10 February 2014

Breasts, lumps and choices

Ignorance in a crisis can have a heavy price. Not knowing what you need to know, when you do need to know it can lead to major problems. So breast cancer – take out the lump or remove the whole breast? What leads to better survival? Then mastectomy - is it worth the risks?

A common experience I encounter is the aftermath from when people have been faced with a major life crisis, been asked to make life-changing decisions when in a frazzled state of mind, and while not knowing all the facts, they have made choices with unhappy consequences that they later regret.

So this week, we go Out on a Limb, check out some pivotal recent research that in my view, everyone needs to be aware of. Maybe a good post to share with friends , but first

Thought for the day
The ultimate measure of a man 
Is not where he stands 
in moments of comfort and convenience, 
But where he stands 
at times of challenge and controversy.

        Martin Luther King, Jr.

Lumpectomy - the best option for early breast cancer
Breast cancer – what to do? Have the lump taken out? Have the whole breast removed? What about radiotherapy?

Clearly the answer will vary from woman to woman and an article like this is not meant as personal medical advice and should not be taken as such, but a recent landmark study just published and claimed by its authors as probably the first of its kind highlights the issues.

This research and the answers it provides are well worth knowing by all women, so that if, heaven forbid, they are ever faced with these choices, they know what the current best evidence base is and as such they can make informed decisions.

This is important as separate research confirms many women may well have been led into making poor choices.

Defining early-stage breast cancer as having a tumor size of 4 cm or smaller with 3 or less positive lymph nodes, researchers examined the records of 132,149 women with early-stage invasive ductal carcinoma who had been treated with breast conserving therapy (BCT), mastectomy alone, or mastectomy with radiation during the period from 1998 to 2008.

Breast conserving therapy (BCT) may be defined as a combination of conservative surgery for resection of the primary tumour (commonly known as lumpectomy – just removing the cancer mass with a margin of surrounding tissue – not the whole breast - which is known as mastectomy) with or without surgical staging of the axilla- armpit (removing the lymph nodes near the breast and checking to see if cancer has spread into them – if so, the prognosis is poorer and medical treatment recommendations are likely to change and become more aggressive), followed by radiotherapy for the eradication of any residual microscopic disease of the breast, with or without adjuvant systemic therapy (commonly chemotherapy, maybe hormonal treatment).

What types of treatment were provided?
Breast conservation therapy (BCT) was used to treat 70% of patients, mastectomy alone was used to treat 27% of patients, and mastectomy with radiation was used to treat 3% of patients.

What were the survival rates?
The 5-year breast cancer–specific survival rates of patients who underwent BCT, a mastectomy alone, or a mastectomy with radiation were 97%, 94%, and 90%, respectively (P < .001).

The 10-year breast cancer–specific survival rates were 94%, 90%, and 83%, respectively (P  < .001).

Multivariate analysis showed that women undergoing BCT had a higher survival rate than those undergoing mastectomy alone (hazard ratio, 1.31; P < .001) or mastectomy with radiation (hazard ratio, 1.47; P < .001).

The researchers concluded 
Patients who underwent BCT have a higher breast cancer–specific survival rate compared with those treated with mastectomy alone or mastectomy with radiation for early-stage invasive ductal carcinoma. Further investigation is warranted to understand what may be contributing to this effect.

Reference: Agarwal, S et al. Effect of Breast Conservation Therapy vs Mastectomy on Disease-Specific Survival for Early-Stage Breast Cancer. JAMA Surg. Published online January 15, 2014. doi:10.1001/jamasurg.2013.3049 Link here

What is happening in real life?
While this latest research indicates lumpectomy actually has better results than mastectomy, it has been known for many years that lumpectomy is at least as good. Fifteen years ago the American College of Surgeons (ACS) acknowledged identical overall survival with the two treatments, yet despite this, they also stated that 50% of all women with early stages of breast cancer were surgically treated by mastectomy.

More recent analysis published in 2013 found very high frequency of mastectomy vs. BCS, again despite the stage of the disease being low. The 2014 study cited above records nearly 30% of women being treated by mastectomy. All the indications are that this is way too many.

When is BCT not a good idea?
These same researchers noted only 20% of absolute contraindications for BCT. The most frequent contraindication for BCT was reported to be multi-centricity of the tumour (with micro calcifications), especially in ductal-in-situ carcinoma.

Reference: Fajdic J et al; Acta Inform Med. 2013 March; 21(1): 16–19.
doi:  10.5455/AIM.2013.21.16-19

What about implants?
I know of no research on this, but from feedback received over the years I wonder if the use of implants following mastectomy may not be related at least in part to the poorer outcomes. I certainly hear of quite a few complications from implants.

Mammography – at what cost?

The issue of potential harm from mammography continues to be raised by major authorities.

In a recent commentary to an article on this theme in one of the world’s leading medical journals, JAMA, 2 researchers from Dartmouth University in New Hampshire, estimate that of 1000 US women aged 50 years who are screened annually for a decade, 0.3 to 3.2 will be spared from dying of breast cancer, while 490 to 670 will have at least 1 false-positive result, and 3 to 14 will be over-diagnosed and over-treated.

Discussing the findings in the New York Times, Dr. Welch said that a "screening program that falsely alarms about half the population is outrageous" and that "whether you blame the doctors or the system or the malpractice lawyers, it's a problem that needs to be fixed."

