by Doctor W. Gifford Jones
September 20, 2004
Why don't doctors learn from history about breast cancer? Over 50 years ago a Scottish surgeon reported that radical removal of women's breasts did not improve their survival rate. Yet for decades many surgeons have continued to do this mutilating operation. Now it's been reported that whether a lumpectomy (removal only of the cancerous lump) or mastectomy (whole breast removal) is done also depends on where you live. What's happening in this country, and the U.S., is partly due to the Yo Yo effect.
A study published in the Canadian Journal of Public Health shows that women living in Prince Edward Island are three times more likely to have a breast removed for breast cancer than women living in Quebec.
Dr Ineke Neutal, an epidemiologist at the University of Ottawa, says, "That's a big, big gap" since published guidelines for treating beast cancer are the same across Canada.
Dr. Monica Murrow, a Northwestern University cancer specialist, urged surgeons to spare the breast in an editorial published in the New England Journal of Medicine. She cited two studies, one Italian, one American, which showed similar death rates after 20 years regardless of whether women had a mastectomy or a breast saving lumpectomy. She stressed that these findings should convince "even the most determined skeptics."
So why don't surgeons simply remove cancerous growths and spare the breast? Sometimes it's the patient's choice. Dr. Bernard Fisher at the University of Pittsburgh says that many women who could have a lumpectomy choose mastectomy. They argue that if you get it all out there can be no further trouble. But evidence shows this is emotional, not rational, thinking, as the survival rate is not improved.
An historical Yo Yo effect has also had a major impact on the psyche of surgeons. For most of the 20th century radical mastectomy was the surgery of choice.
This involved removal of the breast, underlying muscles and extensive removal of lymph nodes in the armpit. It was a desperate, but mutilating, attempt to excise all malignant tissue.
Then in 1984 a major study showed that the outcome was the same whether a lumpectomy or mastectomy was done. This resulted in an increase in the number of lumpectomies.
But in 1987 another shift in the enthusiasm for lumpectomy occurred when a well-known woman had to make a decision. The U.S. President's wife, First Lady Nancy Reagan, elected to have her breast cancer treated by mastectomy. The obvious result followed. If mastectomy is the right choice for the president's wife, it's assumed to be the right treatment for others.
Four years later in 1991, the U.S. National Institute of Health, and later Health Canada, published new guidelines urging restraint on mastectomy. Once again this triggered an increase in the number of lumpectomies. This up and down trend, however has not been pleasant for women.
I've thought for years that lumpectomy makes sense. If the malignancy is still a local tumour, cutting it out cures the patient. But if it's already spread to other areas no amount of surgery is effective. It's like closing the barn door after the horse has escaped.
The finding that rates of lumpectomy vary from province to province should not come as a surprise. In many ways it's like comparing apples and oranges. Prince Edward Island is a small province lacking the medical advantages of the major university centers in Montreal and Quebec.
Ours is not a fair and just world. We also know that patients being treated for colon cancer are also more likely to end up with a colostomy if treated in a non-university setting. Women are also less likely to get early treatment for coronary heart disease than men. The list goes on and on, and history shows these discrepancies are hard to abolish.
But one thing should result from this latest report. Women should not be subjected to mastectomy to treat early breast cancer without being told that there's no medical benefit from this procedure. Surely that's the least women deserve. The positive evidence for lumpectomy has been available for many years. After all it's the woman's breast and the woman's life.
W. Gifford-Jones M.D is the pen name of Dr. Ken Walker graduate of Harvard. Dr. Walker's website is: Docgiff.com
My book, �90 + How I Got There� can be obtained by sending $19.95 to:
Giff Holdings, 525 Balliol St, Unit # 6,Toronto, Ontario, M4S 1E1
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