8/3/97 
DIFFICULT CHOICES ON BREAST CANCER SURGERY 
By Linda Seebach 
 
 
Cancer researchers published a study this month in the Journal of Clinical Oncology suggesting that some women with breast cancer might be able to avoid mastectomies by having chemotherapy before they decided what kind of surgery to have. 
     Depending on how successful the chemotherapy was in shrinking the tumor, or in eliminating evidence of cancer in the axillary lymph nodes under the arm, more women had a lumpectomy, or breast-conserving surgery, than surgeons had originally proposed. 
     The study was solidly done, said Dr. Harmon Eyre, chief medical officer of the American Cancer Institute, and may help persuade doctors and their patients to opt for the less disfiguring lumpectomy. 
     I'm certainly in favor of allowing patients to make decisions about their health care, and the more information they have when they decide, the better. 
     But speaking as someone who had a mastectomy a year ago, I truly don't understand why there is so much concern for appearance in matters of life and death. 
     Doctors offered me a choice between a mastectomy and ``breast- sparing'' surgery plus radiation. It shouldn't make any difference in long-term prognosis, the surgeon said, because if the cancer came back they could always do the mastectomy later. 
     Oh, no, I don't think so. It was almost three months from the first lethal shadow on the mammogram to the pathologist's all clear, or at least as ``all clear'' as one gets until the five-year mark. That was quite long enough to wait, without volunteering for a longer term in purgatory. 
     In contrast, I couldn't see that having a mastectomy would make any difference at all in my life, and it hasn't. The surgery was done on a Friday afternoon, I left the hospital Saturday morning and went back to work on Monday. 
     Just in case, I prepared a response to any intrusive or insensitive questions about why I only had one breast; I was going to tell people that I took archery in high school. But nobody ever asked. They figured it out by themselves, or they already knew, or they didn't notice or they didn't care. 
     My situation is not quite the same as the 1,500 women in the study. They were already scheduled for chemotherapy; they were divided randomly into two groups to test whether doing chemotherapy before surgery instead of after would decrease the number of mastectomies done.  
     And it did, although less than you might think from the breathless news stories. The Associated press story began, ``Many women who have been told they will lose a breast to cancer can safely preserve most of it.'' But approximately two-thirds of the women were already expected to have lumpectomies, and most did _ 67 percent of those who had chemotherapy first and 60 percent of those who had surgery first. 
     The biggest increase in lumpectomy was in women with larger tumors, at least 5.1 cm. It had been proposed for only 3 percent of them, and after chemotherapy it was performed on 22 percent. But that was a very small group, about 13 percent of the entire group enrolled in the study. And 8 percent of the control made the same choice. Describing this as a 175 percent increase, although technically correct, obscures the significant fact that the difference was only about 1 percent of the total number of women involved in the study. 
     For women with small tumors, less than 2 cm., the number of lumpectomies performed was actually less than originally proposed, regardless of when the women had chemotherapy. 
     There may be some useful medical information to be gained by treating the cancer before surgery. If it disappears completely that may be an indication that any metastases have been eliminated as well; if not, it can be a warning to the doctors that more aggressive treatment will still be needed. When the surgery is done first there's no way to know. 
     The study hasn't yet provided information on whether the choice of preoperative chemotherapy affects how long women live or when their cancer returns. 
     Isn't that the most important question? I know it was the only one I cared about. If my doctors had recommended chemotherapy (as they would have if the pathologist's examination had shown my cancer had spread to the lymph nodes) I would of course have done it, but that prospect scared me a lot more than surgery. 
     I certainly wouldn't have done it purely for cosmetic reasons. Yet this study seems to assume that cosmetic results and control of the disease are of roughly equal importance. If that's what they think, I'd like them to know there's at least one breast cancer patient who doesn't agree.