Skip to main content

When removing breast is not the answer

By Sarah Hawley, Special to CNN
May 15, 2013 -- Updated 1455 GMT (2255 HKT)
When "The Simpsons" co-creator Sam Simon learned that he had terminal colon cancer in 2013, he knew right away what he would do with the rest of his life: <a href='http://marquee.blogs.cnn.com/2013/07/29/facing-cancer-simpsons-co-creator-aims-to-give-away-fortune/' target='_blank'>give away his fortune in support of good causes</a>. In November 2014, <a href='http://www.nbcnews.com/feature/maria-shriver/simpsons-sam-simon-gives-away-his-fortune-n245136' target='_blank'>Simon said</a> he's still fighting his health battle and is actively giving back through the Sam Simon Foundation. When "The Simpsons" co-creator Sam Simon learned that he had terminal colon cancer in 2013, he knew right away what he would do with the rest of his life: give away his fortune in support of good causes. In November 2014, Simon said he's still fighting his health battle and is actively giving back through the Sam Simon Foundation.
HIDE CAPTION
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
<<
<
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
>
>>
STORY HIGHLIGHTS
  • Sarah Hawley: Jolie, who's high risk, a good candidate for mastectomy, but word of caution
  • She says women with cancer in one breast increasingly having other breast removed too
  • She says risk of cancer in healthy breast is less than 1%; overtreatment a concern
  • Hawley: Women need control over health decisions, but must have accurate info on choices

Editor's note: Sarah Hawley is an associate professor in the Division of General Medicine at the University of Michigan and a research investigator at the Ann Arbor VA Center of Excellence in Clinical Management Research. Her primary research is in decision making related to cancer prevention and control.

(CNN) -- Angeline Jolie, who has stated that she is a carrier of the gene mutation BRCA1, appears to have been a good candidate for the bilateral prophylactic mastectomy she underwent recently to remove both of her breasts. In Jolie's case -- as with others who have openly discussed a similar action, such as Miss American contestant Allyn Rose and celebrity Sharon Osbourne -- the decision is appropriate: Having a genetic mutation, as these women do, puts a woman at very high risk for developing breast cancer in her lifetime.

But it possible that these very public decisions could lead more women with cancer diagnosed in one breast to consider having their second, nonaffected breast removed. This is called contralateral prophylactic mastectomy and it is on the rise in the U.S. Data from large cancer registry studies, for one example, have shown that the overall rate of CPM among women with stage I, II or III breast cancer significantly increased from 1.8% in 1998 to 4.5% in 2003. Looking only at patients treated with mastectomy, the CPM rate grew from 4.2% in 1998 to 11.0% in 2003.

Sarah Hawley
Sarah Hawley

It is important, on the news of Jolie's decision, to caution women that CPM should be done only for the same reason as bilateral prophylactic mastectomies -- the presence of BRCA1 OF BRCA2. While many women who choose CPM do carry one of these genes, our research suggests that most do not.

Considered in the context of history, this is a jarring development. Back in the 1970s, women with breast cancer and their supporters pushed to have the option of breast conserving surgery (BCS or "lumpectomy") made available as an option to treat breast cancer.

They argued then that they should have access to a less invasive option than mastectomy (surgery to remove all breast tissue), particularly when randomized trials suggested the two treatments gave women the same chance of long-term survival. Yet in the United States we now find ourselves on the opposite end of the spectrum, with patients largely driving decisions -- electing to undergo this most extensive treatment option for breast cancer.

It would be almost unheard of for a woman without cancer to have a bilateral prophylactic mastectomy, as Jolie did, unless she had a genetic mutation.

Angelina Jolie reveals double mastectomy
CNN anchor opens up about her cancer
Wasserman Schultz on her breast cancer

So why would a woman who has cancer in one breast choose to have a second, healthy breast removed? Our research suggests that patients are worried about recurrence. But for the average breast cancer patient who has neither the BRCA1 or BRCA2 gene mutation nor a close relative with breast cancer (Jolie's mother, for example, died from ovarian cancer), the risk of a new breast cancer in the nonaffected breast is less than 1%.

Having the nonaffected breast removed will not translate into any additional survival benefit beyond what is conferred by treating the existing cancer. In fact, research has shown that many women who choose CPM could have been treated with only a lumpectomy, plus radiotherapy, in the affected breast.

