Guest Blog Post: Important Advice if You’re Considering Mastectomy

Ingrid Meszoely, M.D. is Associate Professor of Surgical Oncology and Clinical Director, Vanderbilt Breast Center at Vanderbilt-Ingram Cancer Center.

Following the completion of several large studies in the late 1980s and early 1990s involving thousands of women, it was clearly determined that the number of years a woman lived following breast cancer surgery was exactly the same whether she underwent mastectomy (removing the whole breast) or lumpectomy (just removing the part  of the breast with the cancer). This was a big breakthrough for breast cancer treatment with the realization that more surgery doesn’t result in better outcomes.  Initially this resulted in a trend of women choosing lumpectomy over mastectomy in order to preserve their breasts.

However in recent years, as Dr. Kummerow and many other researchers have found, there is a nationwide trend in choosing mastectomy over lumpectomy despite there being no clear survival advantage.  In addition, many women choose to undergo mastectomy of the non -affected breast despite the fact that the risk of developing cancer in this breast is very low and that it does not have any effect on survival from their current breast cancer.

As a breast cancer surgeon, I see this same phenomenon in my own practice.  The choice of mastectomy on one or both sides is often driven by multiple factors including the fear of cancer coming back or a new cancer on the other side and the wish to do everything one can to prevent this.  This often provides some sense of control and peace of mind in the setting of an overwhelming diagnosis.

When a woman is diagnosed with early breast cancer and given the choice of mastectomy or lumpectomy because she is a candidate for either procedure, the options should be considered carefully.

It should be clearly recognized that mastectomy does not provide 100 percent protection from cancers coming back. Cancers often come back at other sites outside of the breast before they return in the area of the removed breast tissue.  Because mammograms or other imaging studies are not routinely used after mastectomy, the finding of recurrences along the chest depends on continued routine self -exam and clinical exam by their doctor when the tumor is large enough to feel as opposed to being detected on mammogram when it is very small.

Mastectomy is also associated with increased complications compared to lumpectomy and these are often related to the reconstruction, which can be discouraging.  It is even more devastating when there are complications related to the unaffected breast when women choose mastectomies on both sides.

Lymph node surgery often is performed in the setting of mastectomy.  If just a single lymph node is found to be involved with breast cancer, removal of additional lymph nodes is recommended which can result in added complications. However if a lumpectomy is chosen, generally 3 or more lymph nodes need to be involved with cancer before more lymph nodes are removed.

When a woman presents with newly diagnosed early breast cancer and is put in the position of making a decision between lumpectomy and mastectomy, a thoughtful discussion should be initiated with her treating physicians.  Ultimately, the decision is very personal and she should choose the procedure that suits her lifestyle and provides her with the greatest sense of wellbeing.

 

HPV-Positive Head and Neck Cancer Patients May be Safely Treated with Lower Radiation Dose

A new study suggests that lowering the dose of radiation therapy for some head and neck cancer patients may improve outcomes and cause fewer long-term side effects.

The research was presented by lead author Anthony Cmelak, M.D., professor of Radiation Oncology at Vanderbilt-Ingram Cancer Center (VICC), during the 50th annual meeting of the American Society of Clinical Oncology (ASCO), held recently in Chicago.

The study focused on patients with newly-diagnosed oropharyngeal cancers related to the human papilloma virus (HPV). More than two-thirds of new head and neck cancer patients have HPV-positive tumors and the number of these patients is on the rise. Cmelak’s prior cooperative group study found that patients with HPV-positive oropharyngeal cancer have significantly longer survival rates than patients whose tumors are HPV negative.

For the new study, 80 HPV-positive patients with stage III, or IVa,b squamous cell cancer of the oropharynx received induction chemotherapy, including paclitaxel, cisplatin and cetuximab.

After chemotherapy, 62 of the patients showed no sign of cancer and were assigned to receive a 25 percent lower dose of intensity-modulated radiation therapy – an advanced technology that targets the radiation beam more accurately to treat the tumor without harming surrounding tissue. The rest of the patients received a standard IMRT dose. The drug cetuximab was also given to both groups of patients along with the IMRT treatment.

Two years after treatment, the survival for the low-dose IMRT patients was 93 percent.  Those who did not have complete resolution of cancer following induction and went on to get full-dose radiation had an 87 percent two-year survival. Eighty percent of the low-dose patients and 65 percent of standard IMRT patients also showed no evidence of tumor recurrence.  Ninety-six percent of those who had minimal or no smoking history had no evidence of tumor recurrence after two years following treatment, and long-term side effects were minimal.

The investigators concluded that patients with HPV-positive cancer who had excellent responses to induction chemotherapy followed by a reduced dose IMRT and cetuximab experienced high rates of tumor control and very low side effects particularly for those with a minimal smoking history.

Treating tumors in the delicate head and neck region often causes side effects that can be troublesome and long-lasting, including difficulty swallowing, speech impairment, dry mouth, problems with taste and thyroid issues, so any therapy option that reduces these side effects can have an impact on patient quality of life.

“Treatment for head and neck cancer can be quite grueling, so it’s very encouraging to see we can safely dial back treatment for patients with less aggressive disease and an overall good prognosis, particularly for young patients who have many years to deal with long-term side effects,” said Cmelak.

He noted that lower-dose IMRT is not recommended for patients with HPV-negative cancer or larger tumors.

The authors note that further studies of reduced-dose IMRT in HPV-positive patients are warranted.

Other investigators include Jill Gilbert, M.D., VICC; Shuli Li, Ph.D., Dana Farber Cancer Institute, Boston, Massachusetts; Shanthi Marur, M.D., William Westra, M.D., Christine Chung, M.D., The Johns Hopkins University School of Medicine, Baltimore, Maryland;  Weiqiang Zhao, M.D., Ph.D., Maura Gillison, M.D., Ph.D., The Ohio State University, Columbus, Ohio; Julie Bauman, M.D., Robert Ferris, M.D., University of Pittsburgh Cancer Institute; Lynne Wagner, Ph.D., Feinberg School of Medicine, Northwestern University, Chicago, Illinois; David Trevarthen, M.D., Colorado Cancer Research Program, Denver;  A. Demetrios Colevas, M.D., Stanford University, California; Balkrishna Jahagirdar, M.D., HealthPartners and Regions Cancer Care Center, St. Paul, Minnesota;  Barbara Burtness, M.D., Fox Chase Cancer Center, Philadelphia, Pennsylvania.

Funding was provided by The National Cancer Institute, a division of the National Institutes of Health (CDR0000665170).