Bilateral Mastectomy for DCIS is Increasing

"Take it off. Take it all off."

I was recently reminded of this catch phrase (it's from that ancient Noxzema shaving-cream commercial) by reading a recent published study. The research confirmed that more and more young (premenopausal) women who are diagnosed with noninvasive breast cancer (or DCIS, ductal carcinoma in situ) are opting for mastectomies—the most aggressive surgery they can get.

And, hold onto your hats (or bras): Here in the U.S., between 1998 and 2005, the rate of contralateral prophylactic mastectomies (removal of the other breast before breast cancer has even put in an appearance and likely never would have) increased by 188 percent.

What does this mean?  It means that many young women are deciding to have both of their breasts removed when diagnosed with very early-stage breast cancer that is limited to one small area of one breast.

Why this is happening is not clearly understood, since the survival rate for DCIS is 99 percent. Even if she had a lumpectomy with radiation on the affected breast and did nothing at all to the healthy side, her odds are the same. And it's also true in this scenario that if the disease were to recur later on in the breast that had a lumpectomy performed, her survival rate would again be no less.

Some experts assume that these women just don't want to worry with mammograms and the anxiety associated with them. But is this the only reason why so many women with DCIS in one breast are opting for double mastectomies? Certainly, a mastectomy is an effective way to reduce anxiety—the peace of mind of never having to have another mammogram cannot be understated. But I'm thinking there are at least two other possible reasons for this pattern of change and choice.

The first: In 1998, a federal law was passed requiring health insurance companies to cover the expenses of breast reconstruction for anyone with a diagnosis of any kind of breast cancer, including stage 0 cancers, the noninvasive type (DCIS). Prior to this, women had to pay out of pocket for reconstruction. So, more times than not, before the law was changed, a woman would opt for lumpectomy with radiation as her surgical treatment so that she didn't have to go to the poorhouse paying for reconstruction. This law requires coverage of all types of reconstruction, too.

But if a woman eligible for reconstruction decides to use her tummy fat to recreate a new breast, she's used up her personal quota: She'll never have any more tummy fat at her disposal because any fat not used in the operation must be tossed. This means that if she were to become one of the 5 to 10 percent of survivors who develop breast cancer in the other breast sometime in the future, she would need to resort to a different type of reconstruction.

And so she starts worrying about getting a possible tumor in the other breast, and the fact that nothing except her own tummy fat could ever provide her with the same look and degree of symmetry—symmetry that she would have if only she'd had both breasts done at the same time. She worries herself right into a double mastectomy.

Could this theory also explain why more women who have cancer in just one breast are opting to go for broke and do bilateral mastectomies at the same time, with bilateral flap reconstructions in both breasts in a single operation?

The same reasoning could even apply to those having a breast implant: Why have one perennially perky breast (on the implant side) while still having to go out and get a surgical lift for the other one every few years? Get two perky ones in one operation.

My second theory to explain this new surgical trend has to do with the use of MRI. We know that more women are having mastectomies as a result of breast MRIs because, in some cases, the MRI identifies additional cancerous lesions that the mammography wasn't able to see as clearly. And since these additional tumors will ruin her chance to get a simple lumpectomy, she is required to have a mastectomy as her surgical treatment.

And what about all the suspected "tumors" found on MRI that turn out to be harmless artifacts when examined further with a biopsy? These women have been put through the added stress of an MRI experience plus a biopsy, and so they often make an emotional decision to have both their breasts removed—again, a choice driven by anxiety.

So what would you do if you were diagnosed with the earliest-stage breast cancer, stage 0, DCIS, and were told you were a good candidate for a lumpectomy followed by radiation? Would you decide to have a mastectomy anyway? Would you do it bilaterally? Opt for reconstruction? 

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