Given the extent of the procedure, that CPM is done on patients without clinical reason raises strong concerns about overtreatment. This is perhaps the only example of removing a nonaffected organ based on what appears to be patient misunderstanding of the potential benefit of the surgery.

It's unlikely that a surgeon would agree to remove the entire colon of a patient with resectable colon cancer because the patient was worried about getting more colon cancer. Similarly, it is difficult to imagine a man with testicular cancer requesting to have both the affected and nonaffected testicles removed.

In this era of patient-centered care, women do need to feel empowered to make the choices that are best for them in treating their breast cancer. Yet because these choices are so difficult, it is imperative that they be based on accurate understanding of the risks and benefits of treatment. Perhaps we need to turn our attention to helping women remember why they advocated for less invasive options nearly 40 years ago.

Follow us on Twitter @CNNOpinion.

Join us on Facebook/CNNOpinion.

The opinions expressed in this commentary are solely those of Sarah Hawley.

ADVERTISEMENT
Part of complete coverage on
November 21, 2014 -- Updated 1925 GMT (0325 HKT)
Maria Cardona says Republicans should appreciate President Obama's executive action on immigration.
November 21, 2014 -- Updated 1244 GMT (2044 HKT)
Van Jones says the Hunger Games is a more sweeping critique of wealth inequality than Elizabeth Warren's speech.
November 20, 2014 -- Updated 2329 GMT (0729 HKT)
obama immigration
David Gergen: It's deeply troubling to grant legal safe haven to unauthorized immigrants by executive order.
November 21, 2014 -- Updated 0134 GMT (0934 HKT)
Charles Kaiser recalls a four-hour lunch that offered insight into the famed director's genius.
November 20, 2014 -- Updated 2012 GMT (0412 HKT)
The plan by President Obama to provide legal status to millions of undocumented adults living in the U.S. leaves Republicans in a political quandary.
November 21, 2014 -- Updated 0313 GMT (1113 HKT)
Despite criticism from those on the right, Obama's expected immigration plans won't make much difference to deportation numbers, says Ruben Navarette.
November 21, 2014 -- Updated 0121 GMT (0921 HKT)
As new information and accusers against Bill Cosby are brought to light, we are reminded of an unshakable feature of American life: rape culture.
November 20, 2014 -- Updated 2256 GMT (0656 HKT)
When black people protest against police violence in Ferguson, Missouri, they're thought of as a "mob."
November 19, 2014 -- Updated 2011 GMT (0411 HKT)
Lost in much of the coverage of ISIS brutality is how successful the group has been at attracting other groups, says Peter Bergen.
November 19, 2014 -- Updated 1345 GMT (2145 HKT)
Do recent developments mean that full legalization of pot is inevitable? Not necessarily, but one would hope so, says Jeffrey Miron.
November 19, 2014 -- Updated 1319 GMT (2119 HKT)
We don't know what Bill Cosby did or did not do, but these allegations should not be easily dismissed, says Leslie Morgan Steiner.
November 19, 2014 -- Updated 1519 GMT (2319 HKT)
Does Palestinian leader Mahmoud Abbas have the influence to bring stability to Jerusalem?
November 19, 2014 -- Updated 1759 GMT (0159 HKT)
Even though there are far fewer people being stopped, does continued use of "broken windows" strategy mean minorities are still the target of undue police enforcement?
November 18, 2014 -- Updated 0258 GMT (1058 HKT)
The truth is, we ran away from the best progressive persuasion voice in our times because the ghost of our country's original sin still haunts us, writes Cornell Belcher.
November 18, 2014 -- Updated 2141 GMT (0541 HKT)
Children living in the Syrian city of Aleppo watch the sky. Not for signs of winter's approach, although the cold winds are already blowing, but for barrel bombs.
November 17, 2014 -- Updated 1321 GMT (2121 HKT)
We're stuck in a kind of Middle East Bermuda Triangle where messy outcomes are more likely than neat solutions, says Aaron David Miller.
November 17, 2014 -- Updated 1216 GMT (2016 HKT)
In the midst of the fight against Islamist rebels seeking to turn the clock back, a Kurdish region in Syria has approved a law ordering equality for women. Take that, ISIS!
November 17, 2014 -- Updated 0407 GMT (1207 HKT)
Ruben Navarrette says President Obama would be justified in acting on his own to limit deportations
ADVERTISEMENT