Treatments Other Than Surgery or In Combination With Surgery
Although mastectomy in some form is still the response to breast cancer chosen by many surgeons, it is important to know that it is not the only possible treatment. Breast cancers that have already spread through the bloodstream to other parts of the body may be better treated by early, intensive chemotherapy, according to researchers at the medical schools of Harvard, Yale, and the University of Pittsburgh. They believe that when drug treatment is introduced early in the course of the disease (rather than as a "last resort" following surgery and radiation) it is more easily tolerated and more effective at locating and destroying cancer cells, which cannot be reached by other means. Similarly, early radiation of all lymph nodes surrounding the affected area may succeed better than attempts to remove all such nodes by surgery; many lymph nodes lie behind the breast bone and up the back and are difficult to remove. And a woman whose breast is mainly intact may withstand radiation better than one who has had a radical mastectomy, leaving extensive scars and only a thin layer of easily damaged skin covering her breastbone.
Lumpectomy with Radiation Treatments
When breast tumors are detected in an early stage, before they have had a chance to invade surrounding lymph nodes, removal of the tumor and 1-2 cm of surrounding tissue, followed by radiation of the surrounding tissue can be equally effective. Results of lumpectomy followed by radiation, were first published in 1927. More recently, a team of surgeons pathologists, radiologists, and internists ant Massachusetts General Hospital in Boston, reported much the same thing — results of lumpectomy followed by radiation were equally as effective as mastectomy when the tumor was small with no evidence that surrounding tissue had been invaded.
An October 1988 article published in a medical newspaper OB-GYN News reported "the issue of lumpectomy plus radiation, versus mastectomy, has been studied about as well as any medical treatment has been scrutinized." The findings show the survival of patients who had a wide excision of the tumor followed by radiation was indistinguishable from the survival of those who underwent mastectomy. Appropriate selection of patients combined with the proper surgical technique helps ensure survival equal to that of mastectomy.
Do not be reluctant or hesitate to discuss this alternative with your doctors.
Advantages to Less Surgery
There are also important psychological and cosmetic advantages to less drastic surgery — although reconstruction may be less difficult for a patient who has undergone total simple mastectomy than for one who has had a large tumor removed from a small breast.
Patients considered to be at high risk of cancer recurrence may receive additional treatment — often referred to as "adjuvant" therapy. This may also be true of patients who have a mastectomy for a very large tumor or whose lymph nodes in the chest and axilla (armpits) are affected.
Treatment using drugs that kill cancer cells circulating in parts of the body other than the breasts is also improving the survival rates in some women. Scientists are continually searching for drug combinations that most effectively kill the cancer cells while still having the fewest unwanted side-effects.
The National Cancer Institute reported in a 1986 study a significant reduction in death among premenopausal women given chemotherapy in conjunction with surgery. Two more recent studies, one by the U.S. research team and another by a cancer research group in Italy, found there was "clear-cut survival advantage" for premenopausal woman under the age of 50 who were treated with chemotherapy and surgery. There is continued debate regarding the timing of chemotherapy in order to obtain the best results. There is also no definite answer as to the choice of drugs, dose and duration of a treatment.
Studies involving postmenopausal women who were given the hormone tamoxifen in conjunction with surgery also reported a significant survival advantage according to the National Cancer Institute. Tamoxifen, a synthetic hormone, blocks the action of the female hormone estrogen. It was once thought that tamoxifen sped up bone loss in postmenopausal women but recent studies do not support this. As a matter of fact, it may actually offer some protection against bone loss.
While tamoxifen acts against the effects of estrogen in the breast tissue, it acts like estrogen in other systems of the body, according to Cancer Facts published by the National Cancer Institute (NCI). This means that many of the beneficial effects of estrogen replacement therapy such as lowering blood cholesterol and slowing bone loss will affect women who take tamoxifen.
The side effects of tamoxifen are similar to some of the symptoms of menopause. This includes hot flashes, irregular menstrual periods and vaginal discharge or bleeding. However, not all women taking tamoxifen have these symptoms.
