E! talk show host Giuliana Rancic, recently diagnosed with breast cancer (and having failed an attempt to remove the cancer with a lumpectomy) has decided to proceed with bilateral mastectomies and reconstruction for her treatment. Her decision is similar to those made by actress Christina Applegate and comedian Wanda Sykes in recent years. This choice is likely the right one for a number of reasons IMO.

• at 37 years old and without children (she was actually undergoing fertility treatments when diagnosed with cancer), she possesses two significant independent risk factors for future breast cancer 1) personal history of cancer and 2) delay or absence of childbirth.
• She has had prior attempt at lumpectomy, which almost guarantees significant cavitary breast deformity, particularly on a thinner woman such as Mrs. Rancic with additional attempts
• She (being an American adult female in good health) has an estimated life expectancy of almost 95 years, and 6+ decades of future surveillance on a high risk individual treated with breast conservation strategies has not been studied. Mastectomy does seem to have an advantage of lower recurrence rates verus lumpectomy with radiation, particularly as you get decades out from the initial treatment.
• A breast treated with lumpectomy and radiation will progressively look worse and worse over time as it relates to bot appearance and asymmetry with the other breast.

Selecting or suggesting a treatment for a younger patient like Mrs. Rancic becomes as much a question of psychology as it is about treatment of the cancer. While it's likely that a more aggressive surgical treatment of localized cancer will pay dividends as you get farther out from the mastectomy, many women will never be comfortable with the breast cancer surveillance requirements going forward and select a mastectomy to simplify their care. It's telling that when women plastic surgeons have been surveyed on whether they'd undergo mastectomy or breast conservation with radiation, that almost all of them would choose mastectomy (and prophylactic mastectomy of the other breast).

Rob

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The AP wire is reporting that the number of women opting for surgery to remove the healthy breast after a cancer diagnosis in one breast is rising, despite a lack of evidence that the surgery can improve survival. Sometimes this is presented as controversial, but I think this represents rationale behavior by many women choosing this.

There's the powerful slogan that's penetrated popular culture that women have a "1 in 8" risk of breast cancer. That's kind of correct but oversimplifies things. Biology is destiny with breast cancer and appears to overwhelm anything in your diet or the environment in terms of producing breast cancer. Like most cancers, risk of breast cancer increases as you get older. Taking all comers in the United States, a woman's chance of being diagnosed with breast cancer is about 1 in 233 when she's in her 30s which steadly rises to 1 in 8 by the time she's reached 85. However, there are women in that group who are at substancially more or substancially less risk.

Younger patients in particular would seem to benefit the most from prophylactic removal of the breast due to this increasing bias for later tumor development. The survival benefit for this surgery hasn't really been studied (as far as I can tell) in your breast cancer patients out for decades. It's assumed that you'd likely see a significant difference in that groups risk of breast cancer in the post menopausal group. Widely referenced studies (see here) suggest that after prophylactic mastectomy a woman's risk for later developing breast cancer is reduced by an average of 90% (some even suggest closer to 100%).

It's clear to me which way I'd suggest for all but the most favorable tumors in young women. Is it for you?

Rob

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