Each year about 207,000 women are told they have breast cancer. But thanks to better detection and treatment, more women are surviving than ever before. And while the death rates are on the decline, the percentage of women who choose mastectomy (which removes the entire breast) over a lumpectomy (which preserves most of the breast) is actually on the rise. One study found that from 2004 to 2007, 44 percent of women chose to have a mastectomy, compared with just 33 percent from 1994 to 1998. And the percentage of women who decide to have both breasts removed, not just the one with the tumor, has more than doubled since 1998.
Patients often choose aggressive treatments for good reasons, including reassurance. But incomplete, confusing, or in some cases, biased information from their doctors also influences their decision. Here’s what you should know to get the care that’s best for you.
Surgery: Aggressive vs. minimal
Most women with breast cancer receive a diagnosis of either an early-stage tumor or ductal carcinoma in situ (DCIS), in which abnormal cells remain confined to the ducts in the breast and pose little threat of spreading. Some experts question the need to treat DCIS at all, since the abnormal growths usually pose no long-term risks. But because doctors can’t predict which growths might later prove invasive, most treat it like a more clearly dangerous tumor.
Lumpectomy is not a good option if the tumor is too large or diffuse or the patient can’t tolerate radiation. But in other cases it’s as effective as a mastectomy, so the choice depends on individual concerns. A lumpectomy spares most of the breast, leaves a smaller scar, and eliminates the need to wear a false breast or have reconstructive surgery. But it usually entails two to six weeks of daily radiation treatments. That might be impractical if no treatment center is nearby.
Radiation can cause significant fatigue, but many patients fare well enough that they can continue to remain active. It can also cause some permanent shrinking and hardening of breast tissue, as well as itchy and tender skin. In about 25 percent of patients, the skin can temporarily break down and take about a week to fully heal.
Mastectomy usually requires radiation only when the tumor is very large or cancer cells have spread to nearby lymph nodes. The surgery removes all the breast tissue from the side of the chest that has the tumor. That improves the chance of removing all the cancer and makes it less likely that you’ll need a repeat procedure in the future. But losing a breast makes some women feel disfigured. Improved plastic surgery and advances in surgical techniques, such as a skin-sparing mastectomy and simultaneous breast reconstruction, might be part of the reason more woman are choosing to have a mastectomy.
Prophylactic mastectomy, or having a healthy breast removed along with a diseased one, does reduce the risk of developing a future breast cancer. But that is rarely necessary, since the chance of developing cancer in the unaffected breast is low. It’s much more likely for the cancer to spread instead to the lymph nodes or other parts of the body, and prophylactic mastectomies don’t prevent that from happening. Our medical consultants say that women should first consider nonsurgical options, including frequent checkups and possibly taking a drug to reduce any risk of cancer in the other breast.
Drugs: Get the right one
Several medications can reduce the risk of cancer returning after surgery. But which one depends on your age and the kind of breast cancer you have.
Tamoxifen> (Nolvadex and generic) can cut the risk of breast-cancer recurrence when taken for up to five years after surgery, but only if the cancer is fueled by the female hormone estrogen. And because the drug blocks some of estrogen’s effects on the body, it can bring on symptoms similar to those of menopause, including hot flashes, irregular periods, and vaginal dryness. Tamoxifen might also cause indigestion or make you feel nauseated.
Aromatase inhibitors, a newer class of drugs, cause fewer problems than tamoxifen. But they can still cause bone loss, and only postmenopausal women should take them since they shut down estrogen production entirely. Three are now available: anastrozole (Arimidex), exemestane (Aromasin), and letrozole (Femara). Side effects such as aching joints and weak bones seem to be more common than with tamoxifen.
Targeted therapy with trastuzumab (Herceptin) can help the 20 percent of breast-cancer patients who have a protein called human epidermal growth factor receptor 2 (HER-2). People with that protein are more likely to experience fast-growing, treatment-resistant tumors.