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Breast cancer-the unkindest cut

MagazineMarch 1993 (Vol. 3 Issue 12)Breast cancer-the unkindest cut

Most breast cancer surgeons engage in surgical overkill, and many safety questions surround the new wonder drugs

Most breast cancer surgeons engage in surgical overkill, and many safety questions surround the new wonder drugs.

Last month, we concentrated on the dangers and inaccuracies of the various screening facilities to detect breast cancer. With this issue, we offer evidence that most doctors still overtreat early breast cancer, cutting out more than they need to or overloading the patient with drugs or radiation.Despite a variety of surgical techniques, a host of back up therapies and many confident headlines about breast cancer breakthroughs, the astonishing truth is that surgical treatment of breast cancer hasn't advanced one single step in the past century. Edward F Scanlon, MD of the Northwestern University Medical School summarizes the prevailing view: "...over a period of 100 years, breast cancer treatment has evolved from no treatment to radical treatment and back again to more conservative management, without having affected mortality." (The Journal of the American Medical Association, 4 September 1991.)

The standard procedure for breast cancer this century has been the radical mastectomy, a mutilating operation which involves removing the breast, much of the skin, the chest wall and the lymph nodes, developed by Dr William Halsted a hundred years ago.

Shortly after the Second World War, a study at three hospitals in Illinois showed little difference in five and 10 year survival rates between radical mastectomies, simple mastectomies, or simple removal of tumour. In 1969, The Lancet (29 November) reviewed 8,000 cases and again found no difference in survival between any of the procedures. Nevertheless, the Halsted procedure maintained its grip on the average surgical mind well into the 1970s and 1980s, when in some areas it was replaced by a modified radical, which removed tissue and breast, but left the chest wall, or a simple mastectomy, which only removed the breast itself.

Like the earlier studies, numerous trials in the Eighties have shown that mastectomy provides no benefit in terms of cancer recurrence or survival over breast conserving surgery (BCS) such as simple lumpectomy (removal of the tumour itself) or quadrantectomy (removal of a portion of the breast). In one, by the National Surgical Adjuvant Breast and Bowel Project in Pennsylvania of nearly 2000 women over nine years, there was no significant difference in survival without the cancer spreading to other parts of the body between those who had undergone lumpectomy, lumpectomy plus irradiation or total mastectomy.

As a result of these comparative studies, the American National Institutes of Health in 1990 recommended that surgeons opt for breast conservation surgery over mastectomy for the majority of women with stage I or stage II breast cancer. By this they mean cancer less than 4 cm in diameter limited to the primary site (ie, single breast) without involvement of the chest muscle or overlying skin. In the past, doctors felt that cancer found in the axillary lymph nodes was evidence of metastasis (spread), and grounds for radical mastectomy. With the NIH's announcement, the involvement of the lymph nodes (so long as it is on the same side as the tumour) is now considered immaterial.

Regardless of the NIH's decision, most doctors don't offer BCS to the majority of women with early breast cancer. A Seattle study published in the Journal of American Medical Association (25 December, 1991) examined cancer registry information between 1983 and 1989. In total, less than a third of women with stage I or II disease were offered BCS, even though three quarters of all women diagnosed with breast cancer fall into the early stage category. Furthermore, that proportion declined after 1985.

The JAMA study also found that doctors failed to offer radiation therapy to postmenopausal women and were more likely to recommend mastectomy to the older group than to younger women, even for the same stage of breast cancer. The study also found that the more affluent and well educated the woman, the greater her chances of being offered BCS.

In Britain, one 43 year old journalist diagnosed with breast cancer last February wasn't offered a modified quadrantectomy and chemotherapy until minutes before her scheduled mastectomy.

The lack of information or support by doctors for BCS may account for the suspicion with which many women view breast conserving measures. This point of view is epitomized in a letter written by Dr Michael G Sarr and others to the JAMA (19 August 1992): "Many view mastectomy as dealing with the problem immediately and completely, without postoperative radiotherapy. The acceptance, indeed preference, of mastectomy over breast preserving surgery by the majority of our patients...implies that these patients adjust readily to the loss of the breast."

Indeed, several noted cancer specialists have attempted to demonstrate that women given mastectomies suffer no more psychological trauma than those undergoing BCS. Noted breast cancer specialist Michael Baum and others from London and Manchester studied the psychological outcome of women given mastectomies versus those given BCS (British Medical Journal, 22 September 1990). The study found that about a quarter of those given either operation were depressed or anxious, and so concluded that "there is still no evidence that women with early breast cancer who undergo breast conservation surgery have less psychiatric morbidity [illness] after treatment than those who undergo mastectomy". Significantly, the study found that patients treated by surgeons who allowed them to choose were less likely to be depressed than those whose decision was made for them.

Besides your education or ability to pay (in the case of private patients in the UK), where you live has a lot to do with whether you are offered BCS or mastectomy. Two articles in the New England Journal of Medicine (23 April 1992) showed a marked difference in the use of BCS in the US, depending on geographical area. Women were more likely to be offered BCS in the Northeast (17 per cent) or Middle Atlantic States (20 per cent) than they were in the South (5.9-7.3 per cent). BCS was more on offer in urban than rural areas, in teaching hospitals, large hospitals and those with on site radiation therapy. Interestingly, an editorial in the same issue pointed out that higher rates of conservation surgery were found in those 17 states with informed consent laws requiring doctors to offer patients with breast cancer information about their treatment options.

