Lumpectomy survival rate higher in study Breast cancer

Vicki Paul, a licensed vocational nurse, chose to have a lumpectomy. Vicki Paul, a licensed vocational nurse, chose to have a lumpectomy. Photo: Lea Suzuki, The Chronicle Photo: Lea Suzuki, The Chronicle Image 1 of / 3 Caption Close Lumpectomy survival rate higher in study 1 / 3 Back to Gallery

(02-06) 10:47 PST SAN FRANCISCO -- For decades, clinical trials and other studies have shown that women with early-stage breast cancer have the same survival odds whether they choose to have a surgery that involves removing just the tumor and surrounding tissue, called a lumpectomy, or a mastectomy to remove the entire breast.

But a new study that relies on data from more than 112,000 California women has challenged that long-held notion, suggesting that those who opt for lumpectomy followed by radiation actually fare better - with survival rates between 6 percent and 14 percent higher - than those who have a mastectomy.

The study, published last week in the online edition of the medical journal Cancer, may reassure women who've had lumpectomies, but cause others to second guess their choice of a mastectomy.

"The sound bite right now is that lumpectomy is better for survival than mastectomy," said Jenna Glazer, director of development for Young Survival Coalition, an advocacy group for young women diagnosed with breast cancer. "I'm not convinced that is true."

More study needed

Glazer said she thinks the study does not capture the reasons behind the choices patients made. "I would not just ignore years and years of research that said survival is the same," she said.

Most women diagnosed with early-stage breast cancer can choose between having a mastectomy, which is usually not followed by radiation, or lumpectomy, a less-invasive surgery that is typically followed by weeks of radiation.

After studies started showing equivalent survival rates for the two options, the proportion of women receiving mastectomy fell 2 to 4 percent per year between 1990 and 2000.

But more recent national statistics have shown an uptick in the number of patients choosing mastectomy. Improvements in breast reconstruction surgery as well as publicity over high-profile women who've opted for mastectomies when faced with early-stage disease or a genetic risk of developing breast cancer may have contributed to this shift.

Since 2000, the proportion of women receiving a mastectomy has either stayed the same or increased 1 to 2 percent per year, according to a 2010 study by researchers at the Cancer Prevention Institute of California in Fremont. The most pronounced increase was found among younger patients; women living in higher socioeconomic areas; and those diagnosed with ductal carcinoma in situ, often referred to as "stage 0" breast cancer.

The study begins

Noting the trend, researchers from the Fremont institute and the Duke Cancer Center in Durham, N.C., set out to see if the long-held notion that the two options were equivalent was actually holding up in the real world.

They looked at data on 112,154 California women diagnosed with stage 1 or stage 2 breast cancers between 1990 and 2004 and followed them through December 2009.

What they found was surprising: Among all age groups, lumpectomy followed by radiation seemed to improve survival rates among breast cancer patients as well as other conditions over those who chose mastectomy.

The results were particularly pronounced in women who were diagnosed at age 50 or older and had tumors that feed off the hormone estrogen. Those who opted for lumpectomy were 13 percent less likely to die from breast cancer and 19 percent less likely to die due to other reasons during the study period compared with those who had undergone mastectomy.

"We don't know why we see this improved survival for lumpectomy," said Christina Clarke, one of the study's authors and a research scientist at the Cancer Prevention Institute of California. "We don't have the data to explain it. But the fact is we see better overall survival - meaning death from all causes - as well as breast cancer survival."

The study clearly has some limitations. It's an observational study, meaning that it looks at the results after-the-fact and is not the gold-standard, randomized form of research that blindly assigns patients to different treatments and then follows them to see what happens.

Adjusting for factors

But the researchers adjusted the data for as many factors as possible that could have made a difference in the results - age, race, socioeconomic status by neighborhood, tumor type and size - and the results were the same.

Clarke said some factors that could have influenced the choice to choose a mastectomy over lumpectomy - such as a patient's baseline health or whether patient's family history indicated a predisposition for cancer - were unknown.

Other factors may have played a role, such as the distance a patient lived to a radiation center, whether she had access to high-quality reconstructive surgery and how much influence the doctor had in making the decision.

"It's not perfect data, but it's there and we feel it's a disservice not to put it out there," she said. "It definitely should give women who chose lumpectomy confidence that they didn't make the wrong choice."

Vicki Paul, of South San Francisco, is confident she made the right decision when she was diagnosed with breast cancer on Feb. 10, 2006, her 55th birthday.

Paul, a licensed vocational nurse with no family history of breast cancer, had a choice between the combinations of lumpectomy, mastectomy, radiation and chemotherapy. But for her pea-size lump, Paul opted to have the tumor removed followed by 30 sessions of radiation with no chemotherapy.

She said she didn't want to do more treatment than was necessary, but she certainly didn't want to jeopardize her health. "At my age and place in life, the cosmetic part didn't play a role in it for me," Paul said. "My goal was to get it out."

A patient is reassured

Maria Lucas, of Napa, had a family history of breast cancer, but still opted for a lumpectomy and six weeks of radiation when she was diagnosed with stage 1 cancer on Dec. 31, 2010, at age 50.

She said the study results offer her some reassurance. "My mother had mastectomy and she still had it come back four times - it came back in lymph nodes and the chest wall," she said. "I think a lot of women think if you get your breast removed it's a guarantee of it not coming back. But it's not."

Dr. Allison Kurian, Stanford assistant professor of oncology as well as health research and policy, said it's important to note that the study does not explain what causes the difference between the survival rates. It simply shows an association.

"It's hard to make any definite conclusions about whether lumpectomy is yielding a better survival result than mastectomy," said Kurian, who is familiar with the study but was not involved in the research. "There's no evidence here that lumpectomy is worse, and that's reassuring."

Glazer, of the Young Survival Coalition, was diagnosed with breast cancer at age 33. Because of the location of her tumor, she had to have a mastectomy on one breast but she opted to have her other breast removed.

She described mastectomy as "100 percent the right choice" for her. "I would have worried constantly," said Glazer, now 41, adding that younger women tend to have more aggressive disease. She doesn't want other women to worry about their choice because of this study.

"I wouldn't want a bunch of women who had mastectomy to think they have done something wrong or extreme," Glazer said. "Nor would I want people to look at this and think mastectomy was a worse decision."