Easing Women's Constant Fear

By Claudia Wallis

Breast-cancer patients can face a future without disfigurement

At some point in her life, one out of eleven American women will be told she has breast cancer. The dread of this moment is perhaps the single biggest fear that women have about their health. For Nina Miller, 42, of Santa Cruz, Calif., it happened two years ago. Her reaction was typical: "Total hysteria. My only thought was, they're going to mutilate my body, and then I'm going to die." But Miller has lost neither her life nor her breast. Like a small but growing number of breast-cancer patients in the U.S., she avoided a mastectomy and instead was treated with a simple removal of the breast lump (lumpectomy) followed by radiation therapy.

Until recently, such breast-sparing techniques were universally considered to be inadequate and dangerous. Today, the evidence is to the contrary. Last month, at a meeting at the National Cancer Institute in Bethesda, Md., noted Italian Oncologist Umberto Veronesi presented the results of a landmark ten-year study comparing survival after a mastectomy with survival following a less disfiguring operation called quadrectomy (see diagram). His conclusion: "There is absolutely no difference."

Veronesi, who heads Milan's respected National Cancer Institute, bases his conclusion on the treatment and follow-up of 700 Italian patients. Half were treated with a mastectomy and half with a quadrectomy, plus radiation if the malignancy extended to lymph nodes under the arm. All of the women in the study had a very early stage of breast cancer, with tumors measuring less than three-quarters of an inch in diameter. A decade after treatment, 96% of the women in both groups were alive and apparently healthy. Significantly, the study defied the longstanding dictum that anything short of a mastectomy increases the risk that cancer will recur. In fact, the incidence of tumor recurrence was the same in both groups: less than 5%. Said Dr. Bernard Fisher, chief breast cancer surgeon at the University of Pittsburgh: "This makes it awfully hard to justify the radical mastectomy."

Fisher is one of a small number of American medical dissidents who have long opposed the indiscriminate use of mastectomies for breast-cancer patients. At a recent conference in Venice, Italy, sponsored by Bristol-Myers, he and a number of other U.S. doctors reported on their successes with more limited treatment. According to Dr. Samuel Hellman, physician in chief of New York's Memorial Sloan-Kettering Cancer Center, even patients with tumors as large as two inches in diameter may require nothing more than a lumpectomy followed by radiation. Though this approach involves removing even less tissue than Veronesi's method does, the results with some 350 patients seem to be just as good. Moreover, Hellman notes, the physical appearance of the treated breast is "good to excellent" in four out of five patients.

Despite the persuasive force of these studies, Hellman admits, "the consensus among U.S. physicians is still in favor of mastectomy." Indeed, his own institution, Sloan-Kettering, has long been a bastion of radical surgery. A survey conducted in 1980-81 by the National Cancer Institute found that 80% of breast cancer patients in Atlanta and Detroit were being treated with a modified radical mastectomy, an operation in which the breast and some chest muscle are removed. Up to 5% were still being treated with the old-style radical mastectomy, in which so much pectoral muscle is removed that arm motion may be limited for life. Only 7% of patients in Atlanta and 10.8% in Detroit had received a lumpectomy, a quadrectomy, or some other form of breast-sparing surgery.

Many physicians have resisted the new techniques because they fear that without mastectomy cancer will be more likely to recur and more patients will die. The ten-year Italian results may convert the skeptics, although Veronesi warns, "Next the surgeons are going to want to see the 15-year outcome, and then the 20."

Because the mastectomy is so firmly entrenched in American medicine, many breast-cancer patients are never told about the alternatives. To remedy this, California, Massachusetts, Minnesota, Hawaii and Wisconsin have passed laws that specifically require doctors to inform patients of options in treatment before a final decision is made. Even so, reports Hellman, the various approaches are generally offered with "varying degrees of enthusiasm, depending on the physician."

The best candidates for a lumpectomy are women with small tumors that have not yet spread. Most doctors also prescribe additional treatment, with radiation, as a precaution against tumor recurrence. For women with a small degree of spreading (measured by counting the number of malignant lymph nodes), radiation treatment is strongly recommended. Women with more extensive spreading may also be candidates for a lumpectomy, but for these patients chemotherapy might be used as an added safeguard. According to Veronesi's colleague, Dr. Gianni Bonadonna, a leading authority on chemotherapy, there is really only one reason for a complete mastectomy: when the tumor is so large that it fills one-third or more of the breast. In that case, he asks, "What would you be leaving behind?"

The key to getting by with less surgery, and improving the chances for survival, is early detection of the disease: eight out of ten women treated for the incipient stage of breast cancer, known as stage 1, survive for ten years or more; the percentages drop off sharply with later detection.

Because the risk of breast malignancy increases with age, the American Cancer Society has for nearly a decade urged women 50 and over to have their breasts X-rayed annually. This summer, the A.C.S. revised its recommendation to include women age 40 through 49, citing the improved accuracy and safety of low-dose mammography. The first line of defense for women of all ages, however, is self-examination. In 1970 only 25% of breast tumors were detected at stage 1. By 1980, as more women learned how to examine their breasts, the proportion had grown to 60%.

Despite the success rates for early detection of tumors, many women are so terrified by the prospect of a mastectomy that they delay treatment. As former Patient Judy Feinman, 46, puts it: "I knew there was something wrong, but I just didn't want to face it." Perhaps, says Bonadonna, the availability of less disfiguring treatments will lead to less procrastination. "Women will realize that if they come in early, they will not be punished by the removal of a breast.'' --By Claudia Wallis. Reported by Mary Carpenter/Venice and Carol Foote/Santa Cruz

With reporting by Mary Carpenter, Carol Foote/Santa Cruz This file is automatically generated by a robot program, so viewer discretion is required.