Besides the problem of overtreatment, too much surgery might delay your doctor's ability to discover whether the cancer has spread. Dr Bernard Fisher and colleagues from the National Surgical Adjuvant Breast and Bowel Project in Pennsylvania, writing in The Lancet (10 August 1991) about the nine year study of 2000 women mentioned above, showed that mastectomy or radiation therapy actually prevented the diagnosis of distant disease since the recurrence of another tumour tended to be a "powerful" marker that the cancer could spread, thus aiding its early treatment. "These findings further justify the use of lumpectomy," concluded Dr Fisher.

Just as much confusion and ignorance surrounds what has been referred to in medicalese as adjuvant (just in case) therapies which are used after surgery to prevent cancer from recurring.

These include hormonal therapy with drugs like tamoxifen, an oestrogen agonist, which acts against the body's production of oestrogen, a factor in the growth of some types of breast cancer. There is also chemotherapy, orally or by injection, often used to shrink the cancer first so the breast may remain intact; radiotherapy, which employs an x-ray machine or other types of radiation, including the temporary insertion into the body of radioactive isotopes; and ovarian ablation, a medical euphemism for what amounts to castration ("inactivating" or removing the ovaries) by surgery, radiotherapy or drugs. The rationale here is that by wiping out the ovaries, you prevent the source of oestrogen, which helps to grow the cancer. Ovarian ablation is mainly used on premenopausal women, which means that after the trauma of cancer and surgery some young women also face either an early menopause or indefinite use of hormone replacement therapy, which itself appears to cause breast cancer.

Most of these adjuvant methods are used in conjunction with breast conserving surgery, although tamoxifen is sometimes used alone for women over 50 with early breast cancer.

As with most new medical "advances" tamoxifen was hailed as a breakthrough with very little examination of its long term effects. This followed a study by the Imperial Cancer Research Fund's Cancer Studies Unit at Oxford, which analyzed the results of 133 different breast cancer treatment studies on 75,000 women worldwide. They found that for post menopausal women tamoxifen would prevent the recurrence of cancer in the other breast by 39 per cent. The study also found that tamoxifen helped to avoid recurrence primarily for the first four years after breast cancer but would nearly double a woman's chances of survival for 10 years, and that long term tamoxifen (between two and five years) is "significantly more effective" than shorter regimens.

Several other surprise findings included the fact that chemotherapy for six months could produce the same results as therapy of a year or more. The study also found that ovarian ablation reduced the annual death rate by about one quarter, causing one editorial in The Lancet (11 January 1992) to call for ablation as a "alternative to chemotherapy" in premenopausal women.

In all of this enthusiasm, what haven't been communicated to the public are the considerable, potentially fatal, side effects of tamoxifen. Because the drug is often recommended to be taken for five to 10 years many questions have been raised about its effect upon bone mineral density, cholesterol levels, hormone secretion and the potential to develop other sorts of cancers in places besides the breast.

First of all, we still don't know conclusively whether it works. In a Viewpoint in The Lancet (7 November 1992), Adriane Fugh-Berman of the National Women's Health Network in Washington, DC, and Professor Samuel Epstein of the University of Illinois School of Public Health, an outspoken critic of cancer treatment, pointed out that in the massive Oxford study a "statistically significant reduction in contralateral [other breast] tumours in patients with breast cancer was found in only three of eight studies."

Increasing numbers of endometrial cancer cases have been reported in postmenopausal women who have received tamoxifen for breast cancer. Drs Epstein and Fugh-Berman point out in The Lancet article mentioned above that tamoxifen increases the risk of endometrial cancer about five fold. Tamoxifen patients also experience abnormal vaginal bleeding, hyperplasia (excessive cell formation), polyps and endometriosis (BMJ, 26 October 1991).

In a study at the University of Wisconsin and the Department of Medicine, Albert Einstein Medical Center in Philadelphia, Dr Richard R Love and his colleagues found that nearly half of the tamoxifen treated women experienced persistent menopause like symptoms such as hot flushes and vaginal dryness (The New England Journal of Medicine, 26 March 1993). Ten per cent of women receiving the drug discontinued treatment during the first year because they found the side effects unacceptable. Premenopausal women may also experience menstrual irregularities or lose their periods.

Tamoxifen has also been associated with seven times the risk of thrombosis of the veins or arteries (Journal of Clinical Oncology 1991; 9:286-94;The Lancet, 7 November 1992.) An association has also been made between the drug and toxic effects on the eyes, particularly retinopathy (British Medical Journal 1992; 304:495-96), with an estimated incidence of 6.3 per cent.

This drug may also damage the liver or cause liver cancer. Doses equivalent to those given to women produce liver disease in 11.5 per cent of rats, and high doses of tamoxifen, highly malignant liver tumours in nearly 71.2 per cent (The Lancet, 7 November 1992). What this may mean to humans is anyone's guess. Several researchers from City Hospital in Nottingham wrote to The Lancet (11 April 1992) to report on five cases of liver failure (four fatal) and five cases of tamoxifen associated hepatitis (one fatal), 11 cases of liver complications and 15 cases of blood problems. "Tamoxifen should be stopped immediately if jaundice or marrow suppression occur," they wrote.

All of which makes it doubly necessary to find a doctor who is extremely cautious about dispensing adjuvant therapy and carefully monitoring your progress if he or she does.

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