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)
Joan Lunden returned to her old stomping grounds, ABC's "Good Morning America," with a personal news update on June 24. The former "GMA" host revealed that she's facing an "aggressive" form of breast cancer. Joan Lunden returned to her old stomping grounds, ABC's "Good Morning America," with a personal news update on June 24. The former "GMA" host revealed that she's facing an "aggressive" form of breast cancer.
HIDE CAPTION
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities battle cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
Celebrities and battles with cancer
<<
<
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
>
>>
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
July 30, 2014 -- Updated 1941 GMT (0341 HKT)
Stuart Gitlow says pot is addictive and those who smoke it can experience long-term psychiatric disease.
July 30, 2014 -- Updated 1645 GMT (0045 HKT)
Gabby Giffords and Katie Ray-Jones say "Between 2001 and 2012, more women were shot to death by an intimate partner in our country than the total number of American troops killed in the Iraq and Afghanistan wars combined."
July 29, 2014 -- Updated 2357 GMT (0757 HKT)
Alan Elsner says Secretary Kerry's early cease-fire draft was leaked and presented as a final document, which served the interests of hard-liners on both sides who don't want the Gaza war to stop.
July 30, 2014 -- Updated 1158 GMT (1958 HKT)
Vijay Das says Medicare is a success story that could provide health care for everybody, not just seniors
July 30, 2014 -- Updated 1818 GMT (0218 HKT)
Rick Francona says Israel seems determined to render Hamas militarily ineffective.
July 30, 2014 -- Updated 1743 GMT (0143 HKT)
S.E. Cupp says the entrepreneur and Dallas Mavericks owner thinks for himself and refuses to be confined to an ideological box.
July 30, 2014 -- Updated 1311 GMT (2111 HKT)
A Christian group's anger over the trailer for "Black Jesus," an upcoming TV show, seems out of place, Jay Parini says
July 30, 2014 -- Updated 2028 GMT (0428 HKT)
LZ Granderson says the cyber-standing ovation given to Robyn Lawley, an Australian plus-size model who posted unretouched photos, shows how crazy Americans' notions of beauty have become
July 30, 2014 -- Updated 1939 GMT (0339 HKT)
Carol Dweck and Rachel Simmons: Girls tend to have a "fixed mindset" but they should have a "growth mindset."
July 28, 2014 -- Updated 1156 GMT (1956 HKT)
A crisis like the Gaza conflict or the surge of immigrants can be an opportunity for a lame duck president, writes Julian Zelizer
July 26, 2014 -- Updated 1822 GMT (0222 HKT)
Carol Costello says the league's light punishment sent the message that it didn't consider domestic violence a serious offense
July 28, 2014 -- Updated 1251 GMT (2051 HKT)
Danny Cevallos says saggy pants aren't the kind of fashion statement protected by the First Amendment.
July 28, 2014 -- Updated 1852 GMT (0252 HKT)
Margaret Hoover says some GOP legislators support a state's right to allow same-sex marriage and the right of churches, synagogues and mosques not to perform the sacrament
July 28, 2014 -- Updated 1831 GMT (0231 HKT)
Megan McCracken and Jennifer Moreno say it's unacceptable for states to experiment with new execution procedures without full disclosure
July 30, 2014 -- Updated 1744 GMT (0144 HKT)
Priya Satia says today's drones for bombardment and surveillance have their roots in the deadly history of Western aerial control of the Middle East that began in World War One
July 28, 2014 -- Updated 1635 GMT (0035 HKT)
Jeff Yang says it's great to see the comics make an effort at diversifying the halls of justice
July 26, 2014 -- Updated 1555 GMT (2355 HKT)
Rick Francona says the reported artillery firing from Russian territory is a sign Vladimir Putin has escalated the Ukraine battle
July 27, 2014 -- Updated 1822 GMT (0222 HKT)
Paul Callan says the fact that appeals delay the death penalty doesn't make it an unconstitutional punishment, as one judge ruled
July 24, 2014 -- Updated 2225 GMT (0625 HKT)
Pilot Robert Mark says it's been tough for the airline industry after the plane crashes in Ukraine and Taiwan.
July 25, 2014 -- Updated 1510 GMT (2310 HKT)
Jennifer DeVoe laments efforts to end subsidies that allow working Americans to finally afford health insurance.
July 26, 2014 -- Updated 1533 GMT (2333 HKT)
Ruti Teitel says assigning a costly and humiliating "collective guilt" to Germany after WWI would end up teaching the global community hard lessons about who to blame for war crimes
July 25, 2014 -- Updated 1245 GMT (2045 HKT)
John Sutter responds to criticism of his column on the ethics of eating dog.
July 25, 2014 -- Updated 1302 GMT (2102 HKT)
Frida Ghitis says it's tempting to ignore North Korea's antics as bluster but the cruel regime is dangerous.
July 25, 2014 -- Updated 1850 GMT (0250 HKT)
To the question "Is Putin evil?" Alexander Motyl says he is evil enough for condemnation by people of good will.
July 24, 2014 -- Updated 1803 GMT (0203 HKT)
Laurie Garrett: Poor governance, ignorance, hysteria worsen the Ebola epidemic in Sierra Leone, Guinea, Liberia.
July 24, 2014 -- Updated 1349 GMT (2149 HKT)
Patrick Cronin and Kelley Sayler say the world is seeing nonstate groups such as Ukraine's rebels wielding more power to do harm than ever before
July 23, 2014 -- Updated 2205 GMT (0605 HKT)
Ukraine ambassador Olexander Motsyk places blame for the MH17 tragedy squarely at the door of Russia
July 24, 2014 -- Updated 1142 GMT (1942 HKT)
Mark Kramer says Russia and its proxies have a history of shooting down civilian aircraft, often with few repercussions
July 24, 2014 -- Updated 1853 GMT (0253 HKT)
Les Abend says, with rockets flying over Tel Aviv and missiles shooting down MH17 over Ukraine, a commercial pilot's pre-flight checklist just got much more complicated
July 24, 2014 -- Updated 1317 GMT (2117 HKT)
Mark Kramer says Russia and its proxies have a history of shooting down civilian aircraft, often with few repercussions
July 24, 2014 -- Updated 1637 GMT (0037 HKT)
Gerard Jacobs says grieving families and nations need the comfort of traditional rituals to honor the remains of loved ones, particularly in a mass disaster
July 24, 2014 -- Updated 1413 GMT (2213 HKT)
The idea is difficult to stomach, but John Sutter writes that eating dog is morally equivalent to eating pig, another intelligent animal. If Americans oppose it, they should question their own eating habits as well.
July 23, 2014 -- Updated 1630 GMT (0030 HKT)
Bill van Esveld says under the laws of war, civilians who do not join in the fight are always to be protected. An International Criminal Court could rule on whether Israeli airstrikes and Hamas rocketing are war crimes.
July 30, 2014 -- Updated 1209 GMT (2009 HKT)
Gordon Brown says the kidnapped Nigerian girls have been in captivity for 100 days, but the world has not forgotten them.
ADVERTISEMENT