Why Are Mastectomies on the Rise?

Between the 1950s and the 1990s, the medical profession did a virtual about-face on mastectomies. Previously, the surgery had been a brutal, almost barbaric procedure. A woman with a suspicious lump often went into surgery not knowing whether she would wake up without her breast [2]. She often lost the underlying muscle and even part of the rib cage as well. As one physician described a patient who had undergone extended radical mastectomy in the 1950s: “I could practically see her heart pumping [3]. It was separated from the outside world only by a layer of skin.”

Then in the 1970s, a drive to cut back mastectomies became intertwined with feminism and patients’ rights. In 1990, the National Institutes of Health declared radiation and a lumpectomy—in which a malignant lump is removed but much of the breast spared—“preferable” to mastectomy [4] for women with early stage breast cancer. The less extreme surgery offered the same long-term survival rate as the more extreme one, research showed. And so low mastectomy rates became one quality measure for breast surgeons, a way one doctor sized up another.

Yet now, somehow, mastectomy rates seem to be rising again—not because of doctors, but because of women themselves. Evidence shows that when women are more involved in making their own surgical choices, with less, rather than more input from their surgeons, they are more apt to choose mastectomy [5]. Young women also tend to opt for more radical treatment. And, at least anecdotally, highly educated ones do too. Todd Tuttle, a surgical oncologist at the University of Minnesota, told me that when he asked his female surgical residents what they’d do if diagnosed with early breast cancer, “the majority said double mastectomy.”

Some doctors worry that women are overestimating the security that more aggressive surgery offers. It’s true that the risk of cancer reappearing in the breast is slightly higher following lumpectomy and radiation than following mastectomy. But the difference has narrowed. Over 20 years, the risk of a local recurrence is about eight to nine percent following lumpectomy and about two to three percent following mastectomy. And the risk of cancer returning elsewhere in the body—the life-threatening danger, as NIH said—is the same after both procedures.

Yet many women don’t seem to see it that way. You can see this impulse reflected in the data from two leading institutions. At the Mayo Clinic, the mastectomy rate [6] for women with early stage breast cancer fell to 31 percent in 2003, and then climbed to around 43 percent in 2006, according to an analysis presented last year [6]. At the Moffitt Cancer Center in Florida, the mastectomy rate for all breast cancer patients also rose from around 33 percent between 1994 and 2003 to 44 percent in 2004-2007, according to another analysis. That rate has now shot up to around 65 percent, the lead researcher told me. Most of the surgeons I spoke with said they believed the increase is widespread. “There’s always a lag time with national data, but it’s pretty clear that mastectomy rates are rising,” said Monica Morrow, chief of the breast service at Memorial Sloan Kettering.* [7]

On the surface, some of the reasons for the increase appear entirely logical. Women with mutations in the BRCA1 and BRCA2 genes, for instance, sometimes choose to remove both breasts in the hopes of staving off future disease. (Slate contributor Masha Gessen [8] wrote movingly in 2004 about making this decision.) Women with early-stage breast cancer who discover they carry a risky mutation may tend to choose more aggressive surgery as well.

Magnetic resonance imaging, which can pick up more apparent abnormalities than mammography or ultrasound, may also play a role. In the Mayo Clinic analysis, women with early stage breast cancer who had an MRI were 18 percent more likely to end up having a mastectomy.

But each of these factors is double-edged, and points toward possibly unnecessary mastectomies as well as prudent ones. First, hereditary breast cancer represents only 5 to 10 percent of breast cancer cases. But high-profile coverage—for instance, glossy stories about the actress Christina Applegate [9], who carries the BRCA1 mutation and chose a double mastectomy last year—may be influencing the choices of women who do not carry this added risk.

Nor are the potential advantages of revealing stray cancer cells through MRI clear-cut. To date, the evidence that using MRI leads to better outcomes [10], like a lower rate of second operations, just doesn't exist. “So far, the only clinical outcome MRI been shown to change is the mastectomy rate,” said Morrow. The prospect of errant cancer cells elsewhere in the breast is understandably harrowing, but the radiation that follows lumpectomy can target these cells, even if they remain unseen. MRI also carries a significant risk of false positives [11]. Biopsies can sort out whether apparent abnormalities are cancerous or not, of course. But some women become so frightened by the prospect of more cancer that they simply want their breasts gone.

Patients with early-stage cancer who choose aggressive surgery sometimes tell their doctors they sleep better knowing they’ve rid their bodies of the disease. “That response worries me because they haven’t,” said Tuttle of the University of Minnesota. Even after a double mastectomy, cancer can live on in the lung or liver or brain or bone. Doctors worry that women lose sight of that. (Of course, some women still express ambivalence about mastectomy or report that their doctors drove their decision to have one. One woman told me that when she asked what would happen if she didn’t undergo mastectomy, the doctor “looked at me like I was an alien.” But the literature suggests that the majority of doctors are now more conservative, at least for typical early breast cancer cases.)

Maybe, however, the rising mastectomy rate is the inevitable next chapter in the history of women’s struggles with breast cancer. Just as women in the 1970s began to rebel against the extreme nature of the radical mastectomy, so patients today may be reacting—or overreacting—to the downsides of lumpectomy. They may feel that the follow-up radiation is as disturbing as the removal of a breast. They may want to spare themselves fearful yearly mammograms. They may know women who’ve had lumpectomies and felt that the look and feel, afterward, was not as they’d hoped. Still, it’s hard not to worry that more women than need to are choosing to cut off their breasts.

* Analysis of national data through 2003 shows an increase in contralateral prophylactic mastectomies [12], surgeries in which women choose to remove both breasts, although cancer has been found in only one of them. But it does not show an increase in mastectomies involving one breast, perhaps because the data are not recent enough.

Photograph of actress Christina Applegate by Frederick M. Brown/Stringer/Getty Images.

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