Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: TUESDAY, May 11, 1993 TAG: 9305110106
SECTION: EXTRA PAGE: 6 EDITION: METRO
SOURCE: Jane Brody
DATELINE: LENGTH: Long
Often their friends, medical consumer advocates and even some doctors regard their decision to have a so-called prophylactic mastectomy as bizarre, barbaric and unnecessary. But to the women who choose this route, it is nearly always a path to a life less crippled by fear and frequent medical procedures.
Jean T. of New York, who like all the women interviewed asked that her last name not be used, is a typical example. A 53-year-old publishing executive, she says she has never regretted her decision 10 years ago to have both breasts removed and replaced with implants.
"I had very lumpy breasts and over the years I had had a lot of biopsies," she said. "All were benign. Then my brother and my mother died of cancer, as had my mother's father.
"Finally, one of my biopsies revealed a lobular carcinoma in situ, a kind of precancer that my doctor explained may never become an invasive, serious cancer. He suggested waiting and watching me carefully, with exams every three or four months, and even told me he was taking this approach with his wife, who had the same problem.
"But after a few months, this watch-and-wait technique was making me increasingly nervous. I felt like I was sitting on a powder keg and I just couldn't live with that. Even though I wasn't yet married, I didn't think my chances of finding a husband should depend upon my keeping my breasts and risking cancer."
Although she says she has never been sorry about her choice, which did not, incidentally, discourage her future spouse, she concedes that she cannot know "if I am alive nine years later for having done it or whether I would never have developed an invasive cancer."
Survey after survey has shown that even though heart disease and lung cancer kill more American women than any other disease, it is breast cancer that women fear most. This year, the American Cancer Society estimates, 182,000 women will learn that they have breast cancer and 46,000 will die of the disease. The average American woman today faces a risk of one in nine of developing breast cancer by the age of 85.
While early detection techniques and better treatments have improved every breast cancer patient's chances of survival, the lifetime risk of developing breast cancer has been rising, and a woman's chance of getting the disease at some time in her life is now greater than ever. Thus, breast-cancer death rates have changed little over the last half century, since for the population as a whole the therapeutic gains have been all but balanced by the increase in cases.
Prophylactic mastectomies are not common procedures. But even as established breast cancers are increasingly being treated with lesser surgery, mastectomies to prevent cancer may be sought by more women as studies continue to define the characteristics of women who are most likely to develop life-threatening breast cancers. A woman who knows she faces a lifetime risk of 25 percent or more of developing breast cancer may choose to remove the tissue while it is still healthy, especially if she, like Jean, faces frequent checkups and anxiety-producing biopsies.
Among the factors known to increase a woman's risk of breast cancer, the most potent one is heredity, particularly if her mother, a sister or both had breast cancer before menopause. Researchers are now analyzing the genetics involved and may soon be able to tell women whether they have inherited a breast cancer gene. Nearly on a par with heredity is having already had breast cancer in one breast, which is associated with an increased risk of developing cancer in the remaining breast and which prompts some women to have the second breast removed before a cancer is found.
Other less potent risk factors for breast cancer include age (incidence rises with age, although the virulence of the disease declines), long years of menstruation (early menarche or late menopause), never having had children or having a first child after 30 and being well educated and affluent. A diet rich in fats and perhaps protein and relatively deficient in fruits and vegetables may also play a role, some studies say.
The ever-widening use of mammography is another factor likely to increase the popularity of preventive breast surgery. Mammography sometimes reveals suspicious lesions in the breast that represent either premalignant changes or, as in Jean's case, malignant cells that remain confined within the breast duct or lobe in which they arose. Until and unless these cells break through the wall of tissue that surrounds them, they cannot spread or threaten life.
The trouble is, it is not currently possible to tell which women with these very early lesions are likely to develop invasive cancer and which will live out the rest of their lives free of it.
Maggie S. of Minneapolis faces just such a dilemma. Her routine annual mammogram revealed a suspicious area of microcalcifications which, upon biopsy, was found to harbor an intraductal carcinoma, a cluster of malignant cells confined to the breast duct in which they arose.
Maggie, who is in her mid-60s, could try the wait-and-watch approach. But her surgeon explained that 20 to 25 percent of women with this condition go on to develop invasive cancer within about 10 years. Lumpectomy or lumpectomy followed by weeks of radiation therapy can cut the risk of cancer in half.
But Maggie concluded: "Why take a chance? If I have the breast removed, it cannot cause any further trouble. I won't have to worry or go in for exams every few months and I won't need radiation or other treatments after the surgery. I've never associated my femininity or self-image with my breasts, and I'm not about to start now. What's most important to me is to be alive and healthy."
A woman considering a prophylactic mastectomy would be wise to consult several surgeons and breast cancer specialists before deciding to take so drastic and irreversible a step. Although breast reconstruction with an implant is often performed after a prophylactic mastectomy, the reconstructed breast is not the same sensually or physically as the one that was removed.
Dr. Susan Love, director of the breast clinic at the University of California at Los Angeles and author of "Dr. Susan Love's Breast Book" (Addison-Wesley, $18.95), a widely respected and comprehensive work written with Karen Lindsey, cautions against choosing to undergo a subcutaneous prophylactic mastectomy, in which the overlying skin, the nipple and areola are not removed and no radiation therapy is given. Although cosmetically the result is better, cancer can develop in tissues left behind. The New York Times
by CNB