The baffling new breast cancer development.

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. 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. 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 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. 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 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. 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.*

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 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.

Tags: breast cancer, lumpectomy, mastectomy

Amanda Schaffer is a science and medical columnist for Double X and Slate. Read more of her work here.

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Rebecca Skloot
|
May 15, 2009

Health & Science

Why Are Mastectomies on the Rise?