When it comes to cancer, I’m neither physician nor patient, nor even a policy expert. But being both a critical thinker and a feminist, I’m struck by what the juxtaposition of two seemingly unrelated new oncology studies, published in highly respected medical journals a month apart, can tell us about how gender shapes the way we perceive (or misperceive) illness, and the impact that has on patients’ well-being.
On April 14, JAMA Oncology published “Nomenclature Revision for Encapsulated Follicular Variant of Papillary Thyroid Carcinoma.” Although the title may be nearly impenetrable to the non-specialist, the study conveys good news: A condition previously categorized as thyroid cancer has been found to not be cancer after all. No longer labeled cancer, it will also no longer be treated the same way. Previously, approximately ten thousand patients a year in the U.S. with this condition have undergone thyroidectomy, followed by treatment with radioactive iodine and follow-up checkups for the rest of their lives. The recognition that these particular tumors are not actually cancer means physicians can follow a more appropriate and less harmful treatment protocol, leaving the thyroid in place and no longer subjecting patients to radiation, or to the lifelong stress and expense of unnecessary follow-up exams.
It’s hard to imagine any physician refusing to follow this new protocol, continuing to subject patients to unnecessary and harmful treatment, and then justifying such actions as being more sensitive to the needs of the patient. Yet “Growing Use of Contralateral Prophylactic Mastectomy Despite no Improvement in Long-term Survival for Invasive Breast Cancer,” published online by Annals of Surgery on March 11, found that the number of women undergoing double mastectomies (technically referred to as contralateral prophylactic mastectomy or CPM) tripled in the course of a decade — even though for the overwhelming majority of the patients, such surgery was medically unnecessary. These women, who were diagnosed with stage 1, 2, or 3 cancer in one breast, were having their other breasts removed even though those breasts were entirely healthy, and — because the women lacked other risk factors (the BRCA gene mutation, or family history of breast cancer, or chest radiation during childhood) — not at risk for developing cancer.
The study compared women who had breast-conserving surgery (i.e., removal of the tumor while the rest of that breast was left intact), women who had a single mastectomy of the breast where the cancer occurred, and women who had both breasts removed. Women who underwent double mastectomy had no significant improvement in survival than women who had breast-conserving treatment. In fact, less than 1 percent of breast cancer survivors experience a recurrence of the disease in their unaffected breast at a later point.
Given the potential problems involved in double mastectomy — increased risks of operative complications, increased recovery time, higher costs, and possible need for repeat surgery — it would seem clear that women lacking the specific risk factors for a recurrence in their other breast should, like those patients with the non-cancerous thyroid tumor, no longer be subject to unnecessary and unhelpful treatment. Yet in the press release announcing the findings, Mehra Golshan, MD, medical director of international oncology programs at Dana-Farber/Brigham and Women’s Cancer Center and the study’s lead author, uses much more ambivalent language: “Understanding why women choose to undergo CPM may create an opportunity for health care providers to optimally counsel women about surgical options, address anxieties, discuss individual preferences and ensure peace of mind related to a patient’s surgical choice.”
May create an opportunity? Discuss individual preferences? I don’t doubt that as a practitioner as well as researcher, Dr. Golshan has patients’ best interest in mind. I just can’t help wondering why, when it comes to women and breasts, best interest isn’t more clearly defined in terms of categorically declaring that unnecessary surgeries shouldn’t be performed.
The rhetoric around breast cancer, even if initially well intended, has imbued women with an enduring belief that our breasts should be objects of fear. In the U.S., heart disease kills far more women than breast cancer does. Indeed, heart disease, which is responsible for 1 out of every 3 deaths of a woman in this country, kills more American women than all forms of cancer combined. But women, judged in so many ways based on how our breasts appear to others as well as to ourselves, are being encouraged to ignore the real risks they face.
Of course, risk is difficult to define. Any breast can develop cancer. But so can any thyroid, or any pancreas, or any other myriad body parts. Surgeons don’t routinely remove those to assuage a fear of cancer where there is no elevated risk of cancer. We wouldn’t tolerate it if they did.
If we’re singling (or doubling?) out breasts for different, invasive, risky, unnecessary treatment, we need to recognize why. And then we need to stop.
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