H. Gilbert Welch, MD, MPH; Honor J. Passow, PhD Criteria and Procedures for Breast Conserving Surgery; JAMA Intern Med. Published online December 30, 2013. Link Here


Meditation in the Forest : April 11 – 17, 2014

This is the regular Pre-Easter retreat Ruth and I present in the Yarra Valley each year. In 2014, as well as providing the opportunity for some meaningful time out - including the space in your life to regain balance and to be revitalized - you will be gently guided to learn more about relaxation, mindfulness and meditation, and to deepen your experience of these wonderful techniques.

        The meditation sanctuary at the Gawler                 Foundation's yarra Valley oasis.

Each year we have a particular focus or theme for this meditation retreat and in 2004 we will be giving particular attention to the theory and practise of that invaluable (and in my view, seriously undervalued) skill of contemplation.

This retreat is designed to meet the needs of a broad range of meditators. It is well suited to beginners as well as the more experienced, those who are interested in teaching meditation (we hold specific sessions through the retreat for these people), those on the healing path and anyone keen to rest, reflect and deepen their meditation.

For details CLICK HERE

Overmedicalisation, mammography and PSA testing


  1. Thank you for sending your very informative articles.
    I always thought that lumpectomy was not a good alternative and that it was better to go for the more drastic mastectomy. I suppose that was the school of thought in 1981,when I had my cancer.
    breast cancer.

    Of course, as you say, it all depends on so many factors,but at least one should also consider the option of lumpectomy and not -consider mastectomy as the standard treatment for breast cancer - with or without radiation and /or chemotherapy.

  2. Thanks for another interesting post.
    As often happens, research results raise further questions. The questions that came to my mind were: was there any difference in outcomes when the genetic status of the patients was taken into consideration? (of personal relevance - the treatment I chose to for my cancer was a double mastectomy because of my BRC1 genetic status); and was there any trend to the causes of death in the women who did not survive post mastectomy vs those who did not survive post BCT treatment which could explain the lower survival rate?
    Of course, I don't expect you know the answers to these questions, but I'll be interested if you come across further research that teaches us more on these aspects.
    In the meantime, thanks a lot for your informative and entertaining blog.

    1. What seems pretty clear is that there are many basic questions regarding breast cancer where the answers are either unknown or unclear. There seems to be plenty of scope for research that focusses on helping resolve the questions of choice - like what does actually work best.
      I hope to live long enough to see lifestyle as one arm of a breast cancer outcome trial. I am sure many people would be interested in that particular answer, just as they would be with other cancers. We do know elements of a therapeutic lifestyle improve survival, what about the whole package? Dean Ornish has shown its benefits for prostate cancer. What will it take to get trials happening elsewhere?

  3. As a woman with BRCA1 mutation it is very useful to
    know about studies like this.

    And thanks for your books, especially the cancer-book, in which I found hope
    and trust, that I can manage whatever might come. And thanks for your guide
    on meditation. Although I am meditating for decades it gave me new insights.
    And I really like your CDs white light, relaxation and healing journey. It
    is like a loving and gentle touch for my heart.

    As I am living in Germany, it is not very likely that I can ever join one of
    your retreats ...

    I wish you all the best for your work, really good and helpful work in my

    From Germany

  4. A Rapid Genetic Counselling and Testing in Newly Diagnosed Breast Cancer Is Associated With High Rate of Risk-Reducing Mastectomy in BRCA1/2-Positive Italian Women

    Cortesi L, Razzaboni E, Toss A, et al
    Ann Oncol. 2014;25:57-63

    Study Summary

    Italian researchers studied a rapid genetic counseling and testing intervention offered to women who had just been diagnosed with breast cancer and who were considered at risk of carrying BRCA1 or BRCA2 germline mutations. The investigators hypothesized that multidisciplinary approaches and rapid testing (3- to 4-week turnaround for results) could influence the choice of primary surgery, and they explored the psychological repercussions of this approach. This was an observational study with a retrospective design and was performed at the Modena Family Cancer Clinic in Italy.

    In the traditional testing model, women who had already completed primary surgery for breast cancer were referred to a genetic counselor for consideration of testing. This typically took 6 months to complete. Of 1058 patients tested using this referral venue, 19.7% were mutation carriers. Of these, 4.7% chose to undergo a risk-reducing contralateral mastectomy. Among the 110 patients tested at the time of diagnosis using the rapid mechanism, 33% tested positive for a mutation; 42% of these women chose to have bilateral mastectomies, showing that knowledge of their carrier status influenced the choice of primary surgery and led to a decision to proceed with a contralateral prophylactic mastectomy.

    Patients reported that they perceived that the surgery would help save their lives and that they were guided by feelings of responsibility to their children. Although all women were satisfied with their surgical choice, more extensive surgeries resulted in lower satisfaction with body image; the authors note, however, that patients were queried during the reconstruction process before it was complete, and this could have affected responses..

    This study showed the importance of involving surgeons in the counselling process and the need to assist patients in having realistic expectations about surgical outcomes.


    This study confirms the value of providing genetic counseling and testing to women at risk of carrying a BRCA mutation. The information allows them to make a wise and informed decision at the time of initial diagnosis and influences their choice of primary surgery. The number of women who chose to have a contralateral prophylactic mastectomy was significantly higher among those offered rapid testing.

    Although the authors correctly state that more extensive surgery can cause psychological morbidity, ultimately these women were satisfied with their choice. Multidisciplinary interventions to help women understand their lifetime risk for cancer and to help guide and support them in making treatment choices are indispensable to ensure the best possible experience and quality care.

    1. It will be quite a while before we know whether serious lifestyle based preventive measures do compare to the suggested benefits of cautionary surgery as suggested in this study. I guess the surgery is finite in the sense it is done and completed; lifestyle is a commitment for life.
      What do you think?