More choose invasive surgery

Jennifer Bailey had her left breast removed after a cancerous tumor was discovered there and now wishes she had asked surgical oncologist Karen Yeh to remove the right breast also, something she plans to schedule once her radiation therapy is over.

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Dr. Sifrance Tran (left) and Dr. Randy Cooper perform surgery on a breast cancer patient at University Hospital.

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"As soon as possible, that's when I'd like it anyway," Ms. Bailey said. "I even worry about (cancer showing up there) at this point already, and I know that I probably don't have any reason to."

After decades of progressing toward less invasive surgery for early-stage breast cancer patients, some women opting for mastectomy are also asking for the other noncancerous breast to be removed, Augusta surgeons said, a trend that appears to be increasing nationally. It is particularly true in younger patients and could be fueled by increased use of magnetic resonance imaging (MRI) in pre-operative patients, according to the surgeons and several studies.

For decades since its inception in the 1800s, the treatment for breast cancer was a radical mastectomy to remove the breast and even the muscle on the chest wall beneath, said Jack A. Feldman, a surgical oncologist and general surgeon with General Surgery and Oncology Associates of Augusta. The procedure was later refined to take the breast and the lymph nodes under the arm; and then later a lumpectomy to remove the tumor, take the lymph nodes, followed by radiation therapy, he said. Then surgeons hit on the idea of using an isotope injected into the breast and a blue dye to identify the nodes that drain the breast to see whether the cancer had spread first, called a sentinel lymph node biopsy.

"We can now do a lumpectomy with a sentinel lymph node biopsy and if it's negative, there's no more surgery under the arm, they just have the postoperative radiation," Dr. Feldman said. "And that has been just fantastic."

Catherine Moman of North Augusta got a lumpectomy and sentinel node biopsy from surgeon Randy Cooper at University Hospital after a screening mammogram found a small tumor. Though initially very concerned, Ms. Moman's mind is more at ease now.

"I guess that comes from trusting your doctors. And I do trust Dr. Cooper," she said. "I think he's been very upfront with me. I've been blessed to have found it so early."

One study found that removing all of the lymph nodes causes swelling and nerve pain or numbness in the arm in about 15 percent of those patients but in only 5 percent of the sentinel node patients, said Matthew Pugliese, an Augusta surgical oncologist.

In addition to a mircoscopic examination, Medical College of Georgia Hospital and Clinics does a molecular analysis on the sentinel node biopsy during surgery using a system called GeneSearch Breast Lymph Node Assay that can tell whether proteins specific to cancer are there, said D. Scott Lind, the chief of surgical oncology.

"What this does is it spares the woman a second trip to the OR" if further study turns up cancer in the sample, which happens about 10-15 percent of the time, he said.

Other genetic testing can help tailor treatments to a patient's specific condition, Dr. Feldman said.

"The beauty of this is that the therapy for each woman is now totally individualized," he said.

The refinement of techniques and large-scale studies allow surgeons to give patients a wide array of choices, Dr. Pugliese said.

"The wonderful thing about breast cancer surgery right now ... is that we have the opportunity to sit down with a patient and discuss several different surgical options that would be a good fit for that patient, that have been proven to have equal outcomes," he said. "It's something that doesn't necessarily exist elsewhere or in other cancers. It's something that is special and unique to breast cancer."

Increasingly, the trend is for women who are getting a mastectomy to opt to remove the other breast with it. It is called contralateral prophylactic mastectomy. A University of Minnesota study found it had increased 150 percent in recent years; a study of New York breast cancer patients published last month in Cancer found the rate had doubled between 1995 and 2005. Both studies found the rate was highest in younger patients, which surgeon Randy Cooper is seeing in his practice at University Hospital.

"The attitude is, 'I only want to deal with this one time. I never want to deal with this again,' " he said. "And that's even more so if they have small children."

Taking off the other breast reduces the risk of cancer showing up on the other side and has been shown to have benefits for women such as Ms. Bailey, who overexpresses genes that put her at high risk for developing another cancer.

But the treatment for a cancer in one breast might prevent cancer in the other breast, Dr. Cooper said.

The drug Tamoxifen, given to women with hormone-sensitive breast cancers, can cut the risk of a cancer in the other breast by 50 percent, Dr. Pugliese said. Chemotherapy can cut the chance of cancer showing up in the other breast by 20 percent, he said.

"Even with that information, though, you'll find some patients that would be more interested in bilateral mastectomy," he said, even if there is not good data on whether it will ultimately improve outcomes.

The increase in mastectomy could be tied to the use of MRI, which can find small tumors and suspicious areas that mammography cannot, Dr. Lind said.

"This is leading to more women opting for mastectomy and reconstruction," he said. A study earlier this year in the Annals of Surgical Oncology found that increasing rates of MRI in women led to a slightly higher rate of mastectomies and a more than 50 percent increase in the contralateral prophylactic mastectomies.

Whether to use MRI in breast cancer diagnosis is still an open question, Dr. Pugliese said. It might be useful in screening women at high risk of developing breast cancer. And it is clearly needed in cases of occult breast cancer, where there is a metastasis in the lymph nodes, for instance, but no tumor visible on mammography or clinical exam, he said. But in other instances, the information provided could lead to a more aggressive surgery based on information that might turn out to be nothing, Dr. Pugliese said.

"MRI is very controversial now," he said. "At the same time, you see many of us using it."

Reach Tom Corwin at (706) 823-3213 or tom.corwin@augustachronicle.com.