In a word: probably.
Yesterday, NPR ran a talk-show piece that went online with a “scare” headline: “Surgery Doesn’t Help Women with Early-Stage Breast Carcinoma.” In fact, the report doesn’t say you’re going to die if you have early stage breast cancer. In fact, it discusses DCIS, which is not known to be cancer at all.
And yes, for some women, surgery makes no difference in survival rates because some cases of DCIS, which has been described as a “pre-cancer,” never progress to an invasive stage.
However, an unknown percentage of DCIS incidences do convert to invasive cancer. We do not know what that percentage is, because a true randomized study (in which X number of women are randomly assigned to have no treatment and an equivalent number get surgery) would be wildly unethical. Knowing that a substantial risk is there — possibly in the vicinity of 80% — doctors are morally obliged to recommend surgical treatment.
The story reports that survival rates are noticeably improved among women who have intermediate and high-grade DCIS:
For the women who had cells that were closer on the continuum to invasive cancer — those with intermediate- or high-grade DCIS — surgery did provide a significant benefit. After 10 years, 98.6 percent of women with intermediate-grade DCIS and who had surgery had survived breast cancer, compared to 94.6 percent of women who didn’t have surgery. And with high-grade DCIS, 98.4 percent of those who had surgery survived, compared to 90.5 percent of those who didn’t.
My DCIS did contain intermediate and high-grade areas; fortunately, there was no necrosis, which is a marker that the DCIS is about to convert to invasive cancer. So it looks like I have a 98.4% chance of living another ten years.
The problem with these survival rates is that they don’t always distinguish between women who died of breast cancer and women who died of just anything. Some studies take the cause of death into account, and some vacuum up all mortality data. So one can find oneself with a basketful of apples and oranges and no way of knowing which is which.
Survival rates for early-stage breast cancers — I mean the real thing, not DCIS — are quite high. They’re not nearly 100%, but they’re well over 80%. Survival rates for DCIS that has been treated with lumpectomy + radiation + hormone blockers or with simple mastectomy approach 100% when causes other than metastasizing breast cancer are taken out of the equation.
To my mind, a serious problem is the widespread insistence on lumpectomy, which is not “just as effective” as mastectomy. Radiation treatment, tamoxifen, and AI’s are not minor things. Radiation causes some very unpleasant side effects, some of them long-term, and if the idea is to preserve a semblance of your natural breast, it’s a major FAIL. Radiation causes your scar to contract, so that you can end up significantly disfigured. Tamoxifen can cause uterine cancer and blood clots (leading to stroke and deep-vein thrombosis), and both tamoxifen and aromatase inhibitors can cause painful arthralgia. Only about 40% of women stay on AI’s for the entire five years that’s recommended, and the quit rate for tamoxifen is also pretty high.
As many as 50% of DCIS incidences never convert to invasive cancer. Hence it’s reasonable to argue that removing every one of them and performing mastectomies to get rid of it is overtreatment.
But I think that assertion may be debatable. If non-conversion rates really ARE as high as 50% (we do not know and have no ethical way to find out), then it means the rate of conversion TO invasive cancer is at least 50%; it may be significantly higher, possibly as much as 80%. Would you rather go through life boobless or would you prefer to run to the hospital every year for yet another mammogram (mammography also has side effects), possibly yet another biopsy, and worry constantly about what’s growing in your chest?
Funny this is crazy…One would think with all the money going into research we would have a clearer picture of what works and what doesn’t. But of course we can’t even get a correct bill for said medical treatments.
I have been fighting with my insurance company and lab over “routine lab work” during a wellness exam for over 4 months. Despite the fact that my Doc or I requested no additional tests during my check up it appears I owe an additional $9 and some change. Fair enough….I asked the insurance company what test wasn’t covered…they haven’t a clue. I respond I’m going to need to know so as we won’t have these tests again during routine exam….to date no answer. But I did get a “collection notice” from the Lab…for the $9…Guess we’re going to Court….
So, let’s say you, the insurance company, have 100,000 policy holders. You charge each one of them “mystery” bills of under ten bucks, which most people will just pay without arguing. 100,000 x $9 is nine hundred grand: nice little collection of pocket change, eh?
If they refuse to say what the nine bucks is for and you can prove you’ve repeatedly asked for an accounting, I can’t imagine they’d get very far in court. But now of course you’ll be arguing with their collection company, not with the insurer. Hm. Can you take them to small claims court for harassing you to pay a bill that they can’t prove you owe? If so, maybe you can collect some of that excess pocket change in damages…
I’m going to latch onto this: “would you prefer to run to the hospital every year for yet another mammogram (mammography also has side effects).” Ummm, yeah I would prefer not to have a mammogram every year but every doc I’ve had insists that I need to do that, and I don’t even have a history of breast cancer in my immediate family or any abnormal mammograms. Are you implying there’s another option for those of us who still have breasts?
