Prophylactic Mastectomies: Tough Decisions for Young Women
Conquest - Spring 2009
By Laura Sussman
For graphic artist Jill Butler, there was a different kind of calm before the big storm. Just two days before Hurricane Ike made landfall in September 2008, Butler underwent a surgery that gave her peace of mind — a mastectomy to remove both her cancerous left breast, as well as her non-affected right breast, in hopes of reducing her chances of having the disease return.
“The hurricane did add a little levity to the situation. Imagine coming off anesthesia, changing bandages and reading prescription bottles in the dark,” she says.
Diagnosed at age 38 with early stage disease, Butler first underwent a lumpectomy. But when her pathology came back with unclear margins, she knew she had decisions to make.
Catapulted by her young age, pathology results and strong family history of breast cancer — her mother died at 47, her maternal grandmother’s sister also had the disease and her maternal grandmother died from ovarian cancer, which is often genetically linked to breast cancer risk — Butler sought the care of Kelly Hunt, M.D., professor in the Department of Surgical Oncology at M. D. Anderson. Together, they reviewed Butler’s risk factors and discussed risk-reducing options.
What’s in a word?
“For me, the word mastectomy was loaded, perhaps because of my mother’s diagnosis. However, once I came to terms with my decision to have a mastectomy, deciding to remove both breasts was easy. I needed to feel like I was doing everything possible to minimize my risk of the disease returning,” Butler says.
Until recently, clinicians had few tools to determine for whom risk reduction surgery would be most appropriate. Now, researchers at M. D. Anderson have found that the preventive procedure to remove the unaffected breast in patients with disease in one breast, contralateral prophylactic mastectomy, may only be necessary in patients with specific high-risk features.
Their findings, published in Cancer, may one day not only help physicians predict the likelihood of patients developing breast cancer in the opposite breast, but also stratify risk and counsel patients on their treatment options.
Currently, it’s very difficult to identify those patients at highest risk who may benefit from this aggressive and irreversible procedure, Hunt explains. Women often consider contralateral prophylactic mastectomies not because of medical recommendation, but because they fear having their breast cancer return.
“We’ve always known contralateral breast cancer risk is not the same for all women, and it is unnecessary to perform preventive mastectomies routinely,” says Hunt, the study’s lead author. “As we begin to clarify the specific risk factors, the number of women undergoing the surgery may decrease, and those with a low-to-moderate risk may be more open to less extreme options for risk reduction, such as hormonal therapy and newer agents for breast cancer prevention.”
Numbers on the rise
According to the researchers, approximately 2.7% of women diagnosed with breast cancer choose to have the surgery. However, recent statistics have shown that these rates in women with stage I-III disease increased by 150 percent between 1998 and 2003.
To classify risk factors, researchers reviewed the cases of 542 M. D. Anderson patients with breast cancer in one breast who had surgery to remove the second breast. Of these women, 435 patients had no abnormal pathology identified in the opposite breast, 25 had contralateral breast cancer identified at surgery and 82 had abnormal cells that indicate a moderate-to-high risk for breast cancer in the contralateral breast.
Further analysis of patients with contralateral breast cancer revealed that strong predictors are a five-year Gail model risk of 1.67% or greater; an invasive lobular histology; and multiple tumors in the original breast. Patient race, estrogen receptor status and progesterone receptor status weren’t associated with increased risk.
The Gail model, typically used for patients without breast cancer, evaluates factors such as age, age at first menstrual period, number and findings of previous breast biopsies, age at first live birth and number of first-degree relatives with breast cancer.
“We went from having little information on the procedure’s benefit for individual patients to identifying three independent and significant risk factors,” Hunt said. “Each provides valuable insight into how likely a woman is to develop the disease in her other breast and enables physicians to make an educated recommendation if a patient will potentially benefit from surgery.”
While Butler would have loved to have this tool available when she was making her decision, she has no regrets.
"I'm really comfortable that the decision I made was the very best for me. Knowing that I had dramatically reduced my risk of cancer returning was the only way I could sleep at night. I plan to have a long, healthy life ahead of me — free of breast cancer."
Conquest - Spring 2009
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