Breast cancer: alternatives to mastectomy

USA Today (Society for the Advancement of Education), May, 1995 by Kristen Lidke Finn

Studies show that lumpectomy, in which just the tumor and a layer of surrounding tissue are removed, is an effective option when combined with radiation therapy.

THE BIOPSY comes back positive--it's breast cancer. One and a half million American women will be hit with such news this decade. Many of those whose cancer is detected early also will face one of the hardest decisions of their lives: whether to have a mastectomy or a lumpectomy followed by several weeks of radiation therapy.

Health care professionals can offer sympathy, support groups, and survival statistics, but, in the end, it is the women who must make the decision. "These women are largely on their own when it comes to deciding what to do at a time when they're least prepared emotionally to do so," notes Penny Pierce, assistant professor of nursing, University of Michigan.

Upon hearing that they have cancer, many women describe being mentally and emotionally clouded and unable to think, Pierce explains. "They say, `I could see the doctor's mouth moving, but I was somewhere else: I didn't hear a thing that was said to me.' They describe this complete fog that comes over them ... they project themselves into a different place and time and worry about what's going to happen to their children." Soon, if not immediately after hearing the diagnosis, these women are asked to make a choice about treatment--at a time when they have few emotional resources upon which to draw.

"For some women, the process of making a quality decision is more emotionally draining than the diagnosis of breast cancer itself," indicates Pierce, who in 1985 was the first in the nation to study the decision-making experiences of women with early-stage breast cancer. While her initial study involved about 50 breast cancer patients, she since has expanded her research to include hundreds of healthy women to find out what type of breast cancer treatment they most likely would pursue, and why. By better understanding how women make life-altering choices in the face of often-conflicting information and emotional turmoil, Pierce hopes to develop practical clinical guidelines to help patients and their caregivers deal with the grueling decision-making process.

Until about five years ago, they didn't have the luxury of choice. A breast cancer diagnosis almost always meant mastectomy--the removal of the breast and its adjacent lymph nodes--followed by reconstructive surgery. Up to 70% of operable breast cancer cases still are treated this way nationwide.

The remainder are selecting a procedure called lumpectomy, in which just the tumor and a layer of surrounding tissue are removed. Studies show that it is an equally effective treatment option when combined with radiation therapy. The National Institutes of Health has endorsed lumpectomy as the treatment of choice for early-stage breast cancer because it preserves the breast without compromising long-term survival.

Despite essentially identical survival rates for mastectomy and lumpectomy, widespread disagreement exists among medical professionals about which is the best treatment for breast cancer. A study published in the New England Journal of Medicine indicates that physicians who are older, male, and practice in the Midwest, Southeast, and rural areas tend to be more biased toward the traditional mastectomy. Younger male physicians, female doctors. those who specialize in cancer treatment, and those who practice at urban and academic medical centers are more inclined to recommend breast-conserving lumpectomy and radiation therapy.

Because the medical community has not yet come together on the issue of breast cancer treatment, many patients feel caught in the middle. They are torn between the reassuring track record and thoroughness of mastectomy and the less invasive, tissue-sparing features of lumpectomy. "The paradox in decision-making is that you can make a very. very good decision and things can still go wrong," Pierce points out.

While there are no guarantees in life, there are things women can do to help themselves reach a decision they're comfortable with. One is to bring a friend along to the doctor's office to help listen and ask questions. "A good girlfriend or a sister should be assigned to listen and take notes. It doesn't have to be a spouse; in fact, a spouse may have the same problems absorbing the information," Pierce cautions. Patients also can bring a tape recorder so they can review the information at home, at their leisure.

Patients should insist that they be given adequate time--up to a week or two--to decide, if necessary. They should not be shy about getting a second opinion to help clarify the options. "Women need to know this is not emergency surgery; they have time to get their lives in order and to really think about what they want to do." Peace of mind apparently isn't the only benefit of this approach. "We have some notion that if people are comfortable with the intervention they're about to have, they tend to do better; they recover faster and have fewer complications."