Lumpectomy Is Seen as Equal in Benefit to Removing Breast

[Guest guest]

October 17, 2002

The New York Times

Lumpectomy Is Seen as Equal in Benefit to Removing Breast

By GINA KOLATA

After monitoring more than 2,500 breast cancer patients for 20 years,

researchers have concluded that women fare just as well with an

operation that removes the cancerous lump as they do by having the

entire breast removed.

Some medical experts said they hoped the findings, by researchers in the

United States and Italy, might end a simmering debate over whether it is

really safe to offer a lumpectomy, rather than a mastectomy, to most

women with breast cancer.

One study, at the University of Pittsburgh, involved 1,851 women and

compared mastectomies with lumpectomies. The other, at the European

Institute of Oncology, in Milan, involved 701 women and compared radical

mastectomies, which removed more tissue, with a more extensive form of

lumpectomy.

The studies, both described in today's issue of The New England Journal

of Medicine, have reported similar results in years past. But some

experts said then that they would not be convinced until more time had

gone by. Among them, many thought that mastectomies were better for

women with relatively large tumors, aggressive cancers or disease that

had already spread to the underarm lymph nodes.

Dr. Morrow, a professor of surgery at Northwestern University,

said her national survey of women with early-stage breast cancer found

that just 42.6 percent had breast-conserving surgery; the worse the

woman's prognosis, the more likely she was to have a mastectomy instead.

In an editorial accompanying the two studies, Dr. Morrow wrote that

" breast-conserving therapy is still not accepted as equivalent of

mastectomy, but instead is viewed as a less aggressive therapy

appropriate only for women with a good prognosis. " She said she hoped

the new results would change that view.

Dr. Morrow's outlook was echoed by others. " We have science here to back

up the claim that even if a cancer makes you nervous as a doctor or a

patient, you don't necessarily have to do a mastectomy, even if you have

a gut feeling that you want to do it, " said Dr. Barron Lerner, a

historian and internist at Columbia University and author of " The Breast

Cancer Wars " (Oxford University Press, 2001).

But Dr. Lerner added, " That notion of getting it all, of the surgeon

coming out of the operating room and saying, `We got it all,' has such

cultural resonance in the entire cancer experience and the entire way we

treat and understand cancer. "

Some doctors have worried that the radiation treatments usually given

after a lumpectomy may cause cancers themselves.

" We know it takes 15 years or so to begin to see radiation-induced

cancers, " said Dr. Borgen, chief of breast surgery at Memorial

Sloan-Kettering Cancer Center. " These papers put that concern to rest. "

Not every woman will want a lumpectomy, doctors and advocates for women

with breast cancer said. But, they added, women should know they have a

choice.

" I think this is great, " said Dr. H. Gilbert Welch of Dartmouth Medical

School. " This is Cadillac data, just what we want. Someone could always

have argued that things might change at a distant date, that maybe the

problems with a lumpectomy wouldn't occur for 10 or 15 years. This puts

that to rest. "

The American study, by Dr. Bernard Fisher of the University of

Pittsburgh and his colleagues, involved women with tumors up to four

centimeters in diameter, or about an inch and a half, which can easily

be felt. In more than a third, the cancer had spread to their underarm

lymph nodes.

The women were randomly assigned to one of three treatments: a

mastectomy, a lumpectomy alone, or a lumpectomy followed by radiation.

The study found that there was absolutely no difference in the

likelihood that the disease would subsequently spread, in the rate of

death from cancer, or in the rate of death from all causes. Regardless

of the treatment, about 47 percent of the women were still alive 20

years later.

In a sense, Dr. Borgen said, that has been a surprise. " Everyone thought

early on that radiation would improve survival, " he said, " but it

didn't. "

Radiation did, however, markedly reduce the chance of another cancer's

arising in the same breast, sparing many women a mastectomy, which is

the usual treatment for a second cancer. The risk that a second cancer

would emerge later in the same breast was about 40 percent in women who

had a lumpectomy without radiation and about 14 percent in those who

also had radiation therapy.

The other study, by Dr. Umberto Veronesi of the European Institute of

Oncology and his colleagues, involved women with tumors no larger than

two centimeters in diameter, though in all but three cases the tumors

were large enough to feel. Once again, more extensive surgery was no

more effective than surgery that conserved the woman's breast.

Some medical experts say the new findings will fuel the debate over

whether women with newly diagnosed breast cancer should have ultrasound

or magnetic resonance imaging tests, which can detect minute flecks of

cancer in the breast. Such cell clusters occur in 16 percent to 37

percent of women with breast cancer, and doctors often advise them to

have a mastectomy, since a lumpectomy cannot remove those clusters.

But Dr. Morrow and other experts said the two studies indicated that it

made no difference whether tiny clusters of cancer cells were removed

along with the breast in a mastectomy or were left behind when a woman

had a lumpectomy.

" Subjecting women to a mastectomy because we now have a technique that

is sensitive enough to detect microscopic foci is not a step forward, "

Dr. Morrow wrote in her editorial.

" The medical profession needs to ask itself rigorously, Are these cells

medically important, or have we proved they can be controlled by

radiation? " she added in a telephone interview. " I think that the

studies prove that radiation is controlling most of them. "