Undergoing a bilateral mastectomy to prevent a recurrence of cancer when only one breast is affected and the patient doesn’t carry a rare genetic mutation doesn’t alter a woman’s chances of dying.
Dr. Steven Narod, research chair at Women’s College Research Institute in Toronto, conducted a study of 100,000 women with DCIS (ductal carcinoma in situ), or Stage 0 cancer. He found that, although it’s a non-invasive milk duct cancer with a high recovery rate, it is not pre-cancer as previously thought.
In the U.S., about 25 per cent of patients (fewer in Canada) will have both breasts removed for treatment of cancer on one side, he told The Agenda’s Steve Paikin.
“We as physicians and scientists tend to value most importantly any [cancer] surgery for the chance of death to be reduced,” Narod says. “We thought, well, if an operation or a screening procedure doesn’t reduce the chance of a person dying of cancer, then we wouldn’t recommend it necessarily.”
But, he goes on, “Whereas the patient, they’re really thinking they’ve gone through the experience of breast cancer, they’ve gone through it and they’re anxious about it, they’re anxious about it coming back and they’re anxious about dying. On a day-to-day basis they’re anxious about it coming back. So they‘ll accept a procedure as drastic as a mastectomy in order to get the reassurance and the reduction in anxiety or fear.”
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There’s the personal question: what does a patient choose based on her priorities and values and needs? And then there’s the inevitable question from a health care policy perspective: what treatment is most effective in any individual case, and what effect does an aggregate number of treatment decisions have on the overall system?
The cost for a lumpectomy, Narod says, is in the hundreds of dollars, while a bilateral mastectomy with reconstruction is in the tens of thousands. “When it comes to surgery, the patient has the option … No one’s going to say to the patient, I recommend this course of action based on cost to the government. We can have this discussion, I can have this discussion in the halls of the university or with the minister of health but you don’t stand in front of a patient and say, ‘You want this but I don’t think you should have this because it costs too much money.’”
There are no clear-cut answers, Narod says: “When we evaluate these treatments there are several end points: Is this cancer going to come back? Is this woman going to feel better about herself? Is it going to reduce her fear? Will it improve her body image? Is this woman going to die of cancer? You’ve got to take a pretty cold look and make a decision. Should that be done on an individual basis for a doctor and patient? Ideally. Should it be done as a society as medicine looks at ways at saving costs and optimizing care? Yes, of course. All of these are important.”