June 2004
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New treatments: Know your breast cancer options
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More than ever before, breast cancer patients have treatment options. Yet nearly 20 years after the publication of the first study to demonstrate that “lumpectomy” followed by radiation was as effective as mastectomy, or total breast removal, in the treatment of breast cancer, many women are unaware of the choices.
Some of the 210,000 new patients who will be diagnosed this year are candidates for a lumpectomy -- a partial removal of the breast tumor and areas that may contain malignant cells – and follow-up with radiation and in some cases, anti-cancer drugs.
Knowing to ask questions about the best treatment options will insure that patients get the best possible treatment. Patients need to be aware that they have more options, said Anthony Lucci, MD, associate professor of surgery at Baylor College of Medicine in Houston. In a recent presentation before the 57th Annual Cancer Symposium of the Society for Surgical Oncology, Lucci said that doctor reimbursement could have some effect on which breast procedure is recommended.
“The current system has the potential to encourage the use of mastectomy in breast cancer patients, even though breast-conservation has been proven to have the same survival rate as mastectomy,” said Lucci, also a surgical oncologist at the Breast Care Center at Baylor College of Medicine and The Methodist Hospital. “Also, there were fewer complications and a faster return to work in the minimally-invasive surgery group (partial mastectomy and sentinel node mapping) as compared to mastectomy. Yet the reimbursements were 40 percent lower.”
The study included 240 Medicare patients who had been treated for early stage, node-negative breast cancer between 1999 and 2003. Each patient completed a questionnaire 26 months after surgery about their post-operative condition including arm swelling, number of days in the hospital, number of days before the patient was able to return to work, and how long the patient stayed on narcotic pain medication.
Of the 240 patients, 42 had a lumpectomy and removal of the lymph nodes, 96 had a lumpectomy plus partial removal of the lymph nodes and 102 had modified radical mastectomy.
Lucci found that patients who underwent the lumpectomy plus partial node removal required a shorter stay in the hospital after surgery. Post-operative pain was more common in the total mastectomy group.
It is dangerous to have an incentive for more radical surgeries, and it discourages doctors from learning new techniques, he said. Learning new techniques cost doctors time and money for the equipment and courses.
Sometimes physicians are not able to sustain their practice with lowered payments, he said. In extreme cases, physicians are even beginning to give up seeing breast cancer patients, Lucci said.
“The international Anastrozole and Tamoxifen Alone or in Combination, or ATAC study found that living in the United States is a predictive factor for the use of mastectomy over lumpectomy with radiation,” Lucci said. “One factor surgeons use to determine the optimal surgical treatment for a patient with breast cancer is the size of the primary tumor.”
Women who have a lumpectomy plus radiation for tumors under five centimeters, or Stage I or II cancer, have equivalent outcomes as those who undergo a mastectomy or total removal of the breast. Even the chance of a recurrence of the tumor in the breast is not significantly different between a lumpectomy and radiation and mastectomy, in patients with early cancer.
Patients should also know to ask about less-invasive, non-surgical diagnostic procedures such as the stereotactic or ultrasound biopsy, rather than the sometimes unnecessary excisional biopsies that require surgery and a longer period of recovery, Lucci said.
Diagnostic stereotactic procedures or ultrasound biopsies are more cost-efficient, more accurate, and benefit the patient because they are non-invasive. In one study, an average of 70 percent of the patients underwent an operative procedure that most likely could have been avoided if an image-guided biopsy had been used.
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