

Why the difference? Todd Tuttle, MD of the University of Minnesota, says that patients at academic institutions more likely undergo aggressive surgery because physicians refer patients to large institutions when they have a strong family history or have BRCA mutations. Also, MRIs can pick up early lesions in the other breast, perhaps nudging women towards double-mastectomy over breast reconstruction. Some women would rather have mastectomy than six weeks of daily radiation therapy perhaps because transportation is an issue or they don’t want to experience the side effects of radiation.

Tuttle says these choices can mean that some women are over-treated while others are under-treated. He worries about both groups. If women who receive mastectomies don’t have radiation, then the breast cancer mortality could increase. “Patients overestimate the frequency and severity of radiation side effects,” comments Tuttle.
The treating physician is the most important influence, he says, and needs to make certain patients understand the actual risk of developing cancer in the other breast versus the risk and complications of contralateral prophylactic mastectomy.

Women opting for contralateral mastectomy seem to have this in common: they’re young, Caucasian, have more favorable tumors, higher education levels, a family history of breast cancer, and receive treatment by a female surgeon.

V. Suzanne Klimberg, MD, of the University of Arkansas has developed a total-skin- sparing technique that preserves the nipple and matches, by appearance, the reconstructed breast. Klimberg often sees patients who have had poor reconstruction and says the consequences of such surgery can be devastating. When done properly, though, breast reconstruction can bring emotional healing.

“Jane Jones” opted for breast reconstruction. Like Smith, her tumor was node- negative… [TK real patient who chose breast reconstruction. I will find two women whose circumstances such as age, stage, nodes, ER status, date of surgery, etc are as close as can be matched but who chose different surgeries.]

Breast reconstruction isn’t perfect either. Some women, for example, are unprepared for the differences between the two breasts. Klimberg wants her patients to understand that they will experience sensation loss–women often don’t realize that. Also, the weight of the reconstructed breast will differ from the healthy breast. “I’ve had patients with tremendous cosmetic results that really looked like previous breast but the weight of the implant as compared to the weight of the breast is just too much for them to take and they’re unhappy,” says Klimberg.”

Not all physicians agree with nipple-sparing surgery. I sat by Robert Piorkorski MD, a general cancer surgeon at Hartford Hospital in Connecticuit and he thought that Dr. Klimberg’s technique produces a reconstructed breast with a good appearance because she leaves too much tissue under the nipple, which could underestimate the chance of recurrence. He’s not convinced of safety data. Studies indeed show reconstruction is safe from an oncology standpoint but Dr. Piorkorski does make a point that breast reconstruction techniques are surgeon-dependant.

No wonder this choice is difficult. Either option brings physical pain. Videos of nipple- sparing surgery show the skin stretched a lot during the procedure and the incisions look long. The breast may end up looking great but I’ll bet those women wake up in plenty of discomfort. Likewise, losing both breasts at once probably hurts quite a bit. My mom had single mastectomies 17 years apart and she was in great discomfort.

This choice may boil down to peace of mind.

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