My gynecologist called to
say my mammogram showed a change from last year. She sent me to a surgeon
for a biopsy. The results came back--breast cancer. I'm 54 years old, but
the first thing I thought of was losing my breast. I was terrified at the
prospect of being so disfigured. But they told me they could treat the cancer
just as well without doing a mastectomy. I was so relieved, grateful--hopeful
for the first time since the diagnosis.
Breast cancer is expected to strike over 180,000 American women in 1996, and lifetime risk of the disease has risen to 1 in 8. The total breast amputation suffered by past generations of afflicted women is no longer a necessary component of breast cancer treatment for many women. Up to 15 years of patient follow-up in each of several randomized, controlled trials performed in the U.S. and abroad have shown that conservative therapy--defined as removal of only the tumor itself and the adjacent underarm lymph nodes, followed by radiation of the entire breast--results in survival equivalent to modified radical mastectomy. A surgical oncologist recounts:
Previously, surgeons concentrated on removing as much breast tissue as possible because it was believed that breast cancer spread by permeating the surrounding tissues. Mastectomy did decrease recurrences in the region of the breast, but survival was not improved because patients died of distant metastases. Better understanding of breast cancer biology resulted from research demonstrating that metastatic spread occurred principally via lymph and vascular channels. This finding led us to suspect that radical breast surgery was unnecessary.
The few remaining contraindications to conservative therapy relate primarily to the size of the tumor relative to the breast size. With heightened patient and physician awareness and growing use of detection measures such as mammography, breast tumors are increasingly being discovered when they are small, well-defined, and amenable to conservative treatment. Over half of breast tumors discovered today are under two centimeters in diameter with no lymph node involvement. Ongoing clinical trials have focused on testing whether breast irradiation is essential after breast conserving surgery. An NCI radiation oncologist sums up the results:
Radiation of the breast is a critical part of the conservative approach. To date, we have not found any subset of patients with invasive breast cancer that can safely have this therapy omitted. It is reasonable to continue to study this in carefully monitored clinical trials, but only in patients at low risk of local recurrence who are well informed and accept the risk of omitting follow-up radiation.
Our challenge now is to rid the body of micrometastases that occur in many patients before the tumor is removed surgically. Systemic chemotherapy and hormonal therapies designed to combat these distant metastases have improved patient survival in clinical trials. Researchers are working to develop more potent adjuvant systemic therapies for patients whose tumors are unlikely to be cured by local therapy alone. We believe the drop in breast cancer deaths for white women achieved recently reflects in part the wider use of effective adjuvant systemic treatments in the community at large. As these therapies improve, the day may even come when surgery is no longer required.
My doctors gave me a choice--I chose breast-conserving surgery because it left me whole and because it was the best choice for me and my family. The studies assured me that it was a safe thing to do. If my doctors recommend chemotherapy, I'll accept the hardships associated with it. It has meant everything to have these options.
Breast Cancer Prevention Trial
The Breast Cancer Prevention Trial (BCPT) is a randomized clinical trial testing the effectiveness of tamoxifen for preventing breast cancer. Sixteen thousand women at increased risk of developing breast cancer (based on factors such as age, family history, and personal history) are being recruited. Twenty percent of BCPT participants have two or more first-degree relatives (mothers, sisters, daughters) with a history of breast cancer, thus providing a unique resource for understanding breast cancer genetics. The average relative risk for BCPT participants is about five times as great as that for a comparable group of individuals in the general population. Studying preventive regimens in this group may well give us insight into how cancer prevention can be realized.
The trial is being conducted by the National Surgical Adjuvant Breast and Bowel Project (NSABP) in more than 200 sites across the United States, including CCOPs and NSABP members and affiliates. Due to the meticulous collection of data about participants, the BCPT is likely to allow unprecedented opportunities for advancing the scientific understanding of women's health and for studying the effect of tamoxifen in women with predisposing genetic susceptibility to breast cancer. If proven effective, tamoxifen could provide an option to prevent breast cancer in certain women at high risk of developing the disease.