No, not one that’s sane.
No doctor is going to do a prophylactic double mastectomy because you don’t like mammograms. If they would, half the women in this country would be flat as boards. 😆
If you already have an invasive cancer or a DCIS in one breast that’s so extensive it can’t reasonably be removed with a lumpectomy, so that you’re already a candidate for a unilateral mastectomy, in SOME CIRCUMSTANCES it may be worth considering a double mastectomy. Among those circumstances:
* You don’t especially want reconstruction, which is arduous, time-consuming, and painful; or else
* you’re willing to subject yourself to the imperfections and discomforts of reconstruction on both sides.
* You would like to be even on both sides, not lop-sided, and you feel comfortable doing without reconstruction.
* You have a first-degree relative (mother, sister, aunt) who has had breast or ovarian cancer.
* You don’t want to undergo radiation treatment and hormone treatment, and a mastectomy would get you out of one or both.
* You’re irrationally worried about recurrence in the surviving breast and truly can’t shake that fear.
If you must have a unilateral mastectomy, you often can persuade a doctor to do a bilateral job for any or all of the reasons above.
Even though you can experience a recurrence of DCIS or invasive cancer in the chest wall after a mastectomy, the chances are extremely low: less than 1%. And they can’t do a mammogram on a boob that doesn’t exist. So, once you’ve had a mastectomy, that is one little nuisance that you shuck off, once and for all.
The chance that you will develop another DCIS or invasive cancer in a surviving breast is very low (you will not develop a “recurrence” of the same lesion in the opposite breast; if something arises, it will be a new lesion). It’s slightly higher than if you had never had anything in the guilty breast, but it’s not high enough for you to feel you should lob off both boobs for that reason alone.
Is it a good trade-off? Well. It depends on how you respond to mammography. Some women find it very painful. If you’re one of them, you probably would be happy never to go near another mammogram machine. For most women, it’s a nuisance, sometimes a mildly uncomfortable one. I would not choose to have a mastectomy just to get free of a minor nuisance.
But faced with the certainty that one boob had to go, I wanted to get rid of them both, specifically because I wanted to be the same on both sides, and because I was not afraid of going flat.
Had I been younger and felt I couldn’t be happy without breasts or breast-like objects attached to my chest, then you may be sure I would not have opted for a double mastectomy. One reconstruction is one reconstruction too many; for my taste, two would be hideous.
What are the potential risks of mammography?
* It does expose you to low-dose radiation, which in fact can give rise to cancers. Rarely, and usually treatable cancers…but still.
* Mammograms are prone to false-negative results. They do not identify all growths in the breast. (My DCIS was never visible on a mammogram; it was found only after discovery of a growth that had almost zero chance of moving outside the breast tissue.) As a result, some women may think they’re fine and fail to draw something they notice to a doctor’s attention, leading them into very deep water, indeed.
* They are prone to false-positive results. “Abnormal” findings are usually nothing, but they invariably lead to invasive, painful, and frightening procedures. The risk of unnecessary treatment is very high. Once something, anything is detected, there’s no turning back.
Does this mean you should decline regular mammograms?
Probably not.
The degree of regularity depends on your age. If you have no cancer in your family and nothing out of the ordinary has been seen in a past mammogram, there’s no reason for you to have yearly mammograms until you’re over the age of 40. In the absence of a genetic predisposition to breast cancer, your chances of developing it are lower at younger ages, slowly increasing as you age.
Recommendations on this issue change from year to year. No one really understands the disease very well, and as a result there’s a lot of hysteria about breast cancer. At about the age of 40, you should consider having screening mammograms once every year or two. The American Cancer Society (whose members, no matter how well-meaning, have a financial interest in widespread treatment) recommends once-yearly screening mammography starting at age 40. However, the US Preventive Services Task force suggests women wait until age 50. Here’s a pretty rational discussion of the question from the Mayo: http://mayocl.in/1p2BjNn
Now, where DCIS is concerned, bear in mind that DCIS is not cancer. DCIS is not going to kill you. Therefore removing it from your breast will make no difference in your survival one way or the other, EXCEPT THAT… Yes, except that some DCIS will convert to cancer. We don’t yet know exactly what proportion of DCIS cases will do so, nor do we understand why that happens. Until we learn more about how this condition progresses and why, it would be foolish not to try to get rid of it.
Any day, I’d rather be boob-free (and, oh joy! mammogram-free!) than have to wonder whether a DCIS lurking inside my breast might morph into an invasive entity.
Will surgery save your life if you have DCIS? We can’t really say for sure. But I for one would rather be free of it, even if it means getting rid of part or all of a breast, than take a chance one way or the other.