Monday, August 31, 2009

More Mastectomies, Fewer Lumpectomies - Not A Positive Trend

A recent editorial in the Journal of Clinical Oncology asks some valid questions about the troubling trend of increases (31% to 43% from 2003 to 2006) in mastectomies for patients who could benefit from breast-conserving therapy (BCT). The editorial raises the question of whether increased use of MRI at time of diagnosis is creating undue fear resulting in women with early stage breast cancers choosing mastectomy when their breast could be preserved without increasing risk of recurrence. Are MRI's at the time of diagnosis really helpful?

More Mastectomies: Is This What Patients Really Want?

The obvious question is: What has changed? Increased awareness of and testing for BRCA1 and BRCA2 mutations indicating breast cancer predisposition are often cited as factors that have appropriately increased use of mastectomy. But these mutations occur in only 5% to 10% of patients with breast cancer, and the proportion of women in the Mayo Clinic series with a first-degree relative with breast cancer did not increase over time, whereas the mastectomy rate did, making this an unlikely explanation for a large part of the effect observed in this and other studies.


On the basis of these performance characteristics, it had been widely assumed that use of breast MRI for the selection of patients for BCT would reduce the need for re-excision, reduce local recurrence, and even improve long-term survival. At present, no studies have provided support for any of these improved clinical outcomes.12–14 However, breast MRI has been shown to result in additional biopsies and costs, increased patient anxiety, and delays in the start of definitive treatment. Although it is accepted that MRI-detected abnormalities should be biopsied before altering surgical treatment plans, it has been documented that some patients have chosen to forgo these biopsies or additional work-ups and proceed with mastectomy because of concerns about delaying definitive therapy.15 A recent prospective randomized clinical trial16 demonstrated no reduction in the rate of re-excision in women randomly assigned to undergo preoperative MRI compared with those who were not.17 Despite these known disadvantages and the lack of established improvement in any clinical outcome, use of breast MRI at time of diagnosis has been—in our judgment, regrettably—increasing.


Thus, despite the many intuitively obvious advantages of breast MRI in aiding surgical planning, there are no established benefits and several substantial disadvantages, one of which includes the needless increase in mastectomy rates. The history of breast cancer treatment is replete with interventions that seemed intuitively obvious but were eventually shown to be ineffective or harmful. The use of high-dose chemotherapy with bone marrow transplantation rescue is just one glaring recent example; an accumulating body of evidence suggests that use of MRI in selecting patients for surgical therapy is another.

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I must say I agree with the authors, increased use of mastectomy in early stage cancers is cause for concern, particularly in an era of more "personalied medicine" for breast cancer and when there appears to be no benefit in long term survival. Women today know far more about their risk of recurrence at the time of diagnosis and can benefit more from having less invasive surgery. It appears use of MRI at the time of breast cancer diagnosis is showing no benefit and some harm to patients.

What do you think?

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