Resistance to Lumpectomy High Despite Good Results
Whether a woman survives breast cancer with one breast or two depends largely on what hospital she enters and which doctor she sees.
At a prestigious cancer hospital in Boston, her surgeon will almost surely remove the diseased lump and spare her breast. At a renowned cancer hospital in New York, the odds are high that he will cut off the whole breast.
And at the small-town hospitals across the country where this operation is so often done, it is all but certain that breast cancer will be treated as it has been for decades: by amputating the breast.
The disparity reflects the seemingly haphazard way in which the rules of medicine change. New ways of dealing with disease emerge not by fiat or by acclamation, but by evolution.
Lumpectomy and Radiation
Two years ago, Dr. Bernard Fisher of the University of Pittsburgh published a long-awaited study in the New England Journal of Medicine. His team concluded that cutting out the cancerous lump and following up with radiation was just as good as modified radical mastectomy, long the surgery of choice.
It was important news for women, for it seemed to suggest that the fearsome disease that strikes one American woman in 10 could be curbed without mutilation.
Experts agree the study is changing the practice of American medicine. But slowly. Many surgeons remain skeptical about its recommendations. But many other considerations, ranging from fear of malpractice suits to the urgings of other mastectomy patients, affect the decision.
“The reasons why this has not been accepted are not scientific,” Dr. I. Craig Henderson said. “It has to do with psychological components.”
Henderson is director of the breast evaluation center at the Dana-Farber Cancer Institute in Boston, where 80% of breast cancer patients receive lumpectomies and radiation. To him, there is no question about the wisdom of breast-sparing surgery.
Not for Every Woman
“I feel that the data supporting the use of lumpectomy and radiotherapy is so overwhelming that I do not believe there is a scientific basis for not encouraging most patients to consider this option,” he said.
Of course, not even Henderson advocates lumpectomy for every women with breast cancer. Some women have tumors so large or diffuse that there is not enough breast tissue left to save.
Some doctors, especially younger ones, blame stodgy colleagues for the continuing dominance of mastectomies.
“Just remember the old adage: You can’t teach an old dog new tricks,” said Dr. Eric Munoz of Long Island Jewish Hospital. “As a general rule, physicians are like farmers. They don’t want to change.”
Henderson agreed. “Just think,” he said. “You spend four years of your life learning to do a very complicated operation, and you’re making your living doing it, and now somebody comes along and says it’s not necessary. That’s hard.”
At Munoz’s hospital, about half of the breast cancer patients receive lumpectomies. Even this is far higher than at most places. In the early 1980s, the American College of Surgeons estimated that 7% of women got lumpectomies instead of mastectomies. Dr. David Winchester, the professional organization’s medical director, estimates that the nationwide figure is now about 15%.
In general, a woman’s chances of having a lumpectomy rather than a mastectomy are better at a large medical center than at a community hospital. But even among the nation’s best-known cancer hospitals, there are striking differences.
When Dr. Samuel Hellman moved from Harvard to become physician-in-chief at Memorial Sloan-Kettering Cancer Center in New York four years ago, just 4% of breast cancer patients there received lumpectomies. The figure now is 38%, a change Hellman attributes in part to turnover in the hospital staff. He says the percentage is still too low.
However, Hellman grants room for disagreement. “We are looking at data that aren’t certain,” he said. “People are entitled to different opinions.”
That data has been accumulating for two decades. In Europe, where doctors have been studying the procedure longer, the statistics show that women survive just as well when doctors perform breast-sparing surgery.
Fisher’s study, the most intensive look at the question in the United States, found the same thing. Eighty-five percent of the women who got lumpectomies for early breast cancer survived at least five years, and they did as well or perhaps better than those who received mastectomies.
May Recur 20 Years Later
However, breast cancer may recur as long as 20 years after the first operation. Skeptics say many more years of follow-up are necessary to convince them that lumpectomy is as good as mastectomy. They are hesitant to abandon a procedure they know saves lives.
“I go along with lumpectomy and radiation therapy. It’s pretty much proven to be an effective technique,” said Dr. Arthur Holleb of the American Cancer Society. “But I’m not really convinced in my own mind that the 10- or 15-year results are going to be as good, and I’m waiting to see. I think that’s the reason for the reluctant dragons out there.”
Away from the major medical centers, the odds are slim that a woman with breast cancer will emerge from surgery with both breasts intact. At Navarro County Memorial Hospital in Corsicana, Tex., for instance, about 90% of breast cancer operations are mastectomies.
Dr. Lewis E. Gibson, one of the surgeons there, says that if a tumor is big enough to feel, he recommends a mastectomy because he believes the chances of survival are better.
“I always come back to putting it in my mind one way,” he said. “If this was my wife or daughter, what would I do to her? That’s the ultimate way I make the decision.”
Gibson said there was another concern doctors share but rarely express: a fear that they will be sued for malpractice if a woman dies of spreading cancer following a lumpectomy.
‘All That We Could Do’
“If I do the lesser procedure on a larger lesion and that woman dies of metastatic (spreading) cancer, she might still have died if I’d done the modified radical,” Gibson said. “But I know, and her husband knows, that we’ve done the maximum on her. He knows we did all that we could do.”
When a lump is cut out, the job is only half-done. The woman still needs six weeks or so of radiation therapy. This must be administered skillfully to prevent scarring the breast. Many small hospitals simply do not have this expertise.
That’s one reason why women in Caribou, Me., for instance, are unlikely to get lumpectomies if they check into Cary Medical Center, the local hospital.
“We may have done one or two lumpectomies on small lesions, but not a significant number,” said John Myers, the physician assistant who administers Cary’s operating room.
Caribou surgeon Pedro Simon said he does not perform lumpectomies, in part because patients must travel to Portland, at the opposite end of the state, to consult with a radiotherapist. This is too inconvenient and time-consuming.
Dr. Jay R. Harris, clinical director of the Joint Center for Radiation Therapy at Harvard Medical School, said that besides the legitimate doubts about lumpectomies, there was also “a machismo element” in some surgeons’ reluctance to switch.
“They feel the surgeon controls how these patients will be treated, and there’s a change that’s being forced upon them,” he said. “It’s threatening.”
However, surgeons are certainly not entirely responsible for the persistence of mastectomies. After hearing the options, the patient herself often decides she wants her cancerous breast removed.
Afraid of Radiation
The doctors say some women are afraid of radiation. Others simply feel better knowing the diseased breast is gone.
“They have a sense that this breast is cancerous and have more psychological comfort when it’s removed,” Harris said.
Henderson said women who have had mastectomies sometimes urged their friends with breast cancer to undergo the same operation, even though they might be good candidates for lumpectomies.
“Once a woman has had a mastectomy,” Henderson said, “the idea of the next patient not having the mastectomy is frightening to her, because she has to say, ‘Maybe I made a mistake.’ ”
Many experts believe that the number of women getting lumpectomies will grow. But for now, there is no agreement on what percentage of breast cancer patients should receive this surgery.
“You are looking at something in evolution,” Hellman said. “My guess is that 40% is probably lower than it should be. But each year, that number will change. As we get more certainty or less certainty, it will define what that number ought to be.”
