Despite Good News, Misunderstandings Abound
One-third of all new cancers diagnosed in women are breast cancers. The American Cancer Society estimates that more than 230,000 cases of invasive breast cancer were diagnosed in the US in 2015.
But no one should let the fear of breast cancer obscure some very encouraging facts. The overall five-year survival rate from breast cancer now is close to 90%. Less than 7% of breast cancers are diagnosed before the age of 40—those diagnosed later in life tend to be easier to treat. Many women with breast cancer will never need highly aggressive (or disfiguring) treatments.
Despite such good news, misunderstandings about breast cancer are common. Here’s what you need to know now.
Lumpectomy often is the best choice. Many women assume that a mastectomy is the “safest” way to beat breast cancer. It makes intuitive sense that removing an entire breast would improve long-term survival.
Not true. Survival has nothing to do with the amount of additional healthy tissue that’s removed during surgery. About 60% to 75% of breast cancer surgeries are lumpectomies, in which only a small amount of tissue is removed. If your doctor gives you a choice, you can assume that the probability of survival for both procedures will be essentially the same.
The advantages of lumpectomy are obvious. The surgery is less extensive and women need less anesthesia, both of which are associated with shorter recovery time—and the breast probably will look much the same as it did before the surgery.
Downside of lumpectomy: About 25% of women will need a second procedure to remove cancer cells that were left behind during the first surgery if clear “margins” aren’t achieved. Most patients will require a five-to-seven-week-long course of radiation. And the risk of the cancer coming back is slightly higher (usually less than 5%) in women who choose a lumpectomy rather than mastectomy (1% to 2%). Despite the slightly higher risk for local recurrence in the breast, the survival rates between lumpectomy and mastectomy are the same for women who are eligible for both.
A lumpectomy often is the best choice for tumors that are smaller than 4 centimeters (cm) to 5 cm. Some women feel that they’ll have peace of mind only when the entire breast is removed. This can be a valid decision as long as you understand that the medical outcomes are roughly the same.
Of course, there is no “one size fits all,” and absolutely, there are cases where a mastectomy is the better choice for an individual patient. For example, most women who are genetically predisposed to breast cancer and test positive for the BRCA genes are at much higher risk for recurrence with lumpectomy alone. In these cases, mastectomy—and often removal of both breasts, bilateral mastectomy—is recommended.
You may respond well to neoadjuvant chemotherapy. Chemotherapy usually is considered for women whose cancer has spread to the lymph nodes and for those with large tumors. It’s typically given after surgery. For certain types of cancer, however, a different approach is highly effective. In this approach, the chemotherapy is given first.
This therapy, called neoadjuvant chemotherapy, is used to shrink a tumor prior to surgery. In some cases, it will allow women who would otherwise need a more extensive surgery, such as a mastectomy, to have a lumpectomy instead. It’s also the only recommended approach for women with inflammatory breast cancer, which involves the whole breast along with the overlying skin. It also can be a good choice for women with “triple negative” cancers, which don’t respond to hormonal treatments (see below), and those with HER2/neu-positive cancers. In some cases, this treatment shrinks a tumor so much that surgeons can find no residual cancer (but surgery still is necessary to ensure that this is the case).
Consider drugs that block hormones. Between 60% and 70% of all newly diagnosed breast cancers are estrogen/progesterone-receptor positive. This means that exposure to these hormones can increase the risk for a recurrence.
Women with these types of cancers are almost always advised to take medication that reduces their risks. Tamoxifen (Nolvadex) is recommended for women prior to menopause. Aromatase inhibitors (such as letrozole, or Femara) are used after menopause.
The medications kill tumor cells that might have spread beyond the breast… reduce the risk that cancer will come back in a treated breast…and reduce the risk for cancer in the opposite breast. Women who take them can reduce their risk for a cancer recurrence by 40% to 50%. Patients usually take one pill a day and continue the treatment for five to 10 years.
Important: New research has shown that premenopausal women who take tamoxifen for 10 years usually have a greater reduction in cancer recurrences than those who take it for only five years.
The medications can cause unpleasant, menopause-like side effects, such as hot flashes and/or vaginal dryness. Tamoxifen also is associated with some rare but serious side effects such as a slightly higher risk for uterine cancer and blood clots, and aromatase inhibitors can affect bone density, which can be a problem for women with osteoporosis. But the side effects usually are minor, and many women feel the side effects are an acceptable trade-off for the superior protection.
What Else Can You Do?
Studies have shown that surgeons who treat a lot of patients (more than 50 cases a year) have better results. Ask your doctor to recommend a surgeon who specializes in breast cancer. Also helpful…
Ask your doctor if being in a clinical trial makes sense for you. Most clinical trials are conducted by top hospitals and doctors. You’ll get very sophisticated (and attentive) care. In many cases, even if you’re assigned to a control group, you still will get the same treatment that you would have gotten if you hadn’t joined the study. Those in the “active” group will get something that’s expected to be at least as good—and possibly better.
Even if your doctor isn’t personally involved in a clinical trial, he/she can talk you through the issues, including the pros and cons of participating…where to look for studies that involve your type of cancer…and what the studies are likely to involve.
Keep your weight down. There’s no evidence that specific dietary changes affect recovery from breast cancer. However, there is good evidence that maintaining a healthy weight is important, particularly for women with estrogen-sensitive cancers. (Much of a postmenopausal woman’s estrogen is produced by fatty tissue.) Women who maintain a healthy weight may have up to a 5% survival advantage compared with those who are obese. Normal-weight women are less likely to get postsurgical infections and blood clots—particularly important for those who take tamoxifen, which slightly increases the risk for clots.
There isn’t clear evidence that regular exercise helps prevent breast cancer, but I have found that cancer patients who exercise tend to recover more quickly—and of course, they find it easier to maintain a healthy weight.