The Breast Cancer Treatment Pendulum

It seems fitting that during the month of October I should at least mention breast cancer. So that will be the focus of this week’s blog. The American Cancer Society estimates that there will be approximately 192,000 new cases of invasive breast cancer and an additional 62,000 cases of insitu breast cancer diagnosed in 2009. About 15% of all cancer in women is breast cancer. Because it is such a highly publicized cancer women everywhere are, or at least should be, aware of its impact. In addition, because early stage breast cancer is very treatable and often curable, all women should follow the recommended standards for screening. How many women really do? That’s another topic. It is recommended that women in their 20s start performing monthly self breast exams. In the 20s and 30s a clinical breast exam should occur at least every three years. By the time a woman enters her 40s she should have the clinical breast exam with her annual exam and begin having mammograms yearly. With early detection, the chances or cure rise tremendously. That’s really what I wanted to focus on.

We have gotten exponentially better at detecting breast cancer. With the use of MRI, small lumps that once were undetected are being found. So what does this mean to the patient, the doctor, and the treatment plan? Over the past ten years we have seen the treatment pendulum swing. At one time, mastectomy was the surgical treatment most often performed. Many clinical trials have shown the equivalence of mastectomy with breast-conserving therapy with wide excision followed by radiation on overall long term outcomes. With this knowledge and a greater focus on quality of life issues for patients, we saw a swing towards fewer radical mastectomies and more breast conserving therapy including lumpectomies.

However, in recent years, with the improved imaging available with MRI, we are once again seeing an increase in mastectomies. MRI has been used in preoperative staging because it detects additional foci of cancer that are not seen on conventional imaging. Evidence has shown then that MRI does change surgical management. This change is usually from breast conservation to more radical surgeries. But there is no evidence that it improves surgical care or prognosis. In addition, some data does show that MRI does not reduce re-excision rates and that it causes false-positives in terms of detection and unnecessary surgery. With this information emerging and more trials being performed, I believe we will be seeing another swing in the pendulum. Is routine use of MRI for screening necessary? I don’t think that the evidence is telling us this. But still we see it being used often upon the detection of lumps with conventional imaging methods. One idea that has been presented is to use the MRI as a starting point. For each additional lesion that is visualized under MRI, a biopsy should be done to determine malignancy. This can provide a safety net against false positives, and ensures full details available to patients that need to make crucial decisions.

As we get better diagnostic tools, we obviously will have greater ability to detect cancers of all kinds. But I think it is crucial to take the information we have and use it in the best possible way. We should not assume that what we see is what we think we see. When it comes to such a crucial decision as treatment strategies, we must take the time to go back to the basics. Biopsy to make certain, then decisions can be made on the best of information.