12 November 2013

Over the past year, breast cancer and mastectomy has been in the spotlight due to attention from celebrities such as Angelina Jolie and Amy Robach.

There is no question that when public figures share their stories, awareness is raised. The unfortunate part is that important facts are usually omitted from the conversation, and misinformation is spread. While anyone has the right to discuss their disease, public figures should be held to a different standard. Their information reaches millions, and their words are held as truth. Unfortunately, we rarely if ever have the complete story. Most often, an announcement is made about upcoming or recent surgery, and statements are made about “beating cancer” or “being cured”. In the absence of information about the pathology report, stage of disease and other factors, these statements do nothing to educate or inform. I would not expect anyone, including someone in the public eye, to disclose their medical records. However a simple statement such as “I am choosing this treatment with the advice of my physicians” can go a long way towards acknowledging that the treatment decisions are complex and unique to the individual.

Some important points:
– Early detection does not equal cure. Some breast cancers are so aggressive that they will go on to metastasize regardless of how early they were found. Some breast cancers will never metastasize, even if they become quite large. Tumor biology – the behavior of the individual cells – is more important than the size of the tumor at diagnosis. Statements such as “a mammogram saved my life” do not apply to every breast cancer case.

– You will not live any longer if you have your breast removed. The survival rates from breast cancer are the same whether you undergo a lumpectomy with radiation or a mastectomy. Statements such as “I had a mastectomy because I’m young and wanted to be aggressive” have no basis in reality. You can be appropriately aggressive by having a lumpectomy followed by radiation, depending on the extent of your tumor. More surgery is not better.

– Breast cancer can come back even after the breast has been removed – the risk is approximately 1-5%. After lumpectomy and radiation, the risk of cancer retuning in the breast is approximately 5-10% with modern techniques. Statements such as “I had a mastectomy so I don’t have to worry about cancer anymore” also has no basis in reality. With either surgery (lumpectomy or mastectomy), there is a risk of cancer metastasizing, or showing up somewhere else in the body. Any invasive breast cancer has the potential to shed cells from the main tumor into the bloodstream. Those malignant cells may then form tumors in other areas of the body, such as the bones, lungs, liver, and brain. The type of surgery (lumpectomy versus mastectomy) does nothing to reduce the risk of metastatic disease, and the survival rates are equal regardless of the surgery performed.

– In patients who undergo removal of the ovaries (due to the increased risk of ovarian cancer), there still is a slight risk of developing ovarian or primary peritoneal cancer, which mimics ovarian cancer in it’s growth and aggressiveness. Patients who have had breast cancer or are BRCA mutation carriers are also at increased risk for the development of cancers in addition to breast and ovarian, so lifelong surveillance is important.

– Many have the misconception that if they undergo a mastectomy, they will not require chemotherapy. Chemotherapy is given based on the tumor stage as well as tumor biology – the decision is made on the aggressiveness of the cancer. As mentioned above, a mastectomy does not prevent the cancer from spreading, so chemotherapy may still be required after mastectomy.

– Radiation therapy is utilized after lumpectomy to reduce the risk of cancer returning in the breast. While radiation is generally not needed after mastectomy, there are some cases where it is required. Similar to the decision for chemotherapy, the decision for post-mastectomy radiation depends on the stage of disease and tumor biology.

– The recovery from surgery is not always straightforward and most patients are not “back to a normal life” a few days after surgery. As with any surgery, there can be unexpected complications and additional procedures may be needed.

– Reconstructive techniques, while much improved, can never guarantee a perfectly natural or symmetric result. Reconstruction after mastectomy is a much different operation than undergoing implants for cosmetic purposes. Once the breast has been removed, it can never be replaced. The skin (and nipple if preserved) are numb, and the feel and appearance are different. Many patients are very happy with the cosmetic results of their reconstruction, but realistic expectations are needed.

– In regards to BRCA genetic testing, some women struggle tremendously with the decision even to be tested. There are implications not only for the patient but also for her relatives. In patients who test positive for a mutation, there are also difficult decisions to be made regarding surveillance versus prophylactic surgery.

There’s Another Side to the Amy Robach Breast Cancer Story is an excellent post by Gary Schwitzer of the HealthNewsReview on the subject.