Tamoxifen has also been shown to increase fertility thus all premenopausal women taking this medication should use some type of birth control. Oral contraceptives (birth control pills) however, should not be used since they may alter the effects of the tamoxifen.
There have been recent clinical studies indicating that women taking the recommended dose of tamoxifen have an increased risk of endometrial cancer (cancer of the lining of the uterus). All women receiving tamoxifen are advised to have pelvic examinations every six months. Close monitoring of women taking tamoxifen therapy is essential. If an overgrowth of endometrial tissue (hyperplasia) is found, the tamoxifen should be discontinued and appropriate treatment instituted.
Tamoxifen offers the hope of adding may years to a woman's life, confirming the belief of many physicians that the beneficial effects of tamoxifen warrants the increased risks of endometrial cancer. In a study conducted in Amsterdam, and reported in the English medical journal, Lancet (1994:343:448), Dutch investigators concluded "the clinical benefit of tamoxifen in controlling breast cancer far out weighs the modest increase in uterine cancer."
In one of the largest analyses of breast cancer patients ever conducted, benefits of tamoxifen, either alone or in combination with chemotherapy, increased the life expectancy of breast cancer patients even after a relatively brief series of treatments had ended. Tamoxifen treatment appears even more effective in the second five-year period. Analysis of this large study indicated women treated with tamoxifen, with or without chemotherapy, had fewer recurrences and lived longer than these who did not receive this treatment.
Tamoxifen also appears to offer protection against the development of new cancer in the opposite breast. This protection was not seen with chemotherapy only.
Long-term effects of tamoxifen in premenopausal women have not been studied until recently. Current studies suggest that it can produce as good an effect in women under 50 years old as chemotherapy, which is more toxic and produces more debilitating side effects.
A medical alert issued by the National Cancer Institute's Information Service, and mailed to cancer specialists around the country, recommends tamoxifen, used in the treatment of early stages of breast cancer. Side efffects may include hot flashes, slight nausea and changes in the menstrual cycle, but practically no serious side effects in post menopausal women.
Chemotherapy and/or hormonal therapy for patients at high risk are not controversial. With the in-depth analysis of a study, reported in 1992, experts believe tamoxifen therapy with or without chemotherapy, may also be indicated in women in whom cancer is caught in the early stage.
Doctors may prescribe chemotherapy, hormonal therapy, or a combination of the two. Chemotherapy can cause a variety of unpleasant side effects, which in most people, disappear when the medication is discontinued. A small percentage of patients may suffer serious delayed effects. Patients are closely monitored and the dosage adjusted to minimize the risk.
Early Detection Impacts Survival Rates
These potential treatment alternatives should make you more aware than ever of the extreme importance of early detection of any possible breast cancer by BSE and your doctor's diagnosis. Today, the 5 year survival rate for localized breast cancer has risen to 96 percent. If the cancer has spread to areas near the breast, the survival rate drops to 69 percent; for those where cancer has spread to distant areas, the survival rate drops to only 18 percent.
If breast cancer is not invasive, the survival rate nears 100 percent according to "Cancer Facts and Figures — 1996," published by the American Cancer Society. An concerning and frightening fact is that, on the average, women wait five to six months between finding breast lumps and consulting their doctors. And, of course, delay reduces your chances for minimal surgery and possible reconstruction. Remember that finding a lump needn't automatically mean losing a breast; but not finding a breast cancer, or not reporting it, cold mean losing your life.
To date, there are still some key questions which have no answers. Research is continuing to more accurately identify "high risk" patients. This, coupled with insights from clinical studies that ate on-going should, in time, help eliminate the uncertainty of women facing breast cancer treatment.
Discuss these alternative treatments with your surgeon and/or family physician. According to Dr. Marsha McNeese, of M.D. Anderson Cancer Center in Houston, Texas, it not necessary to rush into surgery. She does not advocate postponing surgery for any length of time. Dr. McNeese does feel a woman should not be pressured into making an immediate decision. Rather, she should discuss the alternatives with her doctor(s).
Breast cancer specialists stress that for most patients, the decision of whether or not to have mastectomy should be strictly a matter of personal choice.