Remove Second Breast to Prevent Cancer?
Study Probes First Breast Cancer and Decision to Get Preventive Mastectomy in Second Breast
By
Miranda Hitti
WebMD Health News
Reviewed By
Louise Chang, MD
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Jan. 26, 2009 -- When a woman has a mastectomy to remove breast cancer in
one breast, what should she do about the other breast?
Her first breast cancer may hold some clues, according to a new study,
published in the advance online edition of Cancer.
"Not every woman who has breast cancer will get another breast cancer in
the opposite breast," researcher Kelly Hunt, MD, tells WebMD.
"We tried to distill down some of those factors with our study and
figure out which ones may be the most important ones," says Hunt, a
professor of surgical oncology at the University of Texas M.D. Anderson Cancer
Center.
But the findings don't amount to a checklist for getting a preventive
mastectomy; breast cancer experts say that's still a personal decision that
each patient must weigh with her doctors.
Mastectomy Study
Hunt's study included 542 women who had a mastectomy at the M.D. Anderson
Cancer Center to remove a cancerous breast, and also chose to get a
precautionary mastectomy in the unaffected breast, a procedure called
contralateral prophylactic mastectomy.
Immediately after the contralateral prophylactic mastectomy, tests showed
that the vast majority of women -- about 95% -- had no cancer in that breast,
and only 1.5% had an invasive tumor in that breast.
Because women typically get preventive mastectomies to curb their future
risk, Hunt's team also followed another 1,574 women who had mastectomy to
remove a cancerous breast but chose not to have a preventive mastectomy in
their second breast. Over the next four years or so (50 months), only 2.4% of
the women developed breast cancer in their remaining breast. It's not clear how
many of those cancers were invasive tumors.
Key Factors
Hunt and colleagues found three factors that were more common among women
with cancer in the breast that they had removed as a precaution. Those factors
are:
- Having more than one tumor in the breast that was first diagnosed.
- Having invasive lobular cancer in the breast that was first diagnosed.
- Being at high risk for breast cancer, according to the Gail model.
Hunt points out that invasive lobular breast cancer isn't common; it
accounts for about 5% of all breast cancers. And she notes that the Gail model
was designed to gauge future breast cancer risk for women who haven't been
diagnosed with breast cancer; it wasn't intended for use for breast cancer
patients.
Hunt says the Gail model may be a "useful tool" for women with
breast cancer, but it will take more studies to confirm that. "We're hoping
to develop a risk calculator that we can put online that would be useful to
clinicians and patients," Hunt says.
"We're learning more and more that all breast cancers are not the same
and they really shouldn't all be treated the same," she says. "We have
general guidelines that really help to make sure women get the appropriate
treatment, but each individual patient has unique factors and features ... that
are important to consider."
Breast Cancer Experts Weigh In
Julie Gralow, MD, director of medical oncology at the Seattle Cancer Care
Alliance and an associate professor of oncology at the University of
Washington, tells WebMD that the risk factors noted in Hunt's study "make
sense," but the study "doesn't convince me that we should be
recommending" preventive mastectomy based on those factors.
"Nobody would recommend a prophylactic mastectomy in a group that over
the next four years only had a 2.4% chance of getting it on the other
side," says Gralow, referring to the comparison group in Hunt's study.
Women who have had breast cancer are at "high risk" for another
breast cancer, "but 'high' is a relative term," notes Victor Vogel, MD,
the American Cancer Society's national vice president for research.
"Whether the Gail model is the appropriate way to estimate that risk is
highly debatable," Vogel says. "What you'd want is a study in which
patients with a first breast cancer had a Gail model score, and then in five
years, you look to see whether the Gail model accurately predicted the number
of second breast cancers. And I am not aware that any such study has ever been
done."
Gralow and Vogel also point out that when breast cancer is diagnosed, many
doctors now perform MRI scans of both breasts. Those scans help show the extent
of breast cancer in the affected breast and check the other breast for
cancer.
Hunt's study started before that practice became common, so not all of the
patients got MRI scans before opting for preventive mastectomy. Genetic testing
also wasn't a routine procedure for the patients in Hunt's study, and isn't
recommended for most breast cancer patients.
No Rush to Decide
Hunt, Gralow, and Vogel encourage women to take their time in deciding
whether or not to get a contralateral prophylactic mastectomy and to focus on
treating the breast cancer that they already know they have.
"A lot of women will come to my office and immediately say, 'Why don't
you just take both breasts off?' and I try to explain to them that depending on
their risk, not everyone needs that dramatic measure," Hunt says. "I
always try to get patients to give much more time and consideration to
it."
"There shouldn't be this sense that we have to do this [preventive
mastectomy] right now," Vogel says. "This is not urgent, it's not
life-threatening immediately ... it can be done after the primary therapy, when
you get a little emotional distance from it and you can make these decisions
with a calm heart."
Gralow notes that preventive mastectomy hasn't been shown to improve breast
cancer survival, though it does cut the odds of getting breast cancer again.
That's because if a recurrence happens, chances are it would be found and
treated.
Still, "it's perfectly understandable that maybe women wouldn't want to
go through that a second time," Gralow says. "For some women, even a
couple percent chance of getting another breast cancer is enough to say, 'I
just don't want to deal with it.'"
Gralow says she would support a woman who made that choice, as long as the
patient understood the risks and benefits. Her advice: "If you're not
sure, you shouldn't do it, because it's permanent."
SOURCES: Yi, M. Cancer, Jan. 26, 2009; advance online edition.
Kelly Hunt, MD, professor of Surgical Oncology, University of Texas M.D. Anderson Cancer Center.
Victor Vogel, MD, national vice president for research, American Cancer Society.
Julie Gralow, MD, director of Breast Medical Oncology, Seattle Cancer Care Alliance; associate professor of Oncology, University of Washington School of Medicine.
News release, American Cancer Society.
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