ASCO 2012, Chicago, USA
Decision making in surgical breast cancer treatment
Dr Monica Morrow – Memorial Sloan-Kettering Cancer Center, New York, NY, USA
Dr Monica Morrow, great to have you with ecancer.tv and you are particularly interested in decision making in breast cancer. Decision about what sort of treatment to have and, of course, doctors may have a preferred treatment, what is your main point here that you’re trying to get over?
The point I’m trying to get is patients are faced with an increasingly complex series of decisions about the continuum of cancer treatments, starting with surgery – should they have a lumpectomy or a mastectomy? Should they have the normal breast removed? And then what type of adjuvant therapy to have afterwards. If we don’t understand how to convey complex information to patients to help them make those decisions, all the advances in targeted therapy aren’t going to do us any good at all. So that’s what we’re interested in studying.
It’s very tough for patients though, isn’t it, because they are scared, they’ve got a diagnosis, maybe they would prefer the doctor to have a really big controlling influence.
I think that’s true. We’ve actually looked at that and asked patients did you have too much role in decision making, did you have too little role? And about a quarter of patients say they had too much, a quarter say too little. So it’s clearly very variable.
Let’s start, perhaps, with surgery. What are your thoughts about that because I know you’ve been looking into whether surgery can be too much.
We’ve known for many years that breast cancer survival is the same whether you have a lumpectomy and radiation or a mastectomy. We’re seeing in the United States some alarming trends towards increasing mastectomy rates and, in particular women choosing to remove their opposite breast, at a time when the risk of getting a new second breast cancer for most women is 2-3% at ten years.
What are the factors driving that sort of action and what should the doctor actually be doing with his or her patient?
We’re trying to understand those factors. I think the primary factor is fear, it’s clearly not medical need, and the process of diagnosis and treatment is so traumatic for women, they say, “I just don’t want to do this again. I don’t care how low my risk is.” So it’s not an entirely rational thing and we haven’t figured out how to solve that.
So on the surgical front do you have any words to pass on to busy doctors at this point then, from your deliberations?
It’s important to recognise that over time the risk of local recurrence after breast conserving therapy has declined steadily, that the advances in systemic therapy that prolong survival also reduce in-breast recurrence so that local recurrence is at an all-time low in the breast, we don’t need to over-emphasise that to patients.
Radiation therapy is another difficult issue, what are your thoughts there?
What we’re trying to do across breast cancer is tailor treatment to the individual, so now, as opposed to six weeks of radiation for everyone we know that for some women shorter course radiation of 3½ weeks, which is a big benefit to them, works. We’re studying partial breast irradiation.
