Some with Breast Cancer Opt for Pre-emptive Surgery

 
Listen to Julie Margenthaler, MD, discuss the increase in double mastectomies in a Cancer Connection podcast.
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By Cynthia Billhartz Gregorian
Story originally appeared in the St. Louis Post-Dispatch

June 16, 2008 – On May 28, Marilyn Eiceman, 49, underwent a surgery that every woman fears: She had both breasts removed. Her right breast was cancerous. Even though pre-surgery tests hadn't confirmed there was cancer in her left breast, Eiceman made the decision to have it removed as well.

But Eiceman says she got something in return: "peace of mind."

"I could have tried a lumpectomy, not knowing if that would take care of it," said Eiceman, of Marion, Ill. "I know it seems kind of radical, but I did not want to go through radiation, … knowing there's a possibility I might have to go back to that over and over again for my left breast."

Eiceman is among a growing number of women choosing a more aggressive approach to treating breast cancer, including the removal of breast tissue that may not be cancerous.

Improved imaging technology, specifically with magnetic resonance imaging, has made it possible to detect more suspicious changes in breast tissue and may be partly responsible for a rise in mastectomies. Recently, the Mayo Clinic in Rochester, Minn., reported that the number of women undergoing mastectomies there for early-stage breast cancer had increased in the last three years, after declining during the seven years prior.

Women who had MRIs before surgery were 10 to 15 percent more likely to have a mastectomy than women who did not have MRIs. The study also noted that because the new MRIs are able to detect more abnormalities in breast tissue, they can produce false positives for breast cancer.

Five years ago, nationwide about 30 percent of women with breast cancer chose to have mastectomies; now it's closer to 40 percent, said Eiceman's surgeon, Dr. Julie Margenthaler, who is a surgical oncologist and assistant professor of surgery at Washington University.

Margenthaler's practice, which includes many high-risk women – those who are young, have a significant family history of breast cancer or have the BRCA genes – mirrors that trend.

Three factors are driving the increase in mastectomies, Margenthaler said: greater knowledge about genetics and family history, better imaging technology and fear of a recurrence.

"I have had patients who I felt would be good candidates for lumpectomy who then underwent MRIs identifying other areas of concern," Margenthaler said. "Based on that MRI, the patient has chosen to have a mastectomy instead. In several instances, the other suspicious areas were not cancer."

Several benign conditions that show up as abnormalities on an MRI include papillomas, fibroadenomas and fibrocystic changes, Margenthaler said. But until a biopsy is done on those areas, she said, you cannot be certain they are cancer.

But some patients – such as Eiceman – don't want to wait for the results of another biopsy. They want a mastectomy, and they want to get it over with.

From an emotional standpoint, that's understandable, Margenthaler said.

"They've been through so much physically and emotionally by that point," she said. "A biopsy is another step before treatment, which is what they want as soon as possible.

"The MRI can prolong the course of work-up prior to surgery, and this is very stressful to every patient with a new diagnosis of breast cancer," Margenthaler said. "But it's important to try not to make decisions based on an imaging test alone. We always recommend biopsy of other suspicious areas seen on MRI so that women who would do well with lumpectomy can be clearly identified."

Another of Margenthaler's patients, Nancy Boyd, had breast cancer that was not detected through self-exam, routine imaging, MRIs or even a sonogram.

Boyd, 66, of Godfrey, finally underwent a ductoscopy using a camera. Pathology reports showed that she had local ductal carcinoma in one breast only and none in her lymph nodes. Margenthaler recommended a mastectomy of the diseased breast because of the extensive nature of cancer throughout her breast. Rather than live with the anxiety and uncertainty that she might develop cancer in her other breast, Boyd decided to have both removed.

"If I didn't, I'd have to have a mammogram and MRIs every year and hope it would pick it up," Boyd said. "But how would I know that the mammogram or MRI or sonogram would ever pick something out? And if cancer did come into the other breast, I'd have to go through the same procedure all over again."

Margenthaler tells her patients that she will give them all the facts, but she knows that there are many intangibles in dealing with breast cancer.

"The majority of women with early-stage breast cancer can be effectively treated with lumpectomy," Margenthaler said. "The decision to proceed with mastectomy – or even bilateral mastectomy – should be reserved for those patients with extensive disease or high-risk factors.

"Fear and other emotional and psychological effects … are difficult to measure," she said. "And that's what often leads to